1. Legal & Ethical Strategies for Successful Distance Counseling

2. Learning Objectives 1. Describe 3 ethical dilemmas related to Skype, Google and Facebook, blogging and the ethical codes that help practitioners think through those dilemmas. 2. Discuss the legal issues related to practicing over state lines or international borders, HIPAA and informed consent when practicing online. 3. Outline 3 key elements of a risk management plan for working online with clients to deliver care. 3. Disclaimer I am an MFT and clinical psychologist, not an attorney, physician or Information Technology specialist. The information I present is my best attempt to bring you timely and relevant information in a rapidly evolving area. I therefore make no warranty, guarantee, or representation as to the accuracy or sufficiency of the information contained in my training. My goal is educational only. I seek to outline the issues and alert you to what's happening, including legal, ethical and other risk management issues. You are encouraged to seek specific advice related to your circumstance from your qualified authorities. 4. Housekeeping Schedule Restrooms Questions WiFi Twitter @ica 5. Whats going on? Technology Health Care Reform Distance Counseling 6. Our planet is re-tooling as is psychology 7. Real-Time Telemedicine Patient in rural ER gets benefit of local care plus remote consultation with specialists. Remote doctor examines a patients inner ear from a remote location. 8. Distance Counseling & Other Services 9. December 2013 10. R O B O T I C S 11. Electronic Health Records 12. Step 1: Training Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement OCPM: Online Clinical Practice Management 13. Telehealth vs. Distance Counseling (working model not to scale) Behavioral Telehealth Disciplines, including Distance Counseling, Training & Supervision Telehealth Health Professions Education Administration Evaluation Research Homeland SecurityPublic Health Consumer Education (and Self- management) Regional Health Information Sharing 14. What are the Current Models for Distance Services in Counseling and Other Disciplines? 15. Traditional Behavioral Telehealth Model 16. Traditional Behavioral Telehealth Model Hub-and-spoke model Only work with previously identified clients/patients who have had an in-person assessment Detailed and documented referral requests Detailed health record at fingertips of clinician Client/patient is at the originating site Clinician is at the distant site Community collaborator is available Client/patient is pre-trained by staff Technology is stable IT staff is available during entire time of connection to client/patient 17. Online Norm vs. Traditional Behavioral Telehealth (or Telemental Health) Traditional Online Therapy Mostly Email & Chat Anonymity Accept self-referral online Disclaim Responsibility w/ Website Disclaimers No Clear Channels for Mandated Reporting No Patient Records Traditional Behavioral Telehealth Video Verify clients/patients Rely on referrals from clinical offices Use informed consent processes/documentation Engage in mandated reporting Document as required by law 2014 18. Online Norm vs. Traditional Behavioral Telehealth (or Telemental Health) Traditional Online Therapy No Contact with Other Treating Clinicians No Authentication of Consumer / Professional No Emergency Backup Procedures Misunderstanding of Clinical Processes (suicide) Scant Research for Unsupervised Settings Traditional Telemental Health Obtain signed releases and collaborate Verify identify of both Consumer and Professional Establish emergency backup plan and personnel prior to delivering care 2014 19. Whats happening? OCPM: Online Clinical Practice Management 20. Disruptive Technology Disruptive technology is a term coined by Harvard Business School professor Clayton M. Christensen to describe a new technology that unexpectedly displaces an established technology. Betty Friedan 1963 book The Feminine Mystique Sought to have women be accepted in existing world Gloria Steinman Sought to transform society 21. Society for Technology & Behavioral Health Innovation, Implementation & Consultation COMMUNICATION & COMMUNICATION NETWORKS (e.g., Internet, Blogging, Social media; Cybernetics [e.g., Biosensing/ Feedback]; Social networking) COMPUTING METHODOLOGIES (e.g., Artificial Intelligence; Natural Lang. Processing; Robotics; User Computer Interfaces [e.g., Computer Vision Tracking, Haptic Interfaces]; Computer Simulations [e.g., Virtual Human Agents/Avatars & Environments]; Microcomputers; 3D Imaging; Software [e.g., Video Games] HEALTH IT & INFORMATICS (e.g., Big Data; Controlled Vocabs [e.g., ICD-10]; Decision Making & Support; Data Mining; Electronic Health and Personal Health Records; Electronic Data Privacy, Security and Integrity; Health Information Exchange; HITECH; Information Storage & Retrieval; Interoperability TELECOMMUNCATIONS (e.g., Electronic Mail; Telepsychology; Remote Sensing; Wireless, & Training Technology; Telephones [e.g., Mobile Phones, mHealth, Messaging]; Video Conferencing; Interactive Voice Response) Practice Science Education Public Interest OTHER TECHNOLOGIES (e.g., Biotechnology, Nanotechnology, Nanomedicine) 22. Benefits of Traditional Video-Based Telehealth* Increased client satisfaction Decreased travel time Decreased travel, child & elder-care costs Increased access to underserved populations Improved accessibility to specialists Reduced emergency care costs Faster decision-making time Increased productivity / decreased lost wages Improved operational efficiency Maheu, Pulier, Wilhelm, McMenamin & Brown-Connolly. (2004). The mental health professional and the new technologies. Erlbaum, New York. 23. The Is Video Teleconferencing (VTC) Effective? Yes Medicare & Medicaid required to pay Outcomes are relatively comparable, especially for follow-up care (intakes are still a matter of state law) Literature for specialty groups is sparser, but positive (pediatrics) Also effective for supervision Can improve some ways service is rendered See www.telehealth.ORG/bibliography BUT, traditional VTC isnt the same as Skype 24. Recent Supporting Research Godleski, Darkins & Peters reported in April of 2012 that hospital utilization in psychiatric populations at the Veterans Administration were decreased by an average of 25% since the use of telehealth. It is worthy of note, however, that: This study focused on clinic-based, high-speed videoconferencing and did not include any home telehealth encounters. Mental health patients were referred for telecare by clinicians. Typically, telemental health services were provided remotely at community-based outpatient clinics by mental health providers of all disciplines located at larger parent VA hospital facilities. Equipment consisted of either room or personal desktopvideoconferencing units transmitting at 384 kbps or greater. Godleski, L. Darkins, A. & Peters, J. Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 20062010. Psychiatric Servcies, 63(4). 383-385. 25. Recent Supporting Research Backhaus and colleagues (May, 2012) reported in their abstract of a meta-analysis that: 821 potential articles were identified, and 65 were selected for inclusion. The results indicate that VCP is feasible, has been used in a variety of therapeutic formats and with diverse populations, is generally associated with good user satisfaction, and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. Videoconferencing psychotherapy: A systematic review. Backhaus, Autumn; Agha, Zia; Maglione, Melissa L.; Repp, Andrea; Ross, Bridgett; Zuest, Danielle; Rice-Thorp, Natalie M.; Lohr, James; Thorp, Steven R. Psychological Services, Vol 9(2), May 2012, 111-131. doi: 10.1037/a0027924 26. SYNCHRONOUS TELEHEALTH TECHNOLOGIES IN PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS Janyce E. Osenbach, Ph.D., Karen M. OBrien, Ph.D., Matthew Mishkind, Ph.D., and Derek J. Smolenski, Ph.D., M.P.H. 2013 Meta-Analysis Comparing In-person and Synchronous Telehealth Modalities for Depression Published in DEPRESSION AND ANXIETY 00:110 (2013) 27. Primary Focus: Not the technology, but rather, the service we deliver (also allows for reimbursement) Nonetheless, Different Modalities Require Different Skill Sets In-person Text (email, chat, texting) Audio Video 28. Social Media 29. It is ethical to have a page on Facebook or a similar advertising page on Google+ ? 35 30. 