Telehealth: Ethical and Legal Practice

The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of the continuing education unit provider or the licensing board. Table of Contents

Foreword: Sources and Approach to this Course

Introduction

1. Is Telehealth Effective? Who is it For?
2. Increasing Pressure to Adopt
3. Defining Telehealth and E-Therapy
4. Electronic Communications Services and their Security Issues
5. Additional Risk Factors: Human and Automated
6. Categories of Electronic Communications
7. The Functions of Tele-Mental Health
8. Ethical, Legal, and Regulatory Issues
9. Special Focus: Administrative Issues
Appendix 1. Ethical Framework for the Use of Technology in Mental Health (Online Therapy Institute)
Appendix 2. Generic Private Practice Policies for Tele-Mental Health
Appendix 3. HHS Material on Cultural Competence
Appendix 4. California Board of Psychology: Information on Telepsychology
Appendix 5. APA Statement on Services by Telephone, Teleconferencing, and Internet (1997, Superseded, not in use)
Appendix 6. California Business and Professions Code Section 2290.5 (As revised by the Telehealth Advancement Act of 2011)
Appendix 7. Resources
Citations

Foreword: Sources and Approach to this Course

This program has been developed from diverse sources, including major national telehealth and other clinical organizations, clinical, technical, and legal experts, federal and state legislation, government documents, and peer-reviewed journals. It is designed to be of use to practicing clinicians that may not have a great deal of knowledge about computer technology. Its foundation is the needs that give rise to the use of telehealth, such as those that arise in under-served populations. In addition to practical fundamentals, it includes information as to cutting-edge innovations in technology and society that help put current telehealth developments and opportunities. into perspective. Every effort has been made to produce a balanced course that recognizes that this is a relatively new area in which legislation, case law, and clinical efforts are under development and subject to change.

Introduction - Top

The reader is by now well aware that diverse and widespread electronic communication is pervasive, affecting many areas of our lives. Media such as instant messaging (IM), email, and telecommunications ranging from hard line phones to the audio-video capacities of Skype have replaced face-to-face meetings and dramatically increased the type and volume of data that we can manage. We engage in personal and business communication for working from home, doing banking, shopping, and many other activities. And those are merely some of the more commonplace expressions of the new electronic world of communication.

Taken for granted: Electronic communication is so well embedded into our lives, that we may not always realize that it can be characterized as electronic communication, and that as such, it is pioneering in the sense that the rules for ethical and legal electronic activities are new and rapidly evolving. Media reports of controversies over privacy, government intrusion, and even the role of virtual communities and communication in crime, terrorism, and democratic revolution remind us of the unsettled nature of this domain.

This unsettled nature requires mental health professionals to develop policies and be aware of changes to the landscape in order to provide quality care and avoid unnecessary criminal or civil liability. Our increasing comfort or even nonchalance with electronic communication, including telehealth activities, can make us vulnerable to legal and ethical problems.

The need for caution: We may be tempted to compare the current state of electronic communication to the use of the telephone, saying that such media only amount to an added convenience. However, the issues covered in this course will show that there must be a systematic consideration of the issues. That mental health services are behind medicine in systematically implementing these new media makes this all the more of a concern.

There has already been a dramatic surge in the use of electronic communications by mental health professionals and organizations. There is ample reason to believe mental health services and administration will make increasing use of electronic communication methods in the coming years.

Incentives for adoption: There are many incentives for adopting electronic communications in mental health. They range from business needs and public perceptions or expectations, to the need to reach populations that have been under-served and that can benefit from these new media. A potentially negative influence is the desire to save costs, as this could incentivize substandard care. Fortunately, there are numerous examples of appropriate and successful deployment of telehealth media, with surveys of clients producing positive results. The U.S. military has been an early adopter and has documented such results. (Folen, Jones, Stetz, Edmonds, & Carlson, 2010)

There is also the matter of integration of electronic communications with additional electronic features that enhance services and management. These include the orchestration of media to enhance therapy, somewhat like bibliotherapy; the prescription of reading to augment therapy that began long before the advent of the personal computer. Among the more advanced versions of this are computer-assisted therapy modes. These include using virtual worlds for desensitization in PTSD and for behavior rehearsal in Asperger's syndrome.

During this course, we will cover a number of modern manifestations of telehealth and e-therapy technology and the media that have come to be so pervasive.

Convergence: We are witnessing the convergence of technologies and innovations that have been more or less separate. The melding of some features has become so familiar that we may not think of them as constituting convergence. There is every reason to believe that convergence will continue in useful and fascinating ways. Consider these technologies that have merged, at least to some degree, and are likely to serve us in current and new forms in mental health practice: Mobile devices, automation, recorded media, interactivity, game technology, digital communication methods, massive data aggregation, sensing technology, and, of course, human delivery of mental health interventions.

What's now: This convergence will require much development of law, ethical guidelines, technological standards, research, and practical experience before there a consensus on standards of care for a familiar set of practices and tools in tele-mental health. Pending that, this course relies upon applying existing, accepted ethical guidelines and law to current and emerging scenarios of tele-mental health practice, expert recommendations, and successful application of telehealth media that are taking place in diverse arenas.

1. Is Telehealth Effective? Who is it For?

Yes: In a word, yes. But for whom, under what circumstances, with what policies and technologies, for what diagnoses, and with what kind of providers and systems? A great deal of research attention is being brought to bear on these questions. Research and successful utilization are confirming that telehealth can benefit many clinical populations.

Confidence: Enough research and surveys have been conducted to give us confidence that telehealth, including e-therapy can provide high client satisfaction as well as good clinical outcomes. (Taylor, Symonette, & Singleton, 2009) The first large metastudy considered all (92) studies done up to March, 2006. They found that telehealth was as effective as live therapy for a range of problems. (Barak et al., 2008).

It will be years before there is a well-fleshed-out list of conditions that are proven to respond well to therapy through telehealth media. The landscape will be further complicated by the amount of change in what constitutes therapy. This is because of the integration of interactive and automated media. There is already an array of iPad and computer applications for clients and therapists that range from basic self-help functions to complex treatment, diagnostic, and record-keeping aids.

Specific diagnoses and issues: The state of research on tele-mental health and the more typical e-therapy applications of video conferencing is very promising, though much of it tells us that more research is needed (i.e., replication, larger populations). Reporting on a metastudy on tele-mental health (including telephone, video conferencing, and other Internet interventions), Hailey, Roine, and Ohinmaa (2008) state that they "identified 72 publications on telemental health (TMH) that reported clinical or administrative outcomes. Of these, 65 papers described clinical studies and 32 (49 percent) were judged to be of high or good quality." Research on video conferencing interventions suffered from less quality.

The authors reported promising results for specific problems: "There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorder, substance abuse, eating disorders and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. The majority of the papers (82 percent) were judged to warrant further study indicating a continued need for good-quality studies on the use of TMH in routine care."

Telehealth modalities: Despite concerns about quality of studies voiced by the paper's authors, an earlier study which was the first large metastudy came to conclusions that give us some ideas about effectiveness of telehealth modalities. The metastudy considered all (92) studies done up to March, 2006. They found that telehealth was as effective as face-to-face therapy for a range of problems. (Barak et al., 2008). 14 of the studies directly compared the two approaches, allowing analysis of their results as well as the overall corpus of studies. Theoretical orientations used in telehealth interventions were primarily CBT, psychoeducation, and behavioral.

Let's turn to a comparison of media that were examined other than direct interaction with a therapist. Web-based therapies that used interactive sites were more effective than those using static sites. (Interactive sites have enough automation to allow the client to interact with the site, such as taking a quiz. Static sites have information and images, possibly video, that are not automated for interaction other than actions such as clicking on links.) Closed sites showed more effect than open sites. ("Closed" referring to sites that requires registration for access to content and features.) This may be because of more active filtering and assessment to ensure a fit for the treatment, because of higher quality interaction in forums (discussion areas), or greater commitment on the part of clients.

Asynchronous sites were not significantly less effective than synchronous sites. In other words, real-time interaction was not shown to be an advantage for the contribution of websites to tele-mental health interventions. Asynchronous modes such as discussion forums where people leave messages for later responses or involving email showed good effectiveness. Continuing research support: Newer studies are continuing the trend of reporting similarities between outcomes between face-to-face and video conferencing interventions. This has even been shown in group therapy. Greene, Morland, Macdonald, Frueh, Grubbs, and Rosen (2010) report on a study of 112 veterans with PTSD and severe anger problems that were treated in video conference groups and face-to-face groups. "No significant differences" were found in outcomes or even process variables such as " therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion and attrition." There was somewhat less experience of alliance with the group leader in the video conference groups. Those who had the strongest alliance achieved better anger control. This did not affect the aggregate outcomes, however.

A small study of patients with OCD delivered solely via teleconference and cell phone showed good effectiveness for the condition, as well as very high client satisfaction with the delivery formats. (Vogel, Launes, Moen, Solem, Hansen, Haland, & Himle, 2012)

Clinical common sense: For now, the best advice from an ethical perspective is to follow the soundest time-tested principles, but to adapt them to these new scenarios. This attitude is very much reflected in the model California law on telehealth and the ethics guidelines of the American Psychological Association. With that in mind, we will now view some examples of this from ethical topics that are especially of concern when considering telehealth.

