The Explosion of Psychotherapy on the Net: Opportunities Challenges

1. The Explosion of Psychotherapy on the Net: Opportunities & Challenges Behavioral HealthCare Tomorrow Conference: 2000 Marlene M. Maheu, Ph.D.

2. Opportunities: Harvard Colloquium on E-Health (August 2000) 1. Healthcare in this country is broken. 2. The Internet is transforming healthcare. 3. The healthcare industry is an Internet laggard. 4. Physicians are avoiding the Internet because, as of now, it simply does not save them time or money, and only marginally helps them be better doctors.

3. Internet Population 332.73 million users worldwide (NUA, July, 2000) Average US female user is white, 45 to 54, has children, and earns $75,000+ (NUA, May, 2000) Digital Divide For the first time women comprised the majority 50.8% of US Internet users in May (NUA, July, 2000)

4. Behavioral Telehealth Already, 20% of all telehealth services currently delivered are related to mental health. Videoconferencing is the technology of choice. A minimum of 15 frames per second is the speed that seems to be the standard of care across programs.

5. 40 Years - Behavioral Telehealth Experience Behavioral health care accounted for about 18 percent of all telemedicine consultations in the United States (Allen & Grigsby, 1998). In 1999, the Association of Telemedicine Service Providers surveyed 132 telehealth programs and found that 42 percent involved mental health services (Grigsby & Brown, 2000). Behavioral telehealth the fastest-growing area of telehealth (Dena Puskin, 2000).� 

6. 40 Years - Behavioral Telehealth Experience Services are currently offered in a number of contexts, including hospitals, community mental health centers, nursing homes, home health care, schools, and jails (Gibson, 2000; McCarthy, Kulakowski, & Kenfield, 1994; Oberkirch, 2000; Smith, 1998; Stamm, 1998; Stamm & Pearce, 1995; Whitten, Cook, Shaw, Ermer, & Goodwin, 1999; Whitten, Zaylor, & Kingsley, 2000; Zaylor, 2000). 

7. Patient Care - Videoconferencing Adding video gives access to cues we�ve been trained to identify in diagnosing & treating patients. The range of mental health services using video in telemedicine and telehealth is thereby limitless and includes all of the same services that can be provided in person (Smith & Allison, 1998).

8. Traditional Telemental Health(Smith & Allison, 1998) Services Include: Patient Evaluation Case Management Medication Management Crisis Response Pre-admission & Pre-discharge Planning Treatment Planning Individual Therapy Group Therapy Family Therapy Mental Status Examinations Court Commitment Hearings Case Conferences Family Visits Family & Consumer Support Groups Staff Training Administrative Activities Collateral Services: Vocational Rehabilitation Social Services Healthcare

9. Patient Care - Videoconferencing Videoconferencing has bee the technology of choice for telehealth and telemedicine programs since 1959. Videoconferencing has become synonymous with telehealth and telemedicine in the scientific literature, despite the proven effectiveness of the telephone - which has not been widely accepted by patients or professionals as a primary vehicle for healthcare delivery.

10. Patient Care - Videoconferencing Insurance reimbursement for videoconferencing is already mandated by some state laws. 1999 Federal Budget to cover services by interactive video delivered to Medicare patients. Legislation related to reimbursement also seems to favor the use of videoconferencing as compared to other telecommunications methods (California Telemedicine Development Act, 1996; Telehealth Improvement and Modernization Act of 2000).

11. Patient Benefits Telemental Health Report (Smith & Allison, 1998) High patient satisfaction ratings Reduced sick days from work/shortened recovery periods Convenience > reliance on self-help and support groups Lower program costs Increased medical cost offset Continuity of care

12. Behavioral E-Health: Psychotherapy on the Net Movement of telemedicine and telehealth to the Internet The majority of behavioral and mental health professionals are very reluctant to change their therapeutic relationships by using the Internet. A pace-and-lead approach is most reasonable. Media coverage is raising interest in the professional community, but research findings are difficult to locate. See <www.telehealth.net> for research and links related to behavioral e-health & telehealth.