9/21/2012 36 31. Social Media Is Not Private Anything you say, post, link to, comment on, upload, etc., can and may be used against you by your peers, colleagues, employer, potential employers, fellow members, and so on. APA http://www.apa.org/about/social-media-policy.aspx 37 32. OCPM Step 1: Professionals Self Care Boundaries Office hours Unplug Reputation management Community of like- minded pros 9/21/2012 38 33. All Existing Legal & Ethical Rules Apply 34. http://www.americantelemed.org/docs/default- source/standards/practice-guidelines-for-video-based-online- mental-health-services.pdf?sfvrsn=6 35. Boundaries of Competence 42 Multicultural Issues & Diversity 36. Multicultural /Multlingual Issues Issue Global nature of the Internet worldwide audiences Multicultural issues are quite visible in the document, but English as a second language issue are not mentioned Rarely mentioned anywhere How to measure? Search online for various instruments that might be valid for your population Look for English proficiency tests Free Easy to take Get to know the norms Spoken English is different from written English 37. In-Person Contact APA Telepsychology Guidelines: In addition, psychologists may consider some initial in-person contact with the client/patient to facilitate an active discussion on these issues and/or conduct the initial assessment. p11 38. Do you see well enough? Image Resolution ATA Guidelines Are you conducting an intake or follow-up? Most of the scientific literature described VTC as being used for follow-up care after a primary licensed professional does an intake. How can you compensate for being able to assess glassy eyes, tremors, gait disturbance, sweaty palms, body odor, other signs of poor hygiene or serious mental illness when no local professional is available? 39. ACA Code of Ethics (2005) A.12.c. Inappropriate Services When technology-assisted distance counseling services are deemed inappropriate by the counselor or client, counselors consider delivering services face to face. How do you decide whats appropriate? Copyright 2012 TeleMental Health Institute, Inc. All rights reserved. 9/21/2012 46 40. ATA Patient Appropriateness for videoconferencing- based Telemental Health To date, no studies have identified any patient subgroup that does not benefit from, or is harmed by, mental healthcare provided through remote videoconferencing. Recent large randomized controlled trials demonstrate effectiveness of telemental health with many smaller trials also supporting this conclusion. p9 41. Caution Consider Context Online Norm vs. Standard of Care No Contact with Other Treating Clinicians No Authentication of Consumer / Professional No Emergency Backup Procedures Misunderstanding of Clinical Processes (suicide) Operating w/o Needed Research for Unsupervised Settings 42. Caution Consider Context Online Norm vs. Standard of Care Mostly Email / Chat vs. Video Anonymity / No Patient Records Avoid Responsibility w/ Website Disclaimers No Clear Channels for Mandated Reporting 43. TMHI Client & Patient Selection Study the evidence base (research) People with almost all diagnostic symptoms have been treated with traditional telehealth Treatment to the home has not yet identified which groups are too risky Understand differences between treatment of individuals in 1 setting vs, another (hospital vs. car, park, bed etc.) Consider compliance problems 9/21/2012 50 44. Step 1: Training Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement OCPM: Online Clinical Practice Management 45. Who is Responsible if you make a referral to a long-trusted colleague who suddenly conducts distance counseling with a client you referred? what if the client suddenly decompensates and makes a suicide attempt? 46. Know the Practices of Your Colleagues Ask Keep them informed of your practices and rationales Suggest training when needed Document training suggestions when appropriate 47. Step 1: Training Step 2: Referrals Step 3: Client Education Step 4: Legal Issues Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement 48. Technical Issues Discuss the technical requirements with the patient prior to initiating treatment Consider the level of technology experience of the patient (train if needed) Have a back-up plan if the video connection is lost telephone -- landlines are best, but cell phones are better than nothing 49. Tech Check Tech check review potential technology and infrastructure issues prior to initiating the delivery of care adequacy of bandwidth (the rate of data transfer) reliability of telehealth equipment (computers, monitors, video cameras, audio equipment, etc.). loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement) 50. Explain technical aspects (camera position, lighting , audio, noise, clock, etc.) 51. What are the types of problems that clients / patients have reported when working with clinicians using videoconferencing? 52. Client/Patient Training Email /Texting/Telephone/Video Social networking social media policy File exchange Computer repair Clinical records Insurance Reports Lateness / Missed sessions Non-compliance/Avoidance 53. Clinicians have been reported: Eating Taking personal cell phone calls from family Burping without excusing themselves Picking teeth Combing hair Rocking incessantly in their seats Putting feet on the desk Taking a shirt off Mindlessly tapping the desk with objects Being half way off the screen 54. What should I do when someone enters a client's / patient's room during a call? 55. If someone enters the client/patient room: What would you do in your brick-and-mortar practice? Stop the session / resume control of the interaction Ask the client/patient to speak privately with you Obtain permission to continue Ask for an agenda Reschedule for another day/time 56. What should I do when someone enters my room during a call? 57. If someone enters your room: What would you do in your brick-and-mortar practice? Stop the session / resume control of the interaction Excuse yourself if it is an emergency and step out of the room Reschedule for another day/time 58. Why use initial protocols when videoconferencing? 59. Initial Protocols Educate client/patient about the need for routine opening protocols that might include: Your name and location, name of clinic, hospital, agency ? Client/patient name and location ? direct phone number for emergency services of todays location (tested?) Reason for meeting ? If anyone else is in the room or within earshot ? Are children cared for ? Any expected interruptions ? Door locked? Room scan? Scan your room with your camera and ask patient to do the same Anything else of note with your population? 60. Can I get paid for the time used in helping a client / patient set up and manage their equipment? 61. Paid Tech-Time? No payment for client/patient set-up time Facility fees are available on a per-session basis for Medicare and Medicaid services that are reimbursable See: Reimbursement Strategies Increasing Authorization and Payment (3 CEs/CMEs) 62. How do I handle technical issues created by my video teleconferencing (VTC) system during a call? 63. Tech Problems During a Call Practice before you work with clients/patients Relax trust your training Have an agreement with your client/patient that you will call each other using a designated telephone number Always have that phone number on hand when you conduct a session Have an agreement about who will call the other 64. What is a community champion and when is it appropriate to use one? 65. Community Champion Local collaborator can be helpful for: providing information about the patients history monitoring mood and behavior assisting with treatment planning and coordination coordination with local 911 service when needed provide an additional mechanism for contacting patients if a connection becomes lost provide on-site technical assistance provide support to a patient during emergency situations 66. Community Champion Educate your client/patient about use of a local collaborator such as a family member or close friend Enter name and contact information into informed consent document Stipulate under which conditions these people will be contacted Outline emergency procedures and when collaborator will be notified Clearly define expected roles and responsibilities of local collaborators/champions Encourage your client/patient to discuss their choice of champions directly, before you contact them 67. What are the must-dos for community champions and informed consent to minimize my risks? 68. Community Champion Assess when using a local collaborator may not be advisable: Safety of local collaborators must be carefully considered may be best to rely on trained 911 responders Be cognizant of potential deleterious effect of disclosures made during emergency management on patient confidentiality and relationships, especially in small communities 69. Step 1: Training Step 2: Referrals Step 3: Client Education Step 4: Legal Issues Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement 70. Dr. Trow vs. Oklahoma Medical Board Relevant law The case Skype Lessons to be learned 71. Full style: State of Oklahoma ex rel. Oklahoma Board of Medical Licensure and Supervision v. Thomas Edward Trow, M.D., License No. 10255, case No. 11-11- 4439 (Sept. 12, 2013) 72. "Physician/patient relationship in OK a relationship established when a physician agrees by direct or indirect contact with a patient to diagnose or treat any condition, illness or disability presented by a patient to that physician, whether or not such a presenting complaint is considered a disease by the general medical community. The physician/patient relationship shall include a medically appropriate, timely-scheduled, actual face-to-face encounter with the patient, subject to any supervisory responsibilities established elsewhere in these rules. (emphasis added) OAC 435:10-1-4 Does not say: in person 73. IC: OK Telemedicine Act, OAC 366804 A. Prior to the delivery of health care via telemedicine, the HCP who is in physical contact with the pt shall have the ultimate authority over the care of the pt and shall obtain IC from the pt. The IC procedure shall ensure that, at least, all the