Consumer satisfaction: A large percentage of the public take various forms of electronic communications for granted, and are very aware of the benefits. As important as it is to be watchful of contraindications and limitations of telehealth, the public in general may be better adapted to these modalities than many mental health professionals. In early adoption of mental health videoconferencing by the military, consumers responded well, despite that fact that video quality was inferior to today's standards. In subsequent surveys, they continued to rate this modality high. In fact, these consumers rated it substantially higher than face-to-face communications. (Folen, Jones, Stetz, Edmonds, & Carlson, 2010)

Discrimination or improved service? The greater the need for telehealth modalities, the greater the incentive to push the envelope. This is evident in attempts to improve access for under-served populations. This effort brings to the foreground ethical principles such as putting the interest of the client ahead of the clinician or system, acceptance of diversity, and the need to be relevant to less educated and more socioeconomically stressed populations. This means we must take care not to make guinea pigs out of people in a discriminatory manner. Fortunately, the consistent evidence regarding the effectiveness and advantages of telehealth are encouraging systems of care, government agencies, and the military to expand use of telehealth to reach the underserved.

Contraindications, cautions, and mitigation: There is widespread agreement as to what clinical common sense tells us about red flags for telehealth. For example, persons with significant levels of emotional instability, cognitive impairment, danger risk, sociopathy, delusions, and hallucinations are much less likely to benefit from e-therapy without some form of real-world assistance and supervision. This includes diagnoses such as complex PTSD, borderline personality disorder, serious head trauma, and developmental disability. It includes populations such as prison inmates, children, and persons that have not had much exposure to computers or Internet use. The capacities and consistency of technology for the providers and clients are also obvious considerations. Using an Internet connection to deliver suicide crisis help risks losing the connection at a dangerous point. Mitigation for this might include a backup phone connection, or using a regular phone line for voice and Internet video for visual contact. Loss of video would not impose as much risk as loss of voice. Discussing such issues at the outset and having an appropriate plan in place are essential.

2. Increasing Pressure to Adopt

Demand: An ever-larger share of the population use Internet phone, videoconferencing, and social media like any other utility--they depend on them and they take them for granted. Whether we are ready or not, online activity is vibrant, increasing, and becoming more sophisticated in technology as well as users. This applies to the search for well-being, because it is a popular subject. The public will expect mental health information and services to become more available and more sophisticated. This has important clinical implications.

Adoption patterns: The ways people use the Internet tell us a lot about the future of telehealth and e-therapy. (Fox, 2011) reports on a 2010 survey of Americans by the Pew Memorial Trust. The author found that 80% of people that use the Internet have used it for researching health information. This equates to 59% of the public when we account for those that are not Internet users. At the time of the survey, 74% of U.S. adults used the Internet.

According to the survey, people are more likely to seek health information online if they are caring for someone suffering from a chronic illness or disability, or if they have such a condition.

The New York times reported that half of adults used social media (Sengupta, 2011), while Pew Internet reported that, of those, two thirds used social media. (Smith, 2011) These figures increase every time they are published.

Many people use sites involving interactivity of some kind for mutual support regarding a problem such as depression. Discussion forums are perhaps the best example. Self-help forums are dedicated to specific topics, and allow users to share support and resources. 6% of Internet users had posted a comment or question about a health issue in a discussion forum or similar venue, according to the Pew 2011 study. (Fox, 2011)

Roughly 20% of Internet users use peer support regarding personal health matters. They are more likely to turn to non-professionals for ideas on coping with a health issue or getting quick relief, while they tend to look to professionals for more technical answers. Despite concerns about misinformation and scams on the Internet, people report a good level of satisfaction in their use for health concerns.

New features are being added to sites on an ongoing basis. For example, they can post material such as questions and answers. some sites automatically track user-supplied data such as weight, exercise or mood, and provide feedback such as charts and recommendations. Expectations of professionals and the public are being shaped in a dynamic interplay of the public, competing providers, clinical insights, ethical standards, case law, legislation, new technologies and innovations, research, and incentives from the government and foundations.

3. Defining Telehealth and E-Therapy

Perhaps the earliest exercise of mental telehealth services beyond the telephone took place at the Nebraska Psychiatric Institute in 1959. There, a closed-circuit television (in effect, video conferencing) enabled psychiatric consultation. (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005) Since then, the myriad modern manifestations of mental-telehealth and general integration of computer and network technologies into health care and society have resulted in many new terms and concepts. Telehealth

Note: This section focuses on the more popular terms pertaining to the Web and telecommunications, but, if you are new to any of the terms used here, the next section, "Electronic Communications Services and their Security Issues" describes additional useful terms.

The reader may see terms such as e-health or telemedicine used synonymously with telehealth. E-health is most likely to refer to health services delivered via the Internet.

Our definition, similar definitions: For the purposes of this course, we will use the following definition of telehealth, which is devised from the perspective of the mental health services provider, and made short by focusing on these essential characteristics:

Telehealth provides health services and administration through electronic communications media.

The above definition is similar to one used by the Institute of Medicine (IOM): "Telemedicine [telehealth] is the use of telecommunications and information technologies to share and to maintain patient health information and to provide clinical care and health education to patients and professionals when distance separates the participants." (Field, 1996) Advances in programming and customization, as well as Web 3.0 innovations, may require the integration of software applications into the definition in time.

That aside, we are using a broad, flexible definition because this field is a flurry of innovation. In contrast, the American Psychiatric Association, as of this writing, is still limiting the definition to video conferencing. Further, it limits it ambiguously to "a specifically defined form" whatever that means, and further limits its use to populations in "remote locations or otherwise underserved areas." (American Psychiatric Association, Undated)

Bauer (2009) points out that the Greek prefix "tele" means the end, far off, or distance. Now, it is almost synonymous with electronic or digital when it appears in words such as telephone, telecommunications, or telehealth. This is why the definition used in this course is so simple. Bauer adds that the core elements of any definition must include 1) the use of "information and communication technology" (ICT), 2) "Geographic distance between the participants", and 3) "Health or medical uses."

Billing and Operations: We should stress that telehealth is not just delivery of clinical consultation. When we think of telehealth in terms of using confidential information, we can divide it into three primary areas: treatment, payment, and operations. These are the three sections of federal HIPAA legislation covering the use of what it refers to as personal health information (PHI). It refers to them as TPO, or treatment, payment, and operations. As with treatment, payment and operations (other administrative tasks) can involve transmission of confidential information, but only that which is necessary for these functions. Other information is to be protected from unnecessary access, with special measures for psychotherapy notes.

Security: When we think of the design of telehealth systems or procedures, we can also refer to HIPAA. The legislation covers such procedures in three sections: privacy, transactions, and security.

Regulators and payers: According to material on reimbursement by the American Psychological Association (2011), "When used broadly by regulators and others, the term telehealth services may refer to all interactions between health care professionals and their patients that do not happen in person. By contrast, payers often use much narrower definitions of telehealth services." However, much electronic communication that may include patient information takes place in the administration of health data, and most of this activity does not involve interaction with patients. (Bauer, 2009)

Telehealth systems: From a systems perspective, Bauer (2009) states, "According to one view, a telehealth or telemedicine system can be defined as follows: A telemedicine system is an integrated, typically regional, health care network offering comprehensive health service to a defined population through the use of telecommunications and computer technology." This definition emphasizes larger systems over the more utility-driven use of specific media by individual providers or small groups that are not integrated into a telehealth system.

In legislation: Laws regarding telehealth include a definition for it and related terms. They may be more restrictive than definitions used for clinical purposes. For example, clinicians may discuss telephone and email as part of telehealth, though they are excluded from some legal definitions.

An example from California: A flexible definition for telehealth was developed for California law (and it includes masters-level therapists as health care providers), as follows:

For the purposes of this section, "telemedicine" means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Neither a telephone conversation nor an electronic mail message between a health care practitioner and patient constitutes "telemedicine" for purposes of this section. (Cal. B&P 2290.5 A1) Tele-Mental Health

This refers to telehealth practices that serve mental health needs and systems. You may also see it without the hyphen, as telemental health. E-Therapy:

For this course, we will define e-therapy like so:

E-therapy is the provision of psychotherapy and counseling through telecommunications media.

E-therapy is a subset of the tele-mental health domain. Note that assessment, as an integral part of therapy, is part of e-therapy. Various consultation and coaching services use the same media, so there are terms such as e-coaching. Terms used for e-therapy include e-counseling, cybercounseling, cybertherapy, teletherapy, telepsychotherapy, and psychotechnology. These terms have been used by clinical professionals and mainstream media.

Taylor, Symonette, and Singleton (2009) introduce e-therapy as, "The provision of behavioral health services delivered interactively from a distance, in discussion." Their work provides the following definition, saying that e-therapy "serves as the conceptual framework for the information provided in this document."

E-therapy is the use of electronic media and information technologies to provide services for participants in different locations. It is used by skilled and knowledgeable professionals (e.g., counselors, and therapists) to address a variety of individual, familial, and social issues. E-therapy can (1) include a range of services, including screening, assessment, primary treatment, and after care; (2) provide more accessible modes of treatment than the traditional ones to those who actively use the recent development of technology (i.e., adolescents and young adults); (3) help people access treatment services who traditionally would not seek services because of barriers related to geography, shame and guilt, stigma, or other issues; and 4) be provided as a sole treatment modality, or in combination with other treatment modalities, like traditional or existing treatments. Telepsychology

The American Psychological Association refers to telepsychology in its materials regarding telehealth practice by psychologists. As such, it goes beyond definitions of e-therapy to include psychological testing.

Telepsychology.net defines it thus: "The term telepsychology will be used inclusively on this page to include providing psychotherapy and psychological assessment and testing using various electronic means such as videoconferencing, teleconferencing and telephone therapy, psychotherapy and counseling over the internet through various software packages with or without a video camera or webcam, counseling via email or internet chat, using social networking sites like myspace (sic) and facebook (sic), etc." (TelePsychology.net, 2011) Health 2.0 or 3.0

Changes in the healthcare environment spurred by participative technologies are giving rise to an especially volatile area of development referred to as Health 2.0 or Medicine 2.0. (Hesse, O'Connell, Augustson, Chou, Shaikh, Rutten, 2011) This is an allusion to the changes in Internet use referred to as Web 2.0. It involves integrating social media with health data so as to allow more patient participation in medical records and decision making. It can also allow more rapid or real-time communication and record review by multiple clinicians involved in the same case.