13. Types of Web Services Offered Psychoeducation Referrals Self-help (CBT, EBT) Self-monitoring Assessment/Diagnosis Psychotherapy, counseling coaching or advice-giving Interactive Chat Interactive Video Follow-up (med checks) Consultation

14. Behavioral E-Health Websites Lifescape Epotec BeBetter RealTimeTherapy Goto-Md Here2Listen HelpHorizons OptimumCare CyberAnalysis NetCounselors SelfhelpMagazine CopewithLife MasteringStress NicotineFreedom.com ConcernedCounseling MyMindandBody DrJoyceBrothers WebofCare Lifehelpers PNOnline Mytherapy NetAddiction

15. Challenges: Practical, Legal & Ethical Issues Funding Providers: recruitment & training Licensure for Practice Interstate Practice Definitions of Tx HIPAA Telehealth Improvement & Modernization Act Standards, guidelines, & ethics of information and services

16. State Definitions of Practice The statute defining the practice of psychology in California states: The application of such principles and methods includes, but is not restricted to: diagnosis, prevention, treatment and amelioration of psychological problems and emotional and mental disorders of individuals and groups. Psychotherapy within the meaning of this chapter is the use of psychological methods in a professional relationship to assist a person or persons to acquire greater human effectiveness or to modify feelings, conditions, attitudes and behavior which are emotionally, intellectually or socially ineffectual or maladjustive.� Cal. Bus. & Prof. Code � 2903.

17. Professional Licensure Licensed professionals need to identify their licensure regardless of the professional service offered. For example, the California Medical Board has taken the position that any person: �who practices or attempts to practice, or who advertises or holds himself out as practicing any system or mode of treating the sick or afflicted in this state, or diagnoses, treats, operates for, or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury or other physical or mental condition of any person, without having at the time of doing so a valid, unrevoked, or unsuspended certificate. . . is guilty of a misdemeanor.� California Business & Professions Code Section 2052

18. Interstate Practice The Federation of State Medical Boards has published �A Model Act to Regulate the Practice of Medicine Across State Lines.� Section II (Definition) of the Model Act states: �It is important to view the practice of medicine as occurring in the location of the patient in order that the full resources of the state would be available for the protection of that patient. The same standard of care, already in existence in the patient�s home state, would be required of all individuals practicing medicine within that jurisdiction�.� Interstate Nurse Licensure Compact

19. State Definitions of Practice (cont.) The statute defining the practice of clinical social work in California states: Psychotherapy, within the meaning of this chapter, is the use of psychosocial methods within a professional relationship, to assist the person or persons to achieve a better psychosocial adaptation, to acquire greater human realization of psychosocial potential and adaptation, to modify internal and external conditions which affect individuals, groups, or communities in respect to behavior, emotions, and thinking, in respect to their intrapersonal and interpersonal processes.� Cal. Bus. & Prof. Code � 4996.9.

20. State Definitions of Practice (cont.) The practice of marriage, family and child counseling is defined in California as: �that service performed with individuals, couples or groups wherein interpersonal relationships are examined for the purpose of achieving more adequate, satisfying, and productive marriage and family adjustments�.� Cal. Bus. & Prof. Code � 4980.02.

21. Health Insurance Portability & Accountability Act of 1996 Sets legal, regulatory and standards environment for compliance Transmission of patient information Privacy, security and confidentiality procedures and practices

22. Telehealth Improvement and Modernization Act of 2000 Senate Bill 2505 by Senator Jeffords (VT) Modifies provisions related to telehealth in the Balanced Budget Act of 1997. Services provided to seniors Expands Medicare reimbursement coverage The bill also expands the geographical areas which qualify for the extended coverage Allows direct consultation without a telepresenter Whitten research

23. Traditional Steps forManaging Risk Obtain required licensure. Obtain liability insurance for all states of practice. Limit services to areas of licensure & competence. Cultural Competence Linguistic Competence Identify court definitions of malpractice in your area.