following info is given to the pt: 1. A statement that the individual retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which the individual would otherwise be entitled (emphasis added) 74. IC: OAC 366804, 2 2. A description of the potential risks, consequences, and benefits of telemedicine; 3. A statement that all existing confidentiality protections apply; 4. A statement that pt access to all medical info transmitted during a telemedicine interaction is guaranteed, and that copies of this info are available at stated costs, which shall not exceed the direct cost of providing the copies; and 5. A statement that dissemination to researchers or other entities or persons external to the patient- practitioner relationship of any patientidentifiable images or other patientidentifiable information from the telemedicine interaction shall not occur without the written consent of the patient (emphases added) 75. IC: OAC 366804, 3 B. The pt shall sign a written statement prior to the delivery of health care via telemedicine indicating that the pt understands the written info provided pursuant to subsection A of this section and that this info has been discussed with the HCP or [his] designee. C. If the pt is a minor or is incapacitated or mentally incompetent such that the pt is unable to give informed consent, the consent provisions of this section shall apply to the pts rep. The consent provisions of this section shall not apply in an emergency situation in which a pt is unable to give IC and the pt's rep is unavailable (emphases added) 76. IC: OAC 366804, 4 For purposes of the delivery of mental health care via telemedicine, the use of telemedicine shall be considered a facetoface, physical contact and inperson encounter between the health care provider and the patient, including the initial visit. Services provided by the Mental Health Dept.: initial evaluation may be virtual Mental health services provided by others: initial evaluation must be in-person Other forms of health care: initial evaluation must be in- person 77. Telemedicine for Mental Health (OK 2008 Policy) Telemedicine technology is limited to consultations, psychotherapy, psychiatric diagnostic interview examinations and testing, discharge planning and pharmacologic management. An interactive telecommunications system is required as a condition of the use of telemedicine. The following shall not be considered telemedicine: (1) Phone conversation (including text messaging) (2) Electronic mail message (3) Facsimile (fax) (4) Store and forward 78. Telemedicine for Mental Health (OK 2008 Policy), 2 The telemedicine equipment and transmission speed must be technically sufficient to support the service provided. If a peripheral diagnostic scope is required to assess the patient, it must provide adequate resolution and audio quality for decision making substantially equivalent to a facetoface encounter. Staff involved in the telemedicine visit need to be trained in the use of the telemedicine equipment and competent in its operation. (emphasis added) 79. Telemedicine for Mental Health (OK 2008 Policy), 3 The physician who has the ultimate responsibility for the care of the patient must obtain written consent from the patient, in accordance with state law, that states they agree to participate in telemedicine. The consent form must include a description of the risks, benefits and consequences of telemedicine and be included in the patients medical record Physicians providing mental health care services via telemedicine shall be held to the same standards of care as required in the medical community. Emphasis added 80. Trow: OSBMLS Telemedicine Guidelines Ok. medical practice act requires initial in-person visit before MD can prescribe Rx Exceptions: Emergencies DOs Interactive telecommunications system required TM network standards: all technical, confidentiality requirements under state and federal law Permissible telemedicine functions: Consultations Psychotherapy Psychiatric diagnostic interview exams and testing Discharge planning Pharmacologic management NOT TM: phone, email, fax, store-and-forward 81. Trow: Stipulated Facts Dr. Trow is an unemployed 65 yo pain management physician Orthopedic problems make travel difficult for him Used mail, fax, and phone from home RN often served as telepresenter at clinics Records kept there but not, as Oklahoma telemedicine guidelines require, at Trows home office 10/20/11: DO reported 3 pts getting large doses of Xanax 11/8/11: TL, daughter of deceased, addicted, 62 yo pt RC, complained Dr. Trow prescribed CDS for RC RC died of HBP and COPD No toxicology studies 82. Stipulated Facts, 2 8/17/12 Ok. HC Authority (OHCA) letter: No contract with OHCA Using unapproved equipment No informed consent Inability to produce 2 of 10 requested charts Overprescribing CDS Limited documentation; no physical exam Verbal orders not countersigned 3/13/13: OHCA reported D was 1) seeing Sooner Care patients via Skype and 2) writing for controlled substances without an in-person evaluation OHCA is the primary entity in the state of Oklahoma charged with controlling costs of state-purchased health care. SoonerCare: Oklahoma Medicaid 83. Stipulated Facts, 3 Dr. Trow caused NO patient deaths Dr. Trow billed OHCA for Skype services; not an approved telemedicine modality Trow did not see all pts, even by Skype. 11/9/12: OHCA letter #2: similar to 1; more detailed No initial contact with patients Inadequate records HIPAA violations Inadequate supervision of nurses Failing to heed drug screen results VOs 11/15/12: OHCA terminated SoonerCare 84. Procedural Posture Disciplinary matter, not a private (malpractice) claim ?Possible in future? Defendant pled guilty Waived right to full hearing D admitted violating OHCA telemedicine guidelines: improper equipment; no proper contracts Stated he thought those duties fell to his employer 85. Conclusions of Law: Unprofessional Conduct Dishonorable conduct likely to deceive or harm public Prescribing without Proper doctor-patient relationship; Adequate PE Overprescribing controlled substances No documentation of medical need Inadequate records 86. Consequences License suspended MD to take prescribing course No CDS prescribing until 1. Course completed 2. Dr. Trow meets with Board Secretary MD is on probation Reported to National Practitioner Data Bank 87. New Ok Definition: Face-to-Face Encounter by TM It is the position of the OSBMLS that the face- to-face encounter required by OAC 435:10-1- 4to establish a physician/patient relationship includes real-time telemedicine encounters with audio and video capability[T]o qualify as a face- to-face encounter set out in this definition, the telemedicine audio and video capability must meet those elements required by CMS. OSBMLS, 9/25/13, http://www.okmedicalboard.org/download/705/Tele medicine_PositionStatement.pdf 88. Oklahoma Law is In Flux November 7, 2013: Board held a public forum to discuss the use of telemedicine in Oklahoma Then, public comment First public comment period ran overtime; a special session may be needed to complete the process Then: legislature Finally, Governors office 89. What are the take- home lessons from the Trow case? 90. Take-Home Lessons Case reflects Oklahoma law only But Oklahoma is relatively telemedicine-friendly (SoonerCare views telemedicine no differently than an office visit or outpatient consultation.. OHCA Policies and Rules, 317:30-3-27, revised 7/1/13) Other states could do the same or worse Tort liability presumably remains possible Though wrongful death claims might be problematic Is Dr. Trow insured against this risk? Determine what establishing the physician-patient relationship requires in the relevant jurisdiction Is a virtual visit adequate? Be sure to perform the type of initial contact required by your state law for distance counseling 91. Take-Home Lessons (Cont.) Obtain and document informed consent In Oklahoma, must be in writing Check your states laws Maintain proper records Boards main focus was on excessive prescribing, not Skype per se Does Oklahoma forbid Skype for telemental health services? Nevertheless: Use Skype with caution, if at all No claim of HIPAA compliance Be especially cautious with controlled substances Potentially acceptable: hospice 92. FSMB, as of 8/12 10 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines 57 boards + DC Board require that TM physicians be licensed in the state in which the patient is located Minnesota allows physicians to practice TM if they are registered to practice TM or are registered to practice across state lines http://www.fsmb.org/pdf/grpol_telemedicine_licensure.p df. 93. Full Discussion The previous slides were from a webinar given 1/20/2014 through the TeleMental Health Institute. Guest speaker for that webinar and author of many of the previous set of slides is Joseph McMenamin, MD, JD, McMenamin Law Offices, Richmond Virginia 94. Specific Informed Consent Processes and Documentation 95. ACA Code of Ethics (2005) A.12.a. Benefits and Limitations Counselors inform clients of the benefits and limitations of using information technology applications in the counseling process and in business/ billing procedures. Such technologies include, but are not limited to, computer hardware and software, telephones, the World Wide Web, the Internet, online assessment instruments and other communication devices. 