Standards are under development for telehealth that does not include social media, yet the Web, and practices in medicine and mental health, are moving forward to take advantage of social media and other technologies, well ahead of the articulation of standards of practice.

The confluence of electronic records and social media will result in exploration of a small-scale version of "crowd sourcing" opinions, referred to as collective intelligence, in seeking improved results. This may benefit from increased engagement of patients and clinicians. (Hesse, O'Connell, Augustson, Chou, Shaikh, Rutten, 2011)

The eager adoption of Internet searches by patients seeking medical information and collective intelligence projects in areas outside of medicine and mental health are giving rise to interest in potential clinical applications. The existence of medical, wellness, fitness, and mental health-related apps (programs) in mobile technology such as smart phones provides additional inspiration and motivation for such exploration. Automated "coaching" that provides reminders to people to engage in pro-health behavior is just one of the proliferating examples of such apps, and they are already being integrated with modalities for peer or clinician contact through text messaging, voice, and video in various ways.

It will be years before ethical expectations and general patterns of use in Health 2.0 are conventionalized. Continued technological innovation in terms of software and hardware innovations leave these conventions up to our imaginations.

For some years, the term Web 3.0 has been used increasingly to refer to customization and ubiquity. That is, diverse appliances and devices that provide, or are affected by, large amounts of data from any number of sources, with results or actions that are customized to the individual user in real time. A device that detects your exercise level and provides recommendations based on your changing biometrics, such as weight, and evolving information about health rated by the experience of thousands of users would be an example. Other Terms

You'll see these terms used less frequently: Distance therapy, e-counseling, and cyber-counseling.

4. Electronic Communications Services and their Security Issues

Where we discuss security, we are focusing on weaknesses in the technology, and we will discuss problems with the users themselves (such as being tricked) later. The following are the more commonly utilized services: Telephone

The telephone is the oldest medium for telehealth. The hard line (typical phone line that was nearly universal for decades) is very secure so long as someone doesn't tap directly into the line or use some kind of technology in your location. But it is very easy to tap a traditional phone line.

Cordless phones: Cordless phones do not represent a significantly higher level of security risk than traditional household phone wires because modern wireless phones have security features such as encryption and channel hopping (randomly using different frequencies for broadcast) that elude snooping. Also, the broadcast covers only a short distance, unlike cell phones.

Cell phones have a greater risk because of the stronger broadcast and the channeling of the conversation through multiple points, but only if there is a sophisticated, dedicated spy. They must overcome the digital encryption used by most systems. Breaking of modern encryption is rare compared to other kinds of hacking, such as tricking people to give out their passwords. There is a major problem of people getting data from lost portable or mobile devices such as cell phones.

Smart phones, mobile devices: With the melding of cell phones and computers in today's smart phones, security concerns are much the same as computers, except they are much more likely to be left on the bus. Email

There are two main ways to see your email. The first way involves using an email program (referred to as a "client") such as Outlook. The second way is to view it through your browser while it is shown to you by a "webmail" service such as Hotmail, Gmail, or Yahoo.

Insecure? Email has gotten a reputation as an insecure medium of communication. This is because, for most email services, the email is stored on a number of servers (the computers that relay the email message along its route to the recipient), unencrypted, possibly for years. This creates the risk of staff at Internet facilities gaining access to the message. It would be illegal and against company policy for employees to do so, but that is no guarantee.

HIPAA-compliant? However, HHS (U.S. Health and Human Services) has stated that communications that contain protected health information may take place over email so long as reasonable precautions are taken. What those reasonable cautions are depends, according to HHS, upon factors such as the size of your organization and the needs of your clients. In practice, many clinicians and case managers take this to mean that they should place some limits on the use of email and/or use a secure email solution.

A typical approach consists of:

1. Informing clients of the limitations of email and refraining from using it with the client if the client so chooses.

2. If the client does not object, using email for limited information exchange, but refraining from sending extensive information or disclosing account codes or social security numbers.

Higher-security email: TLS (transport layer security) or SSL (secure socket layer) security are used by major email providers. This type of security is the same as that used for credit card transactions or other purchases on reputable websites. When you are making a purchase or accessing webmail, the website address should start with HTTPS. This security is helpful, but it only helps protect the message and your pass codes on the way to your email service. After that, it's the same unencrypted copy-and-forward story.

Email offered within a secure system is much better-protected. Special email services that require logging on in order to retrieve messages allow encryption and do not suffer from the creation of copies on outside servers. Your website can be set up with such a service, or you can use an email provider that guarantees HIPAA compliance such as LuxSci: http://LuxSci.com.

Another security measure is to encrypt email that goes through normal channels. This requires installation of a program by therapist and client. Texting

Texting, also known as instant messaging (IM), chat, text messaging, or SMS (short message service), is used a great deal. It can be a way to initiate communication with a therapist that has a chat option on their website. This may be more than a convenience for people that are very shy.

Texting can also be a way to conveniently exchange a limited amount of information with another professional or with clients. Some texting services, such as that available through Skype, use modern encryption. Texting can proceed when one party is not available, as the message waits to be seen, much like an email message.

Texting can be an automated part of behavior change, by providing reminders based on criteria such as time of day. Appearing on the client's cell phone or other mobile device, texts can reach the client silently, nearly anywhere. Its silence affords privacy.

Texting is used in a variety of other ways such as in virtual worlds, or as a sort of side conversation during an event such as an online conference or class. Twitter is essentially a texting service. File Transmission

Files such as documents can be sent as email attachments. However, the same security concerns apply as in email. If secure email is not available, encrypted file transmission can take place through services such as Skype. Fax

HHS states that faxing of private health information is permitted. Faxing a document through an online service, however, may have lower security. Since faxing often involves a significant amount of private information, it is preferable to use a secure service, traditional fax, or file transmission, as above.

Discussion Forum

As the name indicates, a discussion forum is a forum for discussions. That forum is in the form of a website where messages can be viewed. Responses in connection with a message form a "thread" and may be viewed in a hierarchy that shows which messages are responses to an earlier message. Paying attention to the responses is called "following the thread," as in, "I didn't follow that thread, it was getting pointless." A forum may have separate areas for topics. Google Groups and Yahoo! Groups have thousands of forums. Not all of them are good or active.

There are countless forums on every imaginable subject. The same concerns you read about for social media (below) exist for discussion forums. Some professional forums require verified membership. In these forums, all members agree to honor confidentiality. However, clinical information is still limited and obscured, and names of clients are definitely not to be divulged.

Because the membership is limited to professionals that are required to maintain confidentiality, a member might be tempted to divulge information that could reveal the identity of the client. This would be a mistake, because there are ways that the information could be made public. Besides, unless the client has given permission, you are violating confidentiality regardless of what happens to the information. If the client gave permission, it would not be in their best interest, and still should not be done. The information must not indicate who the client is.

As for the public, forums are extremely popular for exchanging support around problems, health issues, and interests. There seems to be a support forum for every imaginable (and imaginary) diagnosis.

Other terms for discussion forums include listserve (an older term that actually only applies to certain forums), discussion list, and email list. The latter terms derive from that fact that discussion lists began as email services that sent a copy of each message to every participant. These still exist, and most discussion forums offer the option of receiving email that contains the new messages. This allows the participant to be current and respond quickly to important messages without viewing the online forum.

Discussion forums don't fit the image of direct clinical mental health care, but they can be part of an offering of service. For example, there are discussion forums that provide professional moderation and responses for people with a mental health issue. This could be considered an augmentation of services. But, because a large membership is usually needed for adequate participation, it is more likely that a clinician would refer a client to an existing forum known to be of good quality. VoIP Telephony and Video Conference Calls

VoIP calls are, essentially phone calls via computer. Some VoIP services, such as Skype, also provide video. VoIP stands for Voice over Internet Protocol. This means that the sound of your voice is digitized and sent over the Internet. Well-known providers include Vonage and Magic Jack, but there are many companies providing the service.

There are some characteristics that distinguish VoIP from a normal phone call, though these differences are diminishing as technologies converge. If the power goes out, or there is a problem with the modem, computer, or other features necessary for the call, then a VoIP call will have problems or go dead altogether. There is latency (a brief delay in the line that can be awkward). If the connection is not good enough or there are technical problems, the call may become garbled.

Secure encryption: VoIP services are very secure if they use encryption (as Skype does). However, the calls are more vulnerable to failure or poor quality than traditional phone lines. Unlike email, VoIP calls are not saved on computers as they make their way to their destination.

Privacy Policies: Skype and other providers of VoIP have security policies that are very appropriate for protected health information. For example, they forbid monitoring of calls.

HIPAA Compliance: Some experts feel that HIPAA Business Associate agreements must exist between clinicians and VoIP services. However, services that commit to being HIPAA-compliant and that will provide Business Associate agreements are costly.

There are several factors that suggest that use of a provider such as Skype may be HIPAA-compliant:

1. Use is taking place on a large scale by private practitioners and major organizations, but, as of this writing, there has been no statement or action by the government against this commonplace activity.

2. HHS states that phone calls are permissible, leaving open the likely outcome that VoIP calls will be treated like phone calls.

3. Technical experts point out that traditional phone connections are easily penetrated, making encrypted VoIP far superior for privacy, yet traditional phone calls are permitted by HIPAA for private health information.

4. Better VoIP providers have security measures and privacy agreements in place. Normally, files do not result from VoIP calls, and therefore there are no files to protect.

5. So-called traditional phone calls often have VoIP involved in some leg of the transmission, especially in long distance calls. This is making it impossible to distinguish between VoIP and traditional phone (POTS or plain old telephone service).