24. Traditional Steps forManaging Risk Identify community standards. Identify and follow treatment and practice guidelines for your profession. Conduct scientific research before offering services to the public.

25. Traditional Steps forManaging Risk Define at-risk populations and provide specialized services as needed (backup and emergency). Document consultation and specialized clinical training. Identify requirements for patient consent agreements in every state of practice. Requirements may vary among states. Developing thorough patient consent agreement. Discuss the patient consent agreement with patients both verbally and in writing.

26. Efficacy of Website Disclaimers There is a lack of research showing the efficacy of website disclaimers for any purpose with mentally ill patients. To use website disclaimers as patient consent agreements may not be adequate. Patient consent agreements are best explained both verbally and in writing to patients before treatment.

27. Patient Consent Agreement In addition to your standard patient consent agreement, consider adding these phrases to your document: �Procedures used are outside the standard of care.� �Procedures used are not validated by research.� Describe the specific equipment and services. Describe the limits of confidentiality. Be sure to discuss how breeches in confidentiality may be difficult to remedy.

28. Patient Consent Agreement Describe how services via specific technologies differ from f2f services. Detail the risks and benefits, the positive and negative consequences of engaging in services through technology.

29. Consent Agreement Discuss the purpose of remote contact. Inform patients of who will have access to their email address, phone number, or any other contact information. Inform the patient of who else might contact the patient on your behalf.

30. Consent Agreement Describe the specific roles of any consultant or local referring practitioner and who will have ultimate authority over the patient�s treatment. Discuss whether patient information will be stored in a computerized database. Discuss issues of jurisdiction. Provide written procedures for various types of follow-up when patient does not appear for remote consultation.

31. Consent Agreement 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.

32. Patient Consent Agreement Allow patients to prohibit use of identifiable images or information by researchers or other, unidentified entities. Allow patients the opportunity to prohibit identifiable medical information or images from appearing in any electronic medium. For more information, see: TelehealthNet: <http://telehealth.net/articles/consent.html> AMA: <http://www.ama-ssn.org/physlegl/legal/infcons.htm>

33. Email Contact National Professional Associations AMIA AMA Counselors (NBCC) Private Internet Groups HON Code Internet Healthcare Coalition

34. Ethics of Psychotherapy via Email or Chat room Lack of professional training Challenge to defend in court Lack of precedents Lack of research Lack of support by NIMH Chat rooms seem to pull for impulsivity

35. AMA Guidelines for Patient-Physician Email Drawn from article published by Beverly Kane, MD, and Daniel A. Sands, MD, in the Journal of the American Medical Informatics Association, the AMA House of Delegates adopted guidelines that recognize that e-mail "can aid the health care delivery process by allowing written follow-up instructions, test results and dissemination of educational materials for patients, as well as a means for patients to easily reach their physician on routine health matters," but at the same time, "issues of privacy, confidentiality and security must be addressed to ensure the efficacy and effectiveness of e-mail" (American Medical News, July 10/17, 2000).

36. AMA Guidelines for Patient-Physician Email Communication guidelines: Establish turnaround time for messages. Inform patients about privacy issues. Establish types of transactions and sensitivity of subject matter permitted over e-mail. Configure automatic reply to acknowledge receipt of messages. Print all messages, with replies and confirmation of receipt, and place in patient's paper chart. Develop archival and retrieval mechanisms. Maintain a mailing list of patients, but do not send group mailings where recipients are visible to each other. Use blind copy feature in software.

37. AMA Guidelines for Patient-Physician Email Communication guidelines (cont.): Avoid anger, sarcasm, harsh criticism and libelous references to third parties in messages. Medicolegal and administrative guidelines: Develop a patient-clinician agreement for informed consent for the use of e-mail. This should be discussed with the patient and documented in the medical record. Perform at least weekly backups of e-mail onto long-term storage. Commit policy decisions to writing and electronic form. 

38. Ethics - Worldwide Diversity Cultural limitations Tendency for professionals to forget Need better training When/how professionals ought to respond or not to respond, but use telephone instead