96. ACA Code of Ethics (2005) A.12.g. Technology and Informed Consent As part of the process of establishing informed consent, counselors do the following: 1. Address issues related to the difficulty of maintaining the confidentiality of electronically transmitted communications. 2. Inform clients of all colleagues, supervisors, and employees, such as Informational Technology (IT) administrators, who might have authorized or unauthorized access to electronic transmissions. 97. Verify with a Local Telehealth Attorney Use next suggestions, but I am not an attorney. Develop your document and verify with your own informed, local attorney Be aware that many association attorneys may not be yet adequately well-versed in telehealth issues A good expert should cost you from $500 - $800 to review your agreement 98. Informed Consent Represents a meeting of the minds Information is influenced by many factors, including Client/Patients capacity for absorbing information Time limits Clinicians schedule Subject matter is often complex and technical Clinician thinks she is speaking English Client/Patient may be under stress (or may assert so later) Mental illness Document only serves as important evidence 99. Informed Consent: Function of State Law Specific statutes govern informed consent in telehealth Whos state law controls? Solution: assume that the law of the client/patient residence will most likely be applied More conservative approach is to determine the law in both your and your client/patients state and follow the mandates of the more stringent law 100. TMHI Informed Consent Documentation Basics Date Diagnosis Outline of intervention Risks and benefits of each technology used Risks and benefits of competing approaches Including no service 101. TMHI Informed Consent Documentation Basics Emergency Resources and Plan including names and contact information for local, trusted person(s) to be contacted at the discretion of the clinician Document advantages and disadvantages of using technology Document evidence-base supporting counseling plan Document client preferences re: technology 102. TMHI Informed Consent Documentation Basics Confidentiality and limits thereof as related to mandated reporting (suicide, homicide, abuse) Fees, if any Statements* similar to: My questions have been answered to my satisfaction in language I understand As of the time of my signing, all blanks have been filled in Document method & procedures for data storage Document adherence to local and distant regulations * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed consent document. 103. TMHI Informed Consent Documentation Basics Some risks may not yet be unknown* No physical exam* Identify both the clinicians & clients/patients physical location Statements* such as: Professional will rely on information provided by the client/patient and by any on-site practitioners or other sources Potential problems could arise with electronic transmission in telepractice: distortion, delays, interceptions, interruptions Document all communications with client (written, audio, video or verbal) * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed consent document. 104. TMHI Informed Consent Documentation Basics Discuss the purpose of remote contact Inform clients of who will have access to their email address, phone number, or any other contact information Inform the client of who else might contact the client on your behalf Discuss multi-cultural and diversity issues 105. TMHI Informed Consent Documentation Basics Describe the specific roles of any consultant or local referring practitioner and who will have ultimate authority over the clients treatment Discuss whether client information will be stored in a computerized database Provide written procedures for various types of follow-up when client does not appear for remote consultation Time limit for non-response before collateral person will be contacted if professional is concerned 106. TMHI Informed Consent Documentation Basics Describe how deficiencies electronic equipment could possibly cause interference with diagnosis or treatment Make provision for non-receipt of email, delayed receipt, problems with servers, or unannounced changes in the schedule of email communications Mention how easily human error could lead to incorrectly delivered messages or other unforeseen events 107. TMHI Informed Consent Documentation Basics Document technical requirements with the client prior to initiating treatment Document preferences and level of technology experience of the client (train if needed) Agree upon alternatives if video or audio connections are lost telephone -- landlines are best, but cell phones are better than nothing 108. Emergencies Have a plan. Discuss carefully Write plan in your informed consent document Develop prior relationships with local community: Physician Family School personnel Other leaders (AA, religious?) Emergency response team Know community resources (hospitals, drug/alcohol treatment facilities, etc.) Know your local collaborators Know who and when to call for local assistance. Inform client of when you will contact local leaders, what you will tell them. Cover your termination procedure ( i.e., I will make 2 telephone calls, leave you 2 messages, send you a letter in surface mail with a copy to your physician.) 109. NBCC: Standards For Distance Professional Services NCCs shall carefully adhere to legal regulations before providing distance services. This review shall include legal regulations from the state in which the counselor is located as well as those from the recipients location. Given that NCCs may be offering distance services to individuals in different states at any one time, the NCC shall document relevant state regulations in the respective record(s). 110. NBCC: Standards For Distance Professional Services Boundaries of competence NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means. Are counselors competent to deliver traditional service in technical environments? Technical and clinical training may be needed. 111. Privacy, Confidentiality, Diversity Privacy & Confidentiality Understand your technology (email, texting, video) and its clinical repercussions related to privacy and technology Diversity Multi-cultural, multi- lingual, religious, LGBT, and other issues 112. Service to the Home Scientific evidence base for contact to the home is much thinner, less reliable than traditional telehealth Risk management is a serious concern Likelihood of lurkers, intruders or interruptions is increased Develop signs, code words or phrases to signal something is amiss 113. TMHI Clinical Competence Client Selection Study the evidence base (research) People with almost all diagnostic symptoms have been documented as successfully treated with traditional telehealth Clients experiencing severe anxiety, flagrantly psychotic symptoms or suicide/homicide intent may not be optimal choices while symptom patterns are exacerbated 114. TMHI Clinical Competence Client Selection Most of the studies mentioned above include the assistance of a local collaborator Treatment to the home has not yet identified full range of risk Understand differences when delivering care to clients in different settings (hospital vs. car, park, bed etc.) Establish procedures to minimize attendance & compliance issues 115. Levels of Security Interjurisdictional Licensure Issues 2014 116. 20/20: A Vision for the Future of Counseling 4) Creating a portability system for licensure will benefit counselors and strengthen the counseling profession. 117. Inter-jurisdictional Practice Licensing Boards that may assert jurisdiction: The one in the professionals state(s) of licensure The one in the client/clients state of location at time of call Both Safest Practice: Provide services only where licensed Require client to attest to his or her location on every call2014 118. Inter-jurisdictional Practice (cont.) Special telehealth and in many cases, telemedicine laws have led the way Prescription-writing initiatives led to development of laws in the 90s Reimbursement practices for Medicare 7 Medicaid 32 states now mandate in-person assessment prior to distance contact Special informed consent laws also rapidly evolving Regulatory Case Oklahoma case of Dr. Trow No in-person assessment No informed consent No HIPAA-compliant technology (he used Skype)2014 119. Licensure Requirements for Professional Counselors 2014 Whats New for 2014 (page 4) 120. Licensure Requirements for Professional Counselors 2014 Whats New for 2014 (page 4) 121. Special Telehealth Licenses or Certificates Licenses could allow an out of state provider to render services via technology in a foreign state, or it allows a clinician to provide services via telehealth into a state if certain conditions are met (such as agreeing that they will not open an office in that state.) http://www.fsmb.org/pdf/grpol_telemedicine_licen sure.pdf 122. States with Laws Mandating Private Insurance Coverage of Telemedicine 123. Special Telehealth Licenses or Certificates Alabama Louisiana Minnesota Montana Nevada http://www.fsmb.org/pdf/grpol_telemedicine _licensure.pdf New Mexico Ohio Oregon Tennessee Texas 124. Innovative Models National Council of State Boards of Nursing (NCSB) Federation of State Medical Boards (FSMB) Association of State and Provincial Psychology Boards (ASPPB) 125. Levels of Security Licensure Portability Legislation 2014 126. 2010 127. TELEmedicine for MEDicare Act, 2013 HR 3077, the TELE-MED Act was introduced Sept. 10 in the House by Reps. Devin Nunes, R-Calif., and Frank Pallone, D-N.J. Nicknamed the TELE-MED Act, seeks to update current licensure laws for Medicare beneficiaries, the number of whom is expected to rise to 81 million by 2030 128. TELEmedicine for MEDicare Act, 2013 In the case of a Medicare participating physician or practitioner who is licensed or otherwise legally authorized to provide a health care service in a State, such physician or practitioner may provide such a service as a telemedicine service to a Medicare beneficiary who is in a different State, and any requirement that such physician or practitioner obtain a comparable license or other comparable legal authorization from such different State with respect to the provision of such health care service by such physician or practitioner to such beneficiary shall not apply. If passed, the bill will give licensing or authorizing states enforcement powers and require the Secretary of the Department of Health & Human Services to solicit input from relevant stakeholders in order to provide telemedicine guidance for states. 129. Legal Suggestions Counsel each other & document those conversations Communicate often to your local, state and national professional associations let them know what you need Put information in writing Write to your malpractice carrier and describe your proposed service before investing too much time or $$ Check with an informed, local attorney who specializes in telehealth to verify that all aspects of your telepractice are in compliance with state law 130. Other Legal & Ethical Issues for Distance Counseling 131. Duty to Report / Duty to Warn (v) Failing to comply with the child abuse reporting requirements of Section 11166 of the Penal Code. (w) Failing to comply with the elder and adult dependent abuse reporting requirements of Section 15630 of the Welfare and Institutions Code. CA Business and Professions Code Sections 4989.54 (cont.) 132. Practical Application: Check on Technology Tech check review potential technology and infrastructure issues prior to initiating the delivery of care bandwidth (the rate of data transfer) reliability of equipment (computers, monitors, video cameras, audio equipment, etc.). loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement) 133. Opening Protocol* Identify yourself and your geographic location Ask your client/patient to do the same Audio/video check (e.g., Do you hear & see me clearly?) Is there anyone in your room or within ear-shot today? (Agree on safety code words, signals or phrases) Is there anything else I might notice and find of interest if I were in the same room with you today? Has there been an emergency in your environment today? Is there anything else I should know about before we begin talking today? * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed consent document. 134. Local Collaborators or Champions 135. Mention Other Safety Issues Have an addendum to your informed consent document Include social media policy statements* that fit your client population, such as: I will not friend you on Facebook or other social media sites I will not respond to you on sites such as Yelp * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed consent document. 136. Safety Issues to Consider Is there access to firearms in home-based care? Discuss firearm ownership, safety, and the culture of firearms Be prepared to negotiate firearm disposition with patients and consider involvement of family members when appropriate Use of trigger safety lock devices is an option 137. Safety Issues to Consider Assess potential technology and infrastructure issues prior to initiating the delivery of care adequacy of bandwidth (the rate of data transfer) reliability of telehealth equipment (computers, monitors, video cameras, audio equipment, etc.). loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement) 138. Safety Issues to Consider Identify and use of a local collaborator such as a family member or close friend of a patient Enter name and contact information into informed consent document Stipulate under which conditions these people will be contacted Outline emergency procedures and when collaborator will be notified Clearly define expected roles and responsibilities of local collaborators Consider discussing these issues with family members directly 139. Safety Issues to Consider Local collaborator can be helpful for: providing information about the patients history monitoring mood and behavior assisting with treatment planning and coordination coordination with local 911 service when needed provide an additional mechanism for contacting patients if a connection becomes lost provide on-site technical assistance provide support to a patient during emergency situations 140. Safety Issues to Consider Assess when using a local collaborator may not be advisable: Safety of local collaborators must be carefully considered may be best to rely on trained 911 responders Be cognizant of potential deleterious effect of disclosures made during emergency management on patient confidentiality and relationships, especially in small communities 141. Safety Issues to Consider Discuss the technical requirements with the patient prior to initiating treatment Consider the level of technology experience of the patient (train if needed) Have a back-up plan if the video connection is lost telephone -- landlines are best, but cell phones are better than nothing 142. Intake Summary Explain & sign informed consent document Conduct a formal intake no shortcuts Meet in-person or video, identify geographic location, organizational culture, take full history, medications and medical conditions, mental status and stability, use of substances stressors, treatment history, support system, use of other technology, suicide/homicide intent Identify psychological diagnosis Decide if, then which technology is appropriate / Assess technical competence / ability to arrange appropriate setting Obtain names of all other key providers, get appropriate releases Verify contact information (address, phone, email) Have emergency plan in writing 143. Telemental Health: HIPAA, HITECH & Your State Law OCPM: Online Clinical Practice Management 144. HIPAA Three Rules: Transmission Privacy Security Three HIPAA Rules: Transmission Privacy Security 145. HIPAA Privacy Rule Data are individually identifiable if they include any of the 18 types of identifiers, listed below, for an individual or for the individuals employer or family member, or if the provider or researcher is aware that the information could be used, either alone or in combination with other information, to identify an individual: 146. HIPAA Privacy Rule (cont.) 1. Name 2. Address (all geographic subdivisions smaller than state, including street address, city, county, zip code) 3. All elements (except years) of dates related to an individual (including birth date, admission date, discharge date, date of death and exact age if over 89) 4. Telephone numbers 5. Fax number 6. Email address 7. Social Security number 8. Medical record number 9. Health plan beneficiary number 10. Account number 11. Certificate/license number 12. Any vehicle or other device serial number 13. Device identifiers or serial numbers 14. Web URL 15. Internet Protocol (IP) address numbers 16. Finger or voice prints 17. Photographic images 18. Any other characteristic that could uniquely identify the individual 147. Email A 2009 study by the American Psychological Association showed that 9.8% of psychologists polled reported using email for clinical purposes with clients (Jacobsen & Kohout).* Is such use appropriate without training? * Jacobsen, T. & Kohout, J. (2010). 2008 APA Survey of Psychology Health Service Providers: Telepsychology, Medication and Collaboration. APA Center for Workforce Studies. 148. Email HIPPA Omnibus Act allows us to have email contact without meeting usual HIPAA standards when risks are fully disclosed in Be aware of inherent problems with soliciting email contact from websites and directories. 149. The HIPAA Compliant Email Companies 150. Current Surveys The Professional survey: ttp://tinyurl.com/kpnfh75 The Consumer survey: http://tinyurl.com/mb86oav Research team includes: Drs. Marlene Maheu,. Robert Glueckauf, Ken Drude, Eve-Lynn Nelson 151. Skype? 152. Skypes Most Recent Hacking November 2012 153. Is Skype Reliable? Skype tiles & pixelates, the audio gets tinny, echoes develop, and often calls drop entirely. Sometimes consumers can see you and hear you, without your awareness. 154. HIPAA requires an audit trail. Skype doesnt provide audit trails and isnt obligated to . 155. Skypes Privacy Policy Skype may gather and use info about you Identification data (e.g. name, username, address, telephone number, mobile number, email address) Electronic identification data (e.g. IP addresses, cookies) List of your contacts and related data Content of instant messaging communications, VMs, video messages Skype uses its own cookies for a variety of purposes, including to Provide internal and customer analytics and gain statistics and metrics about our websites Skypes analytics, ad-serving and affiliate partners may also set and access cookies on your computer Skype will take appropriate organizational and technical measures to protect the personal data and traffic data provided to it or collected by it with due observance of the applicable obligations and exceptions under the relevant legislation 156. Skype and Health Privacy AES 265-bit encryption Free Access to patients environment BUT Skype makes no claim that its services can be used in a HIPAA-compliant fashion Skype does not offer a BA Agreement Cannot verify transmission security No audit trails No breach notifications No offer of technical support Frequently dropped calls Emergencies? 157. OCPM Step 3 Legal Issues: Which Technologies to Use? No Guesswork Needed 158. Internet-based, VTC Companies Claiming HIPAA Compliance* Access Psychiatry Adobe Connect Behavior Imaging Solutions CopeToday Consult a Doctor Counsol.com EasyShare VC eCounseling E Mental Health Center Forefront Telecare GEMS GoToMeeting iCouch Interactive Care iTel IVE (cloud) Lifesize (Logitech) MDLive MyTherapyNet Revation Secure Telehealth SecureVideo.com (FREE) Shepell fgi Smart House Calls Soltrite Via3 VisHealth (Visual Telehealth) Vsee (FREE) VirtualTherapyConnect WeCounsel * TMH Institute has partnered with some of these companies and will receive a referral fee if you mention TMHI. You may also get an added discount. 159. What makes you a covered entity? 160. Use HIPAA compliant technologies and develop written processes Document policies Security & privacy policies Repairs Staff training Breach notification, etc. HIPAA Policies 161. HIPAA Final Rule January 17, 2013 Business associates of covered entities are directly liable for compliance with HIPAA Privacy and Security Rules requirements. Includes contractors, subcontractors and business service companies working for health care providers, (e.g., companies providing electronic health records software, teleconferencing, data back-up and storage, billing, transcription and other IT services). Raises the maximum penalty for data breaches from a previous cap of $250,000 to a maximum penalty is $1.5 million per violation. 162. HIPAA Final Rule Infrastructure, documentation, and procedures for information privacy and security, and data encryption and disposal will have to be evaluated and brought into compliance. Companies need to provide formal security training to all employees, designate a security official and implement appropriate business associate contracts with their own subcontractors. 163. HIPAA Final Rule When HIPAA was first passed in 1996, most health care practitioners, hospitals and insurance companies scurried to bring themselves into compliance with the new standards. In the face of these final rules, business associates will have to engage in the same process. HHS is stepping up enforcement efforts. See Federal Register available online at http://federalregister.gov/a/2013-01073, and on FDsys.gov 164. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved. All Business Associates in health care must sign an agreement stating their adherence to HIPAA standards Transactions Security Privacy True for any service you hire It is now enforced by the HITECH ACT HIPAA, Business Associates & HITECH 165. HITECH If aware of a potential breach of protected health information: Conduct risk assessment Mitigate breaches report them to affected clients, the federal government, and in some cases, the media 166. HITECH Implement or update privacy and security policies and procedures: Need policies to be written (a paragraph is ok) Staff education Breach procedures Consult your attorney 500 or more records notify media 167. HITECH Do not disclose treatment information to your clients health insurance carrier for they have paid out-of- pocket, unless the disclosure is required by law 168. HITECH Clients may ask for copies of their electronic health records in electronic form. For example, you cannot make a unilateral decision to download and print electronic records and send the printed version to a client who requests them. 169. HITECH Email Send PHI in unencrypted e- mail only if the client is advised of the risk and still requests use of email as a means of transmission 170. What are risks of sending unencrypted email? 171. HITECH There are additional new restrictions on marketing and sale of PHI, which should be included in counselors HIPAA policies and procedures and Notice of Privacy Practices if relevant. 172. HITECH Update your Notice of Privacy Practices: OCR and the Office of the National Coordinator for Health Information Technology released a Model Notice of Privacy Practices, get it here: http://www.hhs.gov/ocr/priv acy/hipaa/modelnotices.html 173. HITECH NPP Make available to existing clients on request Post on your website Display in a prominent location in your professional premises Provide copy to all new clients 174. HITECH Update Business Association Agreements (BAAs) Contractors & subcontractors Billing Data storage 175. HITECH Many states have their own privacy laws, which can be more stringent than federal law HIPAA & HITECH. Consider obtaining a legal review of your HIPAA policies, procedures and other documents by your local attorney. 176. Where can you get all the needed HIPAA forms? 177. Enforcement The most common types of covered entities required to take corrective action: Private Practices General Hospitals Outpatient Facilities Health Plans (group health plans and health insurance issuers) and Pharmacies http://www.hhs.gov/ocr/privacy/hipaa/enforcement/highlights/inde x.html 178. http://www.counseling.org/docs/ethics/aca-hipaa-hitech-9-23-13-compliance-date.pdf?sfvrsn=4 179. What about text messaging? 180. Privacy Cross-over Technologies Many people send text messages over Skype. Do they count? 181. Safety Tips Some large text- messaging system vendors marketing to health care professionals don't bother with HIPAA, and may leave you at risk. 182. Global Smart Messaging Suite How text messaging was utilized for reminders and an educational tool to ensure adherence to patient self-care behavior Results of the study showing positive outcomes in patients receiving text messages How AT&Ts Global Smart Messaging Suite can be applied to similar use cases for highly secure messaging 183. Other Platforms Engaging targeted audiences with text messaging has become a cost effective tool in health and wellness management. Utilizing encryption technology in support of HIPAA compliance allows PHI to be shared for maximizing the value of information to improve self-care behavior. 184. Safety Tips Most cell phones message are unencrypted. Encryption is required when transmitting any form of protected or Personal Health Information (PHI) via text messaging. Use an encryption program. 185. Remedy for Breaches Under HIPAA, when a device used for text messaging is lost, any text message about a clinical, billing or administrative exchange can be considered a breach of privacy, and a violation of that consumer's confidentiality. The compromised individual must be informed in writing. 186. Safety Tips The Australian Psychological Society advises against the use of slang and emoticons when communicating with clients and patients in text messages. 187. Safety Tips Download your text messages from your cell phone into your patient files. You can find software for this function online. 188. Safety Tips Be aware that you can text the wrong person in your address book with information that shouldn't be shared with unauthorized parties. 189. Safety Tips All text messages reside on your SIM card in your phone, even if you erase them from your visible message area. 190. Stolen Phone Safety SAFETY TIPS Password protect your phone as soon as you receive the device. Change your online and voicemail passwords often. Protect your service. Add a security passcode to your online account. Download device protection and privacy apps for your messaging or smartphone. Don't text - just drive! Learn how to back up your SIM card contacts. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved. 191. Empirical Guidance for Text Messaging? Where do you find research? http://telehealth.org/ Look at: funding sources meta-analyses Copyright 2012 TeleMental Health Institute, Inc. All rights reserved. 192. Security Suggestions Dont Download Any Clinical Data Authenticate Passwords to lock; passwords to access networks Biometric authentication is on the rise Use Antiviral and Malware programs CounterACT is a security control platform that automatically identifies what devices and users are on a network, controls access to the network, blocks threats, remediates security violations at endpoints, and measures compliance to an organization's security policies. 193. Step 1: Training Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement OCPM: Online Clinical Practice Management 194. http://www.counseling.org/docs/vistas/multiple-assessment-methods-and-sources-in-counseling-ethical-considerations.pdf?sfvrsn=4 195. Copyright 2009 TeleMental Health Institute, Inc. 215 215 196. 216 197. APA Ethics Standard 9: Assessment 9.02 Use of Assessments - research based, valid, reliable for populations tested 9.03 Informed Consent in Assessments 9.05 Test Construction use proper procedures 9.06 Interpreting Assessment Results 9.07 Assessment by Unqualified Persons 9.09 Test Scoring and Interpretation Services 9.10 Explaining Assessment Results 9.11 Maintaining Test Security 198. OCPM Step 5: Clinical Assessment Be aware of language limitations across distance Use English proficiency tests to measure language comprehension Written language Spoken language 218 199. Pros & Cons? 200. Private Pay Googles Helpouts Set your own rate by-the-minute Google takes 20% / You keep 80% 2. Offer your services for a flat-rate 45 minutes for $75 10 minutes for $20 Self-pay models will become more prevalent / Risk will increase Blog discussion: http://telehealth.org/blog/go ogle-steps-into-telemental- health/ 201. Step 1: Training Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement OCPM: Online Clinical Practice Management 202. Where to Get Reimbursement for Telemental Health? Contractual & Grants Direct Services Government Services US Department of Education Medicare Department of Corrections Medicaid (based on state) Department of Defense Veteran Health Administration Indian Health Service NIH, NIMH, SBIR, State Programs Bureau of Prisons in Department of Justice Private Foundations 203. Where to Get Reimbursement for Telemental Health? Private Pay / Fee for Service Private Insurance General These 16 states now mandate payment: California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, Oklahoma, Oregon, Texas & Vermont 13 more states are pending since Jan.1, 2013 Niche (smoking, drug/alcohol etc.) CPT code approval Boutique (high-end services, rich & famous) Self-help Apps 204. Access regular updates at: www.telehealth.org/mandated-states http://telehealth.org/mandated-states Keep informed by getting our newsletter: http://telehealth.org/newsletter-signup 205. OCPM Step 7: Reimbursement Medicare & Medicaid Reimbursement Psychiatrists, Psychologists and Social Workers but not counselors yet Action item for counselor advocates: work with Mike Thompsons office, located in CA) 206. 2014 Reimbursement Bill As part of the 2014 National Defense Authorization Act, service members transitioning into civilian life are eligible to receive 180 days of health insurance coverage for services provided through telehealth. Rep. Glenn Thompson (R-Pa.) pushed for the bill, specifically citing its importance in helping service members receive treatment for Post Traumatic Stress. "All too often, symptoms related to Post Traumatic Stress do not appear until eight to 10 months after deployment," Thompson said. https://www.govtrack.us/congress/bills/113/hr 1960/text (see section 704) 207. Medicare Billing and Reimbursement Limited to rural and Health provider Shortage Areas (HPSA) Modifiers: GT for interactive audio and video telecommunications system GQ for store-and-forward applications Failing to use appropriate modifier code may constitute Medicare fraud Debate about how to identify location of services Many billing services bill inapprorpriately 208. To download, go to this webpage: Telehealth.org /CPA2013 209. How and when are new services added to the growing list of reimbursable services? 210. Adding New CPT Codes CPT codes originate in the Office for Medicare and Medicaid Services (CMS) Annual call for data to support new codes Large professional associations such as the American Telemedicine Association help organize and submit data for new codes to CMS Decisions are published in the National Register every November 211. When is credentialing required for reimbursement and how is that best accomplished? 212. Credentialing Needed for payment by Medicare, Medicaid and 3rd party carriers Similar to being credentialed when we sign onto managed care companies The credentialing body examines and documents: Licensure Malpractice coverage History Specialty areas / required training Other areas as needed 213. Which 3rd party insurers are paying, and where? 214. 3rd Party Carriers Largest barrier is practitioner reluctance Most large groups are paying State-dependent No consistent data (Study by ATA just now in publication for sample across disciplines inconsistent patterns) Difficult to make predictions 215. Are rates for telemental health different from in- person care? 216. Rates Traditional telehealth: About the same as in-person care Private Pay Whatever the market will bear 217. Which CPT codes need to be used? 218. CPT Codes Medicare, Medicaid, and 3rd Party Payers Differ by Payer Contact your payers and ask them to send you their list of CPT codes for telemental health Get your information in writing 219. CPT Codes for TMH Individual psychiatric interview Individual psychotherapy Individual & group health & behavior assessment & intervention Neurobehavioral status examination Pharmacologic management Smoking cessation 220. Smoking Cessation and CPT codes CPT code 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) HCPCS code G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) HCPCS code G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes) http://archive.aweber.com/tmhinews/CDqmc/h/New_T elehealth_CPT_Code_Approved.htm 221. Centers for Medicare and Medicaid Services (CMS) G0396 and G0397 -- Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and brief intervention, 15 to 30 minutes and intervention greater than 30 minutes, respectively. G0442 -- Annual alcohol misuse screening, 15 minutes G0443 -- Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes 222. Centers for Medicare and Medicaid Services (CMS) G0444 -- Annual depression screening, 15 minutes G0445 -- High-intensity behavioral counseling to prevent sexually transmitted infections, face-to- face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semiannually, 30 minutes G0446 -- Annual, intensive behavioral therapy for cardiovascular disease, individual, 15 minutes G0447 -- Face-to-face behavioral counseling for obesity, 15 minutes 223. Distant vs. Originating Sites Distant Site where you are Originating Site where your client/patient is 224. TMH CPT Code Modifiers - GT Most insurance carriers will only reimburse GT coded services for telemental health Some dont require modifiers Always contact carrier to know rather than assume that you or your billing agent know how to proceed 225. CMS Eligible Providers Physicians Nurse practitioners (NP) Physician assistants (PA) Nurse midwives Clinical nurse specialists (CNS) Clinical psychologists (CP) Clinical social workers (CSW) (CPs and CSWs cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. Registered dietitians or nutrition professionals (notice that counselors are not included) 226. More Information 227. Which "location of service" category gets reimbursed most frequently? 228. Location of Service Speak with payer before billing Indicating the service was rendered in the home is likely to lead to payment rejection Service to the home has not yet been approved by many payers Indicating service was in your office may or may not lead to payment 229. What's a reasonable fee to request for telemental health? 230. Reasonable Fees Typically, fees for TMH are the same as in- person For CMS, can add $24 per session for facility fees Whatever the market will bear New Internet models such as Googles Helpouts 231. Are reimbursement rates discipline- specific in telemental health? 232. Fees Across Disciplines Disparities exist across disciplines with Medicare, Medicaid and 3rd Party Payers Psychiatry Psychology Counseling not yet covered Social work Behavior analysis not yet covered 233. Are reimbursement models relevant if I have a self-pay practice? 234. Self Pay Reimbursement Models are irrelevant Concierge services springing up Self pay practitioners are the most likely group to success in health care reform (Robert McGrath, TMH Summit: Health Care Reform: How to Get Paid) 235. Which telemental health practice models get paid the most? 236. TMH Practice Models Traditional hub-and-spoke models Servicing Health Care Shortage Areas (HPSAs) 237. Is telephone work reimbursable under new telemental health opportunities? 238. Telephone-based Models Dependent on state definitions of telehealth Contact your payer and ask how to bill for telephone Why bill accurately? Insurance fraud is considered a very serious offense In some states, insurance fraud is considered a criminal activity Being found guilty of insurance fraud can lead to the forfeiture of malpractice coverage 239. How is inter-state practice relevant to reimbursement? 240. Inter-state Practice & Reimbursement Most often, professional must be properly licensed in the geographic location of the client/patient at the time of contact to practice legally If practicing illegally, you may be committing insurance fraud Insurance fraud may lead to forfeiture of malpractice coverage the time of the contact 241. How is Health Care Reform changing the playing field for reimbursement in general? 242. Health Care Reform Most significant upheaval and reorganization of US healthcare system we are likely to see in our lifetimes Law was effective January of 2014 60 million new people will be eligible for US government-backed health care in the US No extra money 243. How is private industry and consumer demand impacting telemental health? 