Added security: There are additional encryption solutions such as ZPhone or In-Confidence, but they require cooperation by both parties. This encryption prevents monitoring of your conversations, even if it is court ordered.

Government intrusion: As with other communications, a court order can penetrate your privacy or that of your clients, despite the encryption, because the service provider must allow them to monitor calls.

If user encryption is used, and the call is saved as a file for some reason, a judge could order you to decrypt the file if there is sufficient reason to trump the fifth amendment. However, VoIP calls do not normally result in a saved file, whether it's encrypted or not.

An order for decryption was made in a case in which there was testimony by a border guard that an individual had child pornography on their encrypted laptop files. (McCullagh, 2009) Some U.S. government officials want to make it illegal for companies to allow communications that they cannot decrypt. (McCullagh, 2010)

Video Conference

Two or more people can meet through audio and video (and use additional media such as on-screen slides or white board) during a video conference. The relevant HIPAA issues are discussed in the VoIP section above. People with little technical knowledge can have simple web conferences (with video, chat, and even multiple participants at separate locations) for free on Skype.

As with VoIP, make sure to use a provider that encrypts the calls and has a good privacy policy.

Social Media

Social media allow people to easily communicate and collaborate with many people online. Facebook, Twitter and LinkedIn are popular examples. This is a rapidly evolving and multifaceted phenomenon bristling with threats and opportunities. Perhaps the greatest threat these sites pose to personal health information is that a clinician or staff person might purposely or inadvertently post private client information. Clinicians have posted comments about cases in which they unintentionally posted enough information for the individual to be recognized.

Issues with social media will be discussed in more detail in "Additional Risk Factors."

Social Virtual World

Sites such as Second Life are a world unto themselves in which the user interacts with others using avatars, the modern-day equivalent of puppets. Unless the therapist has a full-blown business plan for doing business there, a fully developed ethical and legal basis, and a very solid understanding of the virtual world, they should only venture there under a pseudonym, and preserve the security of their password as with any other account. This is a very specialized issue that falls outside the scope of this course. Intranet

This is a network for data sharing and processing that is privately managed and not necessarily able to access the Internet, except through a controlled channel. Data can be kept within an organization or set of organizations, without being accessible through the Internet or only in a very controlled and limited manner. Most corporations have intranets. This has not prevented breaches. HIPAA has been expanded with mandatory reporting and tracking of breaches. In the first year of this tracking, beginning in 2009, 4.9 million patients are known to have suffered data breaches. It is not known how many additional breaches went undetected or unreported. (Miller, 2011) Later, we'll cover how so many breaches have been able to take place.

5. Additional Risk Factors: Human and Automated

The following are risk factors for security breaches. Each has implications for policy development, such as managing laptops and their data.

Inadvertent HIPAA Violations

Clinicians and staff may take online functions for granted, to the point of violating privacy. A medical practice paid a $100,000.00 fine for violations after a complaint that they were using an online appointment calendar service that allowed users to see others' appointments. They were required to get a HIPAA Business Associate agreement from any calendar provider, and email provider. We discussed HIPAA-compliant (and non-compliant) email in the previous section.

Wireless (Wi-Fi) Networks

There are good reasons not to do banking or transmit private client information using public wireless networks. If someone looks over your shoulder or overhears you making a call, they don't have to be a hacker to receive private information. It is also possible for a person to create a wireless network that you might mistake for the network provided by the establishment. This is called a rogue access point. If you log on to such a network, the rogue computer receives all input from you. This is a "man in the middle" scheme, meaning that computer provides your Internet connection as a go-between, just like the wireless network of the establishment--but with criminal motives.

Bumbling and Lack of Encryption

Human error, it seems, knows no bounds. One of the greatest causes of privacy breaches is the lost laptop. This periodically makes the news, and in the period of one year beginning in 2009, affected at least 1.5 million patients' private data. (Miller, 2011)

How many therapists and other mental health workers keep records on their personal laptops? How many have already lost laptops containing private client information (or had them stolen)? Encryption would prevent anyone from getting access to the information. In the absence of encryption, secure passwords would prevent all but dedicated individuals from access. But if you keep passwords on your computer, then any number of accounts could be compromised, including your banking.

Cracked encryption is very rare compared to all other sources of data breaches. When encrypted data is breached, it is almost always because of access to key codes. Current encryption methods are so strong, even technical experts that know exactly how the encryption method works are highly unlikely to succeed in decrypt a file encrypted using these modern methods.

Boundary Crossings at Work

When staff look at private health information without authorization, this is a data breach. In many cases, no other harm is done, and no one is the wiser. The data may not make it out into the wild, but it has been breached, nonetheless.

Mischief at Work

Sometimes an employee will, for some reason, pull an inside job, in effect, by gaining access to private information and doing something inappropriate with it. Whether it is to sell it to a tabloid because it concerns a celebrity, or post it as revenge for a broken heart, it is a serious breach. Massive data breaches of this kind have taken place involving corporate, military, and government records released by whistleblowers to outfits such as WikiLeaks. Mental health organizations have similar vulnerabilities, and must do their best to prevent breaches of this kind.

Finding and Guessing

One of the most common sources of breaches is stolen passwords. The codes that you use to log into online accounts and (we hope) your computer are supposed to be carefully-guarded secrets. But if they are not well-hidden, they may be found. If they are not tricky enough, they may be guessed.

Social Engineering

This refers to the art of getting people to compromise their own security. Phishing scams, phreaking, and other terms hint at the diverse, dark world of people dedicated to violating your privacy or that of your organization. Scams can be simple as when someone poses as someone authorized to ask you for information. These fraudsters can be very nice. They've been known to bring cookies, or even to have ID cards. They don't have to appear in person. They may send you a very convincing email from a bank or online service, indicating that your privacy has been breached. The message provides a link you can click on so you can log in and change your password. However, the link is to the scammer's computer, and your input is playing into their deception. Many credit card numbers have been acquired from unsuspecting people this way.

Sophisticated Snooping

There are many ways to get access to computer input or online data. A keylogger installed on a computer will record everything you do and send it to the snooper. An IT staffer at work might do this in the course of servicing the computers, because he or she also leads a life of crime. An employer may do it (legally) simply to find out if employees are wasting time or doing other inappropriate things.

Hacking

Hacking involves sophisticated means of compromising computers. Unfortunately, the hacker community becomes more sophisticated and powerful as legitimate programmers race against them to preserve security. Many hackers are funded by organized crime. Organized cybercrime is surging. Bots

Hackers and snoopers create digital robots called bots to do their bidding. They do things such as search the Internet for computers that don't have firewall protection. They turn these computers into "zombies" that send out spam or perform other tricks.

The Medium is the Immorality

Crowell, Narvaez, and Gomberg (2009) argue that electronic communication poses an elevated risk of unethical behavior, because "the usual social or moral constraints operative under normal (non-technology-mediated) circumstances (e. g., face-to-face communication) may be reduced, thereby facilitating the occurrence of unethical activities..." They cite factors such as psychological distance, disinhibition, and devaluing of intellectual property rights.

They take the position that this makes it all the more important that education engender "ethical sensitivity." They feel that ethics must be integrated into education, and they cite works that go into detail as to how to carry this out. They suggest using means such as having students work through moral dilemmas and discuss the ethical aspects of various scenarios. Social media multiply this risk.

Social Media

The enemy is us, mostly: We were introduced to social media in the section on security risks of various electronic communications media. With sites such as Facebook and with blogs, clinicians can be their own worst enemies. Greysen, Kind and Chretien (2010) point out that social media have created "several new hazards for medical professionalism." These can easily apply to therapists as well as physicians.

First, many physicians may find applying principles for medical professionalism to the online environment challenging in certain contexts. Second, physicians may not consider the potential impact of their online content on their patients and the public. Third, a momentary lapse in judgment by an individual physician to create unprofessional content online can reflect poorly on the entire profession. (Greysen, Kind, & Chretien, 2010)

There have been many examples of clinicians posting content that is seen as unprofessional. Some clinicians, especially younger ones, have been lulled into a sense of privacy, forgetting that the world may get access and take a dim view of their posts. (A post is anything you put online, such as text and photos, as in "He posted pictures of the party. OMG!")

Privacy settings? Nice try! Even if your Facebook privacy settings are "friends only" (meaning that the general public cannot see your posts), your content may be posted by someone in your friends list (the people that do have the ability to view your posts). You may be surprised at the poor judgment of some people you trust. They may not understand your professional needs.

Other external factors may compromise your information. Your account may be hacked, or there may be a larger security breach of some other kind. While it may seem onerous to a person that takes it for granted that social media are a "right" and an expected part of our social existence, the realities of social media require reevaluation.

Perception is everything: Innocent pictures of drinking and partying may give people the impression of public drunkenness, alcoholism, or loose morals. This not only reflects on the individual, but also their employer or group, and the profession in general.

Up to a point, younger people that are used to the idea that people can be caught in compromising-looking positions may take such images or media with a grain of salt or be completely desensitized, but it is far too soon to expect society in general to see things this way--if ever.

You must also consider the prospect that you may desire a job or other responsibility that you haven't been considering during your online postings. Your online history could torpedo your dreams, despite your bona fide qualifications.

Clinicians have said things online that were disrespectful of clients, other professionals, or their employers. This can result in unfortunate consequences for any number of people, including the professional. Madden (2008) suggests thinking of your Internet behavior as leaving "digital footprints."

Our educational institutions, supervisors, and agencies should articulate policies regarding online behavior and educate clinicians as to the latest thinking and development on these issues. We must also educate our clients, as many of them may not have mature judgment or may be affected by loneliness or intense emotions to do things online that they may later regret.

Monitor your reputation: Clinicians and organizations should arrange to receive notifications of any mentions of their names, at the minimum. This can be done with Google Alerts and other free or fee services. Google can send an email any time it notices new content containing topics that you want to track. It may also be advisable to visit major ratings sites. In some cases, such as verifiable inaccuracy, bad ratings or comments may be removed when the clinician takes action. An incentive for clinicians to monitor and take action when possible to clean up their image is that employers may use search engines or visit ratings sites to monitor employees or making hiring decisions.

Making a judgment call: Some clinicians are deciding to drastically limit their presence or use of social media, even to the point of terminating their Facebook account. Some are exclusively maintaining a professional presence in which they promote their practice or engage in other professional activity, but do not make personal posts.

Leverage social media for good: Clinicians can use social media for valuable professional purposes. Greysen, Kind and Chretien (2010) discuss several:

1) "respectful clinical narratives written by medical students that avoid disclosing any personally identifiable information about patients can promote understanding, reflection, and greater appreciation of the patient-physician relationship."

2) "improve patient safety" "share sound medical information and help the public interpret medical studies, thereby becoming sources of credible medical information" (Substitute "clinical" for "medical," to apply this to psychotherapy.

3) "maintaining an online presence that is accessible and useful to patients (can lead to) quality improvement through better communication via social media"

4) "utilize the power of social media to facilitate interactions with patients and the public that increase their confidence in the medical profession" (or in the mental health profession.)

Innovations in social media utilization may produce surprising shifts in the way therapists are available, if innovations in medical practices are any indication. Add to that the technological breakthroughs in sensor technology, massive data aggregation, ratings and other input by the public, and automation of reminders and other forms of computer-human interaction, and the possibilities test the imagination.

Programs, Apps, and Affiliate Programs

Software programs (referred to as programs, applications, or apps) are being released that involve therapists in various ways, such as providing content or interaction. The clinician must take care to size up potential ethical or legal problems with apps. For example, a promise to treat a psychiatric disorder might be perceived as making an app into a medical device not approved by the FDA.

Affiliate programs are those that pay a commission for online visitors or purchases originating from another website or program. Therapists may establish relationships with such programs simply by signing up and allowing the program to post ads on their website. Amazon.com is one of the most popular affiliate programs. Take care to review claims and representations of affiliate programs or other online businesses that may affect your reputation. Some websites have had embarrassing ads appear that are antithetical to the theme of the site, simply because the affiliate program did not filter ads properly. Also, there may be conditions in which a therapist can be perceived as neglecting their duty to put the client first, by having their judgment biased by the promise of money from the affiliate program.

Motivations for Data Theft and Other Intrusions

Below are examples of motives that drive people to violate security through means such as hacking.

Stalking and Manipulation: Stalkers have gone techno, using various means to track and bother their victims. Hacking accounts (gaining unauthorized access) is a popular means. The GPS data continuously provided by many smart phones and cars is another vulnerability. Many people do not know how to turn it off, or even that they should. The same goes for the computer's wireless connection.

Identity Theft and Transactions: By stealing enough information to pass as someone else, the thief can withdraw money from the ATM, make credit card transactions, produce checks, all in your name. A thief can get money or costly items just with your name, credit card, and address information. ID theft can be very low-tech, but if you are tricked into opening a malicious program, you might not know that your most critical information is being downloaded by a criminal with every intent of using it.

Medical Identity Theft: This is a variation in which the person passes as someone else in order to get medical care. If the billing is not noticed by the victim, they may be surprised one day to find that they have used up the limit on their insurance policy, or that they have new pre-existing conditions.

The Ponemon Institute estimates that 0.2% of the population may engage in this practice in a given year, with much of it apparently facilitated by the "victim." In many cases, family members' unmet medical needs drive the person to allow them to take advantage of their insurance or other benefits. (Mills, 2010)

Being Special, Very Special: Some hackers go about their craft for the thrill of achievement, and the ego-inflating bumps in status they can achieve before the hacker community. Their drive is to be legendary.

Protest, Revenge, and Corporate Spying: These motives drive many conspirators to seek forbidden data. Groups such as The Yes Men and Anonymous have made social statements out of breaches. Corporate spies take many forms, gathering illicit corporate intelligence for substantial, secret financial rewards from competing firms or governments.

Curiosity: Unauthorized access is often committed by staff out of curiosity. However, that curiosity might also have a profit motive. Tabloids pay for photos of celebrities and inside information.

6. Categories of Electronic Communications

This section will go a long way in helping you understand the various media used in telehealth. We'll also cover some means of communication that don't loom large in telehealth, to provide a well-rounded tour. We'll see these media in terms of various categories, as a means of seeing them from different practical perspectives--practical in that they are intended to help you understand their roles in telemental health.

By Media Utilized

The most basic distinction between media is between audio, video, and text.

Text: Instant messaging involves, usually, real-time exchanges of text messages. This is synchronous communication, because it is real Email is, mostly, text messages that sit until they are reviewed by the recipient. This is asynchronous communication.

Audio and video: Internet telephone services involve audio and (optionally) video. Skype is a very popular Internet telephone service. Such services (Internet telephony) are called VoIP (Voice over Internet Protocol) because the sound is digitized for transmission across the Internet, which is a digital medium. The distinction between VoIP and regular telephones is becoming blurred as the technologies mature. Long distance services may use VoIP as part or all of a transmission in order to offer lower rates.

Synchronous vs. Asynchronous

This is an important distinction, because it refers to whether the interaction is immediate or delayed. A telephone conversation is synchronous, while an email exchange is asynchronous (not synchronized in time; not immediate). Clearly asynchronous communications such as email have serious disadvantages posed by the lack of immediacy. However, asynchronous communication also has advantages. Consider online discussion forums. These are opportunities for a discussion of topics, usually organized by theme. For example, people can discuss the challenges of raising children with ADD. An advantage is that the posts (submissions of text by participants) accumulate over time. This means that the discussion can serve as a source of helpful material at any time. Also, people can join the discussion after reading what has already been said. Regular participants can participate according to their schedule, without having to be there for a live discussion scheduled at a specific time. These advantages have made the discussion forum a very popular venue for diverse topics.

Consider email. The therapist can provide additional support to clients without the restrictions of additional meeting times or connecting by telephone.

These categories may be combined in a virtual environment or social media site. One may participate in a real-time text chat and then receive follow up messages in one's virtual mailbox later.

By Level of Security

The security of various media changes regularly. Security measures are constantly researched, tested, and improved. Although it is not a very stable category, security is a vital characteristic of electronic communications. Businesses, governments, and psychotherapy clients all want their privacy. Legislation such as HIPAA imposes legal requirements regarding privacy.

By Level of Virtual Reality

Virtual reality is an artificial environment represented through digital media and with which the user can interact. This category asks how fully the user's experience is enveloped by a virtual reality? The author divides the levels into:

1. Minimal: The telephone is a physical object that provides sound. A Skype (computer telephone) interface may be used similarly. Although both media have additional elements that lend complexity, they are minimal compared to other deployments of electronic media where virtual reality is concerned.

2. Supported Engagement: Such services use additional support features such as those that can be added to a teleconference. These may include showing slides or other additional media, and additional data management features such as providing a recording of the service or connecting to social media features such as those of Facebook. These services begin to resemble a world because of the kind of engagement they create and the degree to which they begin to envelop the user's identity and senses. Facebook is not a virtual reality platform, but it can be like a world unto itself.

3. Virtual Reality: These media are exceptionally artificial in the sense that the "reality" is what is represented to the user through the computer. The visual environment is on screen, or seen through video goggles that block out the rest of the world.

Social virtual worlds such as Second Life enable users to interact by controlling avatars (people, animals, or objects that represent them in the virtual world). Multiplayer interactive games such as World of Warcraft involve social virtual worlds, but in a very structured game environment.

Non-social virtual worlds are limited to the user, and are used for more control over what takes place. These virtual reality media are used for exposure therapy to achieve desensitization and skill practice. The user may not have an avatar, simply seeing the world as though he or she is there. This first-person view is more like real life and can be a more intense experience than watching your own avatar.

In science fiction, we see virtual realities in which the user has a completely embodied illusion. The film The Matrix is an excellent example. In time, neuroscience may yield a fourth category that covers such experiences. The developments in virtual reality and neuroscience pose fascinating philosophical questions as to the nature of humanity and consciousness.

By Format or Equipment Required

The requirements for the application and activity should not exceed the equipment and connection available to the user. The main concerns are:

Bandwidth is the amount of data that can flow through an Internet or other data connection during a given amount of time. For example 4 Mbps means four megabytes per second. Speed is a little different, because it has to do with how long it takes for a given amount of data to arrive at its destination. Speed is affected by a number of things, such as the number places the data stops along the way.

Some applications require a lot of bandwidth to work well. VoIP (computer phone calls) need more than text, because of the flow of audio data. Video conferencing requires even more because it transmits many images per second as well as audio.

Processing speed: Some tasks require more computing power than others. Various factors affect how fast a computer can "think."

Screen space: Email can work pretty well on nearly any screen size, including small cell phones. However, a virtual world or highly interactive website may be impossible to use on a small screen. Many websites and applications have "mobile" versions intended for the small screen.

Peripherals or additional equipment: The user must know how to use any required accessories. Headphones with a microphone (a headset) will be needed for computer telephone calls or other live verbal interaction.

By Scenario

This is a very practical category for the practitioner or delivery system, and can readily be discussed in terms of legal and ethical implications. We will cover some of the most common examples.

Distant location: Here, most or all the service from the provider is via telecommunications of some kind. This is because of the distance involved (or difficulty of access). Generally, this takes place because there are not enough, if any, qualified providers in the area.

Too many locations: A variant on this is that the population is spread across such a large area that too much staff time would be occupied by travel. This makes telehealth a cost-effective choice.