244. Private Industry & Consumer Demand Non-healthcare companies coming into the market with disruptive technologies Disruptive technology is a term coined by Harvard Business School professor Clayton M. Christensen to describe a new technology that unexpectedly displaces an established technology Can expect many more companies to jump in 245. Disruptive Technology Betty Friedan 1963 book The Feminine Mystique Sought to have women be accepted in existing world Gloria Steinman Sought to transform society 246. Private Industry & Consumer Demand Non-healthcare companies coming into the market with disruptive technologies Googles Helpouts Phone companies mHealth 5.6 billion people have cell phones 2 billion have internet connections 247. Evidence-based Models Where might you earn a legitimate income? 248. Schools 249. Childrens Hospitals 250. Specialty Schools & Services Special Needs Autism Residential Treatment Centers Drug & Alcohol Other 251. Rural Hospitals Rural Hospitals 252. Correctiona Facilities 253. Nursing Homes 254. Home Health 255. Employers 256. Migration ModelMilitary & Veterans Administration 257. Private Companies Serving Consumers Online* CopeToday MDLive SecureVideo VirtualTherapyConnect WeCounsel * TMH Institute has partnered with some of these companies and will receive a referral fee if you mention TMHI. You may also get an added discount. 258. Migration Model Start with your current clients Select those who are reliable, have good support systems and with whom you have a good working relationship Consider their diagnosis Take the time to prepare them Plan in-person sessions at regular intervals Do not work through their secretaries or others 259. Professional Training Clinical Competencies Department of Defense (DoD) Ohio Psychology Board Professional Associations Society for Technology & Behavioral Health TeleMental Health Institute Technical Competencies Association for Counselor Education and Supervision (ACES) 260. ACES Technical Competencies Technical Competencies For Counselor Education: Recommended Guidelines For Program Development (2007) http://files.acesonline.n et/doc/2007_aces_tech nology_competencies.p df 261. TeleSupervision http://telehealth.org/ica 262. mHealth OCPM: Online Clinical Practice Management 263. Todays teens use media an average of: 10 hours and 45 minutes every day 7 days per week* *Kaiser Family Foundation, 2010 264. Selecting Smartphone Apps Empirical support for theory Empirical support for app Utility User ratings Peer review Blogs Ease of Use Confidentiality / Security 265. Future? OCPM: Online Clinical Practice Management 266. Health & Behavioral Care in 20 Years Mobile devices and peripherals will deliver most health and mental health care Sensor-based information gathering Mirrors, scales, vests, chairs, mattresses, steering wheels, exercise equipment, etc. Self-report 267. Health & Behavioral Care in 20 Years Mobile devices will be networked into central database that will correlate all real-time data with your genetic profile: as reported by you, family members, friends and neighbors who share your environment; and demographics of people who share your habits, lifestyle, and personal preferences for food, drink, exercise; medical conditions and medication; combined with latest empirical evidence about each source 268. Health & Behavioral Care in 20 Years Data will be complied into recommendations that will deliver medications, foods other ingestible substances and behavioral prescriptions in ways that will help remedy diseases and problems before they can even be noticed now. 269. Remote Monitoring Technologies Over the next 25 years, remote monitoring technologies are projected to save nearly $200 billion in the US, particularly by managing chronic diseases: reduce costs for caring for the elderly in rural areas by 25 percent 62.7 % of polled hospital personnel reported increased productivity for mobile clinicians and staff 38% reported productivity gains of 5% to 20%, and 10% reported productivity gains of 45 to 60 % http://www.brookings.edu/~/media/research/files/papers/2012/5/22% 20mobile%20health%20west/22%20mobile%20health%20west.pdf. 270. Step 1: Training Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement OCPM: Online Clinical Practice Management 271. Learning Objectives 1. Describe 3 ethical dilemmas related to Skype, Google and Facebook, blogging and the ethical codes that help practitioners think through those dilemmas. 2. Discuss the legal issues related to practicing over state lines or international borders, HIPAA and informed consent when practicing online. 3. Outline 3 key elements of a risk management plan for working online with clients to deliver care. 272. Exercise: If we have time OCPM: Online Clinical Practice Management 273. The American Red Cross reports that on average, 30 40 percent of people who are direct victims of the disaster experience one or more mental health disorders after the event, such as PTSD, depression and anxiety. In disasters that directly affect thousands, local and community mental health resources could not conceivably accommodate an increased treatment demand of this magnitude. American Red Cross (2012). Disaster Mental Health Handbook: Disaster Services. Disasters & Mental Health 274. Distance Counseling Summary Exercise 275. Lac Megantic, Quebec Photo by Simon Villeneuve used under Creative Commons license 276. July 6, 2013 277. Image printed in BBC News, US & Canada, July 10, 2013 278. Photo printed in BBC News, US & Canada, July 10, 2013 279. What if you were the 3 year-old child witnessing this disaster? 280. What if you were a five year old in this resort village? 281. What if you were a grade school child in this disaster? 282. What if you were a teen in this disaster? 283. What if you were parents of a young family in this disaster? 284. What if you were an elderly person in a nursing home in this disaster? 285. What if you were waiting for fire fighters to find your missing loved one? 286. What if you were a fire fighter in this disaster? 287. Levels of Security Resources 2014 288. Get Expert Advice Consultation from topic experts in telehealth Professional Training Also seek the aid of an experienced billing professional and/or accountant if you have any financial questions 289. TMHI News http://telehealth.org/sign-up/ 290. To Keep Up To Date TMHI faculty blog about these issues from a mental health perspective as the news breaks Options: Visit Blog at www.telehealth.org/blog Receive RSS feed You can also receive free weekly newsletter that gets sent to your in-box: http://telehealth.org/sign-up/ 291. References Biba, E. (2005, February 17). Lost your cell phone? Call a cab! PC World. Retrieved June 26, 2010 from http://www.pcworld.com/printable/article/id,119702/printable.html Borland, John. Breaking GSM with a $15 Phone Plus Smarts. Wired, December 28, 2010. www.wired.com/threatlevel/2010/12/breaking-gsm- with-a-15-phone-plus-smarts. Cellular Telecommunications and Internet Association (CTIA). (2010). US wireless quick facts. Retrieved June 26, 2010 from http://www.ctia.org/advocacy/research/index.cfm/AID/10323 comScore. comScore Reports October 2011 U.S. Mobile Subscriber Market Share. Press release. December 2, 2011. www.comscore.com/Press_Events/Press_Releases/ 2011/12. 292. References Connell, M., Drogin, E., Foote, W., & Sturm, C. (2010). The American Psychological Associations Revised Record Keeping Guidelines: Implications for the Practitioner. Professional Psychology: Research and Practice, 41(3), 236-243. Dolan, P.L. (2010, February 22). Data security breaches often triggered by carelessness. American Medical News. Retrieved June 26, 2010 from http://www.ama-assn.org/amednews/2010/02/22/bil20222.htm Greene, Adam H. HIPAA Compliance for Clinician Texting. Journal of AHIMA 83, no.4 (April 2012): 34-36. Gross, B. (2009, August 18). Mobile liability. Annals of the American Psychotherapy Association. Retrieved June 24, 2010 from http://www.annalsofpsychotherapy.com/articles/news/30/15/Mobile- Liabilit... HIPAA, Public Law 104-191, 45 CFR 164.524, 164.526. 293. References HIPAA, 45 CFR 164.501. Ponemon, L. (2009). Fourth annual US cost of data breach study: Benchmark study of companies. Traverse City, MI: Ponemon Institute. Retrieved June 26, 2010 from http://www.ponemon.org/local/upload/fckjail/generalcontent/18/file/Cos t%. Office for Civil Rights. Guidance on Risk Analysis. Office for Civil Rights. Are the following entities considered 'business associates' under the HIPAA Privacy Rule: US Postal Service, United Parcel Service, delivery truck line employees and/or their management. March 14, 2006. www.hhs.gov/ocr/privacy/hipaa/faq/business_associates/245.html. 294. References Office for Civil Rights, US Department of Health and Human Services. Guidance on Risk Analysis. July 14, 2010. www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/rafinalguidan cepdf.pdf. SMS. Wikipedia. http://en.wikipedia.org/wiki/SMS#Vulnerabilities. TigerText. "Physician and Hospital Texting Is on the Rise." Press release. October 12, 2011. www.tigertext.com/physician-texting-on-rise. 295. Questions? Marlene M. Maheu, Ph.D. TeleMental Health Institute, Inc. Phone: 619-255-2788 Email: mmaheu@telehealth.ORG