Client unable to travel: Physical or psychiatric disability (e.g., agoraphobia) prevents the client from going to a therapist. It is not feasible to have a therapist provide house calls.

Specific client needs or preferences: In this scenario, it is not contraindicated to use telehealth media, and the client is attracted to it. Example: The client is pressed for time and does not feel that face to face sessions are necessary because of their relatively good level of functioning.

Search Engine Superstar: Some therapists market their availability online so well that they are very successful at competing against therapists that are available for face-to-face sessions. This course will address ethical and legal issues concerning distant treatment.

Online impulse buy: Immediacy and convenience may snag a surfer, whether they are looking for a therapist or became interested by an online offer. Such surfers may have little idea of what a therapist really does, and they may have no inclination to fill out forms or learn about matters covered in informed consent. They may want to relate to the therapist like they would an online psychic or real-world bartender. This raises legal and ethical issues.

There appear to be legitimate, legal ways to connect with potential clients in an impulse buy (or similar) scenario. The initial contact can function like an initial phone call with a client considering psychotherapy. However, it may start with a "click to chat" offer or some other online method. However, professionals should not fall into this kind of service lightly.

It's just coaching: The same caution goes for therapists that believe they can function at a lower standard of care because they frame their work as coaching.

This brings up issues such as the obligations of a therapist who doubles as a coach. Again, these are not patterns of service that a provider should fall into without due consideration, consultation, and policy development. For an example of the liability issues, consider the therapist that is seeing a client as a coach, and is accused of malpractice in some form.

A conflict with the coach, whether a malpractice claim or a disagreement about money, may involve the licensing board. Because of the therapist's marketing, training, and methods used, he or she might be found to have been practicing psychotherapy, but to have failed to have discharged certain duties to the client, such as informed consent, adequate assessment and diagnosis, or management of boundaries (matters typically handled much less formally in coaching). This is especially likely to happen when a coaching client turns out to have more serious issues than initially anticipated. Clients initially can appear to be much higher functioning than they really are.

Special or integrated systems: This is a developing area. An example would be the use of virtual reality for exposure therapy where the virtual environment is controlled by the therapist, who is present. In this scenario, special technology is only available at the treatment office. The electronic medium is used along with the physical presence of the therapist. Military use of virtual reality in PTSD treatment is an example of this.

Enhanced reality: This nascent technology provides an overlay on what you are actually experiencing. For example, glasses that use GPS to show you which way to go along with special deals on a product you are looking for. This is not yet a telehealth medium. Five Not-Very-Useful Categories

Therapeutic Effectiveness: Not only is it too soon to draw sweeping conclusions about the relative merits of given systems or electronic media, the variations in deployment are far too diverse. Conclusions about therapeutic effectiveness are emerging and guiding further development in a reciprocal fashion. This landscape will not stabilize in the foreseeable future.

Danger: Every electronic service or medium poses certain risks. Their deployments are too varied to yield an overall danger rating. Online classified ads such as Craigslist have famously resulted in scams, opportunities for pedophiles, and even murders.

Cost: A telehealth system can be deployed with any combination and number of components, and any level of scale. The investment to develop and maintain a telehealth system can vary wildly.

Addictiveness: Addiction associated with electronic media is a very important clinical and social concern. But people vary so much in their vulnerabilities to addiction, so it is questionable to attempt to rate a medium as to its level of addictiveness. Besides, the media themselves are deployed with quite variably. For example, a virtual community with gambling will be more addictive to some, while a virtual community for anonymous sex between avatars will be more addictive to others. Meanwhile, most people will not get hooked. As of this writing, telehealth practices in themselves have not been determined to be addictive. And it is not the medium that is likely to be addictive, so much as what content and interactivity is provided through the medium.

Text or Non-Text Based: This distinction misses the point that media online are quite diverse. It is better to distinguish between the various media as specified above. Text-based communication increasingly occurs mixed with other media now.

Social virtual worlds often involve text chat as the primary mode of communication, but they take place in a graphic virtual environment with avatars. Text is being supplanted by live audio.

7. The Functions of Tele-Mental Health

In this section, we discuss clinical and administrative functions and their functions.

Clinical Functions

These divisions can blur, because functions and media overlap. For example, data from a clinical discussion may be converted into data for record keeping quite easily. Outreach

Most persons with psychiatric problems do not receive adequate mental health care. There are many reasons for this, and telehealth practices may help to lower some of these obstacles. Broadly, key aspects are 1) the public perception of desirability, appropriateness, and potential value of getting help, and 2) the availability and accessibility of help.

Specific examples of these include: The diversity of offerings (including those that do not require direct human contact), potentially lower costs, time savings, added features, and the increased availability and persuasiveness of information that encourages people to get help.

A free initial consultation by phone is an early telehealth offering. Now there are diverse channels that may bring a person into contact with a therapist or other help source, and there are diverse means of communication along the way. Instant chat and therapist-monitored discussion forums are two examples.

Assessment, Diagnosis, and Progress Monitoring

Assessment tools range from informal checklists designed by amateurs to sophisticated systems of analysis and interpretation. They can serve various purposes, including deriving a diagnosis, charting progress (through repeated administration), educating clients through feedback on the results, and engaging potential clients by creating an interesting means of getting feedback or doing self-assessment.

The later function can be an aspect of marketing, and is used by legitimate clinical programs as well as questionable or cult programs. The Internet has allowed a great proliferation of diverse assessments. Screening tools may be online or loaded onto the client's computer as a software program.

If a provider provides clients with assessment tools, or directs them to online tools, the provider must make sure that the tools are legitimate and useful, since there are many amateur assessments for various problems, personality types, and so forth. Some tools provide feedback designed for clients to understand without interpretation by the clinician.

These tools can extend the value of therapy without incurring excessive additional costs. Many are free. They range from self-scored questionnaires for sophisticated systems of analysis and feedback.

Managed care systems, employee assistance programs, and the military are investing in assessment and media that can improve behavioral (and physical) health while reducing the load on clinicians to some degree. This may smack of replacing clinicians or misleading clients into thinking they don't need help that they actually need. However, such systems can reinforce the importance of therapy and clinician contact as well. This is an important design consideration with ethical and legal implications.

There are many variations on this aspect that can be considered. For example, certain results during an informal and free online assessment can trigger the system to provide a connection to an appropriate in-network provider and encourage the user to take advantage of the opportunity for a live call or other appropriate form of contact.

Internet self-assessment has been shown to be as helpful as those done with paper and pencil

(Vallejo, Jordon, Dioz, Comeche, & Ortega, 2007). The practitioner should be careful not to allow software to substitute for a live assessment. Although it is too soon to say with assurance where to draw the line, many assessments require the clinician's capacity to assess the client through all senses, especially taking in clues such as body language and verbal inflection. (Fenichel, 2000) Provider-Client Communications/Direct Treatment

We haven't heard of psychotherapy by telegraph, but long before there were computers, much communication, including therapeutic communication, took place by phone. Initial phone evaluation, appointment setting, and crisis calls have long been common place.

These activities have extended from telephones to cell phones, Skype, and to some degree texting. Potential clients also fill out online forms at therapists' sites and sites that market therapists. From there, they may have some email correspondence prior to initiating direct contact.

Psychosocial Education

When therapist provide information that can aid clients, this is referred to as psychosocial education. This activity has historically involved direct communication by the therapist, having clients attend presentations, or recommending media such as books.

Therapists have used media to augment or extend psychotherapy services since before the personal computer. Computer media and interactive programs increased the availability and diversity of such offerings. The web has increased the diversity and richness of the offerings further, with added social or human interactive aspects and widespread availability.

Therapists have at least some responsibility to understand the current offerings well enough to be conversant and to keep track of especially relevant and high quality offerings for the problems in which they specialize. This includes websites that are rich with legitimate information or that have well-managed discussion forums.

Self-help

Clients often get information (and sometimes misconceptions or alarmist material) by visiting various sites or discussion forums. Some of the comments on psychosocial education are applicable here. Therapists have a responsibility to follow their ethical guidelines and legal obligations when preparing materials for the web, just as they do in writing articles or books. However, ethical standards may need to expand to embrace the high level of interactivity, rich media, and automation that can now be delivered.

Group Support

Online group support can take the form of chat rooms, discussion forums, conference calls, and meetings in virtual worlds. Discussion forums are a very popular means of group support for many diverse problems. Virtual worlds and chat rooms can have real time group support meetings. A chat room allows real time exchange of text messages for everyone that visits a chat room. A chat room, on its surface, appears on the screen as a window in which new messages pop up, one after the other, as they are input by the various people visiting that Internet address (URL).

Social Support

People are building social support locally and globally. Interactivity is improving as the feature set of social platforms such as Facebook improve. Users have reported that they feel more supported and better able to deal with psychiatric or emotional challenges.

However, there are concerns that people who spend too little time involved in real-world social functioning may experience impaired social functioning in a use-it-or-lose-it fashion. The online world may provide an escape that is self-reinforcing in people that do not practice managing their moods and confronting situations in the real world.

There may be a good deal of individual variation in these matters. The best advice at this point in our understanding may be to make clients aware of the pros and cons and resulting needs (such as the need to develop a local support network of friends), and help them monitor themselves for red flags such as increasing isolation or anxiety in social situations.

On the positive side, consider the example of gay youth in low-population areas who found it easier to reduce suicidal impulses with the online support of others in the gay community.

Behavior Practice And Exposure Therapy

Therapists and personal coaches have assisted people in navigating environments in which they have had trouble. This is been done in the real world as well as via imagination. Now virtual worlds are providing another venue. Even without the assistance of a therapist, some users of Second Life report that they have gained therapeutic value by exploring social situations and self-concept in this medium. They say that these experiences have improved their performance in the real world through reduced anxiety and improved social expression. One theory is that the illusion of having a sexy, well-built avatar that mingles with glamorous people disrupts existing self-representations, allowing change to take place more easily. This has significant implications for therapy, in that therapists can use virtual social worlds as a cross between bibliotherapy and in vivo behavior practice.

Non-social virtual worlds can be used for a more controlled experience, and are typically thought of as a means of desensitization. The military is investing in such applications for veterans with PTSD. Of course, they are also being used as training aids for everything from flying aircraft to carrying out maneuvers on foot in tight urban warfare.

The boundary between virtual and real is blurring as our own navigation is increasingly supported by technology. Game controllers are connected to real weapons and robotic devices. Missiles allow a virtual piggyback ride and heads up display through a camera signal and telemetry. The pervasive exposure to virtual environments is increasingly taken for granted by a large portion of the population. This is paving the way for continued innovation and integration of telehealth as well as generating new ethical quandaries.

Manual or Automated Reminders

Various forms of reminders can be automated or carried out personally by therapists or paraprofessionals. Automated messages have helped people remember to take medication, to avoid situations that provoke relapse, and to use cognitive strategies that reduce anxiety or improve self-esteem. These can appear on cell phones as verbal or text messages.

Problem-Solving or Crisis Contacts

The telephone has long been the primary means of fielding crisis contacts (crisis calls). EAPs and major group practices designate "on-call" staff to field such calls. With the addition of video, counselors have the ability to use another sense for assessment. Moderated discussion forums can be monitored for posts that indicate a crisis. With instant chat and online interfaces, staff or automated programs can guide callers to the appropriate resource while reducing the load on clinical professionals.

Aftercare

Aftercare means treatment following inpatient care for substance abuse or another psychiatric problem. Often, a structured outpatient program is required as the level of care. This can mean group therapy three times per week, individual counseling once per week, involvement in a self-help group such as Alcoholics Anonymous, use of media such as books, homework such as journaling, and lifestyle modifications that help to prevent relapse.

There is an online aftercare program that provides multi-modal services. It is eGetGoing.com. We will review this program's features because online substance abuse treatment programs have shown merit (Copeland and Martin, 2004), this program is in use on a full scale, and because it demonstrates the integration of multiple telehealth media and features.

According to their promotional material, the features are as follows:

Modeled after existing, traditional outpatient programs

Has support of an affiliate treatment organization that provides live treatment (CRC Health Corporation)

Staffed by certified addiction counselors

JCAHO and other program certifications

Coverage by most major insurers

Measures to protect anonymity

Less costly treatment through use of online platform

Two weekly online recovery group counseling meetings (real-time, fully interactive)

Individual counseling as needed (live audio and video)

Videos provided during each group meeting that show a simulated (with actors) group therapy process. Each video illustrates and inspires discussion of recovery issues such as managing emotions in the service of recovery.

Coordination and communication with other providers or referring organizations such as EAPs or Probation staff in the same manner as occurs with live programs.

The program offers additional tools, including:

A white board (an area of the screen that the counselor can use to show text or diagrams generated real time or from files)

An internal email system that allows private contact among group members with the counselor.

A personalized page for each client where they can access materials and receive messages left for them by the counselor such as personalized feedback.

A personalized page for professionals involved with the case, where tracking can take place as authorized by the client.

A measure to aid confidentiality is that the participants in group do not see each other's faces. It is quite possible to have a portion of the screen used to show each participant's face, so this is not a default condition, necessarily. One could ask why this is necessary, when clients of live programs are able to see each other's faces as well as take in their body language. This fact brings into question whether this measure is actually a technological convenience for the program.

Case Management and Provider Collaboration

Various telehealth approaches to these issues are used, with more creative approaches yet to be developed. Consider the fact that you can easily create conference calls on Skype. You have the ability to copy an email response to multiple recipients (especially if you share encryption) to expedite coordination of information among clients and other professionals.

Avatar Therapy

Research is beginning to demonstrate what has been claimed by people involved in virtual worlds such as Second Life: That self-image and behavior can change for the better, simply by participating with an avatar. (Blascovich, & Bailenson, 2010)

As you'll recall, the avatar is the "being" that represents you in a virtual world. If you're having trouble imagining this, you can find countless videos showing this by going to YouTube.com and searching on "Second Life."

It may be that social acceptance and a highly fit and attractive avatar trigger the behavioral genetics of hierarchy that we observe in animals. This phenomenon may also be part of a class of observations concerning the use of optical illusions that alter the way we remember and process things about our own existence. Optical illusions have cured chronic pain with a mirror illusion or with an expanding hand illusion. Perhaps avatar illusions (if we can call unconscious identification with an avatar an illusion) are already curing low self-esteem.

This area will need a lot of study before it is adequately understood. Whatever we learn may result in new ways of purposely designing avatars, their environments, and their activities to produce desired change. Add to this our ability to match avatar movements precisely to our own body movements (through automation; no mouse or joystick) and we see yet another way that these illusions are becoming more influential, not just entertaining.

If avatar therapy becomes fully realized, it will provide an especially radical example of the convergence of technologies and new clinical practices.

Clinician supervision and training

Electronic communication can facilitate supervision and training. (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005) The methods used are similar to those discussed previously. They can include unobtrusive session monitoring (or post-session review) and feedback when the client permits it. Supervision resources can be extended by reducing travel time. Therapists and interns in remote areas can have access to supervision and training that otherwise would not have been possible. Some therapists are getting continuing education credits online. (But you knew that.)

Administrative Functions

We must also attend to the administrative uses of telehealth, because of 1) organizational needs, 2) intra-organizational needs, 3) legal and funding requirements, 4) ethical requirements, and 5) the potentially high level of challenge and investment that these systems can require (where poor execution can result in legal liability and ethical breaches, such as compromised privacy).

Fait Accompli: This is not a problem looming on the horizon--electronic communications in the administrative domain are a fait accompli. Those providers that are less technologically engaged are getting more and more incentives for electronic communications in service of administrative functions. Few, if any, group practices that take insurance are without the technology and policies needed in this domain.

Safety and Privacy: The legal and ethical requirements of the administrative arena are primarily those of client safety and privacy of records.

HIPAA (Health Insurance Portability and Accountability Act) legislation was developed largely because of 1) the needs of health corporations for a legal framework that allows for electronic transmission of records, and 2) the needs of citizens to have their privacy protected.

For more on HIPAA, see "Additional legal and Liability Issues."

Mobile apps and automation: The high level of mobility of healthcare workers presents opportunities for tremendous cost savings, as well as reduction of sources of medical errors. Mobile applications that are able to comply with privacy and other telemedicine standards are being adopted by major organizations. Mental health systems will probably find variations on this, although the demands are not as intense. Even small groups and solo providers are beginning to do mobile telehealth, perhaps without thinking through the issues.

Mobile telehealth activities include the following when used for professional health purposes: Cell phones, laptop use of Skype, exchange of text messages by cell phone or other mobile device, and the river of new applications being developed for mobile devices. These applications automate various mental health relevant activities. These are as simple as automated reminders to clients regarding appointments, medication, or new habits that need reinforcement. They are becoming much more complex and interactive.

8. Ethical, Legal, and Regulatory Issues

As with most innovations, ethics codes and laws have lagged behind the opportunities and changes stemming from tele-mental health. (Alemi et al., 1994) For many issues, it has not been difficult to recognize how the ethical guidelines should shape our practices. However, technological change can sometimes lead to uncertainty or neglect of ethical issues.

It's one thing to say that privacy must be protected, and another to say how much risk or exposure should be tolerated where there is a wide divergence in levels of security available. If a client is perfectly comfortable risking their privacy in an insecure medium such as email, should the therapist insist that this is not acceptable and require other means of communication or require encryption? How much is too much to expect a group practice to invest when putting security measures in place? How long and obscure should a password be when a provider protects their computer files? How much should a therapist know about the threats to safety posed by each of the online service types such as Facebook in order to discuss with a client their online behavior in terms of the client's safety or addiction risks?

No legislation or ethical guidelines can achieve that level of detail, (Ragusea & VandeCreek, 2003) especially given the constantly changing nature of telehealth and the larger technological and social environment. New threats and new applications of technology appear regularly. Ethical guidelines cannot provide precise standards for managing each ethical issue posed by telehealth practices. They offer guidelines to be applied using professional judgment, sometimes in novel circumstances.

Professionals, including mental health clinicians, have run into trouble through their personal or professional use of social media such as Facebook or discussion forums. Therapists must do their best to maintain a separate professional and personal identity online. However, the details of one's personal identity can profoundly affect one's professional identity. This means that the professional must consider the consequences of online disclosures.

Clients, meanwhile, expose themselves to risk by posting personal information too casually. Attorneys and law enforcement professionals now make it a routine matter to explore social media and other sites for helpful (read damaging) information about parties to lawsuits and suspects. There is the case of a woman whose long-term disability insurance was unexpectedly terminated because the company found an excuse: the woman had some pictures of herself smiling in happy environments. As of this writing, a lawsuit has been filed on the woman's behalf. To what degree should therapists and psychiatrists be accountable for guiding clients to avoid such threats? A general guideline is to develop at least a basic understanding of the electronic world that many clients inhabit, and to discuss potential problems with their involvement, such as posting potentially damaging information, or putting too much trust in people they have met online.

Specific Issues: Applying General Ethical Guidelines

In this section, we will review ethical topics that can be found in accepted ethics guidelines such as those of the APA and NASW. We will select ones that are especially germane to telehealth. The primary source of inspiration for this section is the California Board of Psychology (2011)

Competence: Professionals should not assume that their existing skills fully translate into electronic media, even the audiovisual environment of Skype. They must understand any special skills they may need that stem from technical requirements, strengths, and limitations or risks associated with the media used.

Contraindications: The professional must consider the technical and personal capacities of the client, as well as any threats that the media may pose. For example, an unstable and suicidal client may not be able to tolerate the therapist suddenly vanishing because of a power outage. A telephone that derives its electricity from the phone line, rather than the household current is important, because phone lines are not subject to the same outages as local power outages. Both client and therapist should have these available. Cell phones may run out of charge at a bad time.

Emergency policies and availability: Telehealth media pose additional requirements in this area. Distant clients should be aware of local emergency resources and back up communication access. A toll-free hard line is an alternative to Skype for clients with telephones. The therapist should know how he or she will initiate a welfare check should the client become unavailable or make comments that arouse concern.

Documentation and policies: The professional should make their documentation reflect the measures they have taken in all areas affected by telehealth media. Their policies should be reflected in forms such as their disclosure statement and statement of policies, including their emergency procedures.

Informed consent: Laws and ethics require that clients understand the procedures they are agreeing to. This means they should understand the nature of telehealth media that are to be used. Your state may have specific regulations on this. California requires verbal consent and does not provide details as to the contents of that consent in the law. (Cal. B&P 2290.5)

The appendix: "Generic Private Practice Policies for Tele-Mental Health" provides plenty of food for thought, and for additions to your written policies for clients. It reminds you to inform clients of things as basic as when you would charge to respond to an unscheduled call from a client, as well as addressing matters such as potential loss of videoconferencing connection and the unique privacy issues in telehealth. Having a signed policy statement helps to confirm informed consent, but you can document informed consent with a simple statement to the fact in your case notes, unless there are additional requirements in your state.

Remember to distinguish between legal and general definitions of telehealth and other terms. For legal purposes, telehealth may be defined more narrowly than its more typical use. For example, California considers neither a "telephone conversation nor an electronic mail message" to be telemedicine, but you can include policies for both of these media along with videoconferencing or other telehealth procedures.

Sometimes informed consent is confused with getting consent for the use of protected health information as required by HIPAA. This requirement is to have clients read and (if they are willing) sign a document disclosing the uses of their information and the limits of privacy. HIPAA sets forth specific requirements so it accurately reflects this federal law. Thus, so long as the information is integrated accurately into your existing Policy Statement, you do not need to create a separate one for HIPAA.

Privacy: Informed consent should include the implications of telehealth technologies for privacy, because electronic media pose their own threats. This can include policies regarding the specific media used. For example, email is a relatively insecure medium. (See "Specific Ethical Guidelines" below and the appendix section for help on policy development.) Additional Legal and Liability Issues

HIPAA: HIPAA is a big subject. Here we will just touch on a few key points pertaining to telehealth. Providing treatment or consultation electronically does not activate HIPAA. However, if you transmit PHI (protected health information, as defined in the legislation) for billing purposes in electronic form, your entire practice is required to comply with HIPAA--it does not just apply to those cases.

These requirements include a specified disclosure of policy practices that complies with HIPAA. There are various requirements concerned with security and privacy of PHI. With the HITECH (Health Information Technology) Act, providers are required under HIPAA to notify clients of any breaches of their privacy.

It is very likely that any given practice should be made HIPAA compliant. Actions that are commonplace for even solo practices trigger the need for HIPAA compliance. In general, what triggers HIPAA is electronic transfer of client information for billing-related purposes, usually health care claims. This includes using a managed care company website, email, or a computer-generated fax for these purposes.

Fortunately, the regulations are intended to be scaleable. That is, a solo practitioner or small group practice is not expected to comply with all the measures demanded of a large corporation. Also, the measures are generally so reasonable and realistic, that people familiar with security issues would consider them to be common sense. Thus, the HIPAA-compliant practitioner is afforded the additional level of protection from liability. If it has been some time since you reviewed HIPAA requirements, you may want to review the most current information for changes in the rules or improvements in our understanding of the rules.

Geographic area served: This topic can be frustrating and disappointing for clinicians who which to acquire clients from anywhere in the world. Laws of most states preclude practitioners from treating people in states in which they are not licensed to practice. (Morgan & Polowy, 2012) However, most states have guest licensure provisions that allow temporary exceptions, with quite diverse requirements. (American Psychological Association, 2010)

A 2010 review of state laws by the American Psychological Association (2010) indicated that for California, a licensed out-of-state psychologist may practice for up to six days per year with no advanced registration required. Their penalties for violation of the law included a possible fine of up to $2,000 and possible imprisonment up to six months. Delaware has a similar law, but it specifies a period of up to six days per year. Their penalties included a required $500-$1,000 fine for the first offense. Violations could result in imprisonment for up to one year per violation. A good number of states did not have any allowance for temporary practice, but their penalties were similarly harsh.

Reasons offered for such temporary practice laws include situations where a client is traveling or moving.

There are also liability and case law issues that are a moving target. For example. in a liability suit, questions may be raised as to why a therapist would see a client from a distance with electronic media, when there are therapists that are just a qualified that are available to see the client face to face. There is also the matter of liability insurance: will it cover the practitioner that treats someone in a state in which they are not licensed?

Fortunately, there are trends that are supportive of interstate practice. The most fully realized of these in the United States is that of military and Veterans Administration (VA) regulations that allow interstate practice of clinicians, including civilian employees. (Morgan & Polowy, 2012) There is also the work of the Health Resources and Services Administration (HRSA) to promote telehealth, including interstate work. This agency helps medically underserved communities such as low-population rural areas. (Morgan & Polowy, 2012)

Licensing: As indicated in the geographic topic, the professional must be in compliance with the licensing laws in their own state, and consider the laws pertaining to the area potentially being served or be at risk for being outside scope of practice. (Taylor, Symonette, & Singleton, 2009) States are passing laws pertaining to this issue, and they can be very restrictive.

As of this writing, it is not clear whether those laws will stand as they are, or whether legislation allowing more freedom in this regard will be passed. There are efforts to make it easier for telehealth providers to function across state lines. The American Bar Association is recommending measures along these lines, such as easier reciprocity and a standardized application that can be used for multiple areas. (Demetriou, American Bar Association, 2008)

Liability coverage: Consult with your malpractice provider as to the insurance and liability implications of any new media that you are considering. You could end up practicing naked without realizing it, especially when consulting with clients residing in states in which you not licensed.

Privacy policies for websites: Websites that accept user data such as posts or intake forms should have a privacy statement that spells out the privacy policies of the company or provider that operates the site. Federal laws are being proposed, some state laws already have such requirements in place, and some companies you may do business with (including Google and the bank that your merchant card account is with) require businesses to post a website privacy policy that contains certain prescribed elements. Also, the public expects their privacy to be protected according to transparent policies posted online. There are websites that automate the process of preparing a website privacy policy. For example, www.FreePrivacyPolicy.com.

Acquisition of forms and signatures: If the professional is not systematic, he or she may find that they have not made sure to get signed policy, disclosure, or release forms back from clients, when they are seeing clients at a distance. This leaves the therapist exposed, perhaps unwittingly. If mental health information is collected online for professional services, the forms must be secure. A competent webmaster can arrange this, or you can outsource to an organization that guarantees HIPAA compliance, such as LuxSci: http://LuxSci.com.

Resources: The appendix section includes two especially helpful items, one for your private practice policy form, and the other for a complete set of ethical guidelines.

The item for private practice provides text designed so that you can easily customize it and use it in your existing forms. It is based on existing ethical guidelines applying to telehealth. See "Appendix: Generic Private Practice Policies for Tele-Mental Health."

The appendix section provides ethical guidelines consolidated from all ethical guidelines as of 2009 by the Online Therapy Institute. This resulted by taking into account the telehealth-related ethical guidelines provided by the National Board of Certified Counselors (NBCC), the American Counseling Association (ACA), the International Society for Mental Health Online (ISMHO) and the British Association for Counseling and Psychotherapy (BACP).

Good example: The American Telemedicine Association: An oft-cited effort to provide practical and ethical guidelines for tele-mental health comes from the American Telemedicine Association (2009). The document, Evidence-Based Practice for Telemental Health, available online (see citation), provides detailed guidance in the ethics section, as well as specific technical and administrative guidelines. They parallel existing, accepted ethical guidelines. Much of the text would stand as a collection of general ethical guidelines for clinical practice if "telemental health" were substituted by "mental health practices" throughout. However, they are selected and slanted to deal with issues that are especially likely to occur (or have been known to occur) in telehealth practice. For example:

Telemental health organizations and providers shall ensure that appropriate staff are available to meet patient and provider needs before, during, and after telemental health encounters of all types. Organizations and practitioners shall have agreements in place to assure licensing, credentialing, training, and authentication of patients and practitioners as appropriate and according to local, state, and national requirements.

Some items are much more obviously a response to telehealth issues, such as this requirement to be aware of emergency resources available in the client's vicinity.

A patient site assessment shall be undertaken that includes obtaining information on local regulations and emergency resources, identification of potential local collaborators to help with emergency management.

The document appears to be on shaky legal ground regarding consent:

Although no special consents are needed to use telemental health to serve patients, additional layers of consent are required during the course of treatment of persons with mental health conditions.

The document does not include standards for discussion with patients of the special requirements of the telehealth media to be used in treatment. Although California law is minimalistic regarding telehealth and consent, it does require up front consent--but only verbal consent. (California B&P 2290.5) In contrast, other guidelines recommend more detailed consent. (Labardee, 2009) Of course, professional ethical guidelines often exceed the level of detail provided by laws.

The document covers specific areas of telehealth that require special attention. For example, it recognizes that telehealth has its own privacy vulnerabilities:

Special attention shall be paid to the enhanced need for privacy and confidentiality and every attempt to preserve the patients right to privacy shall be employed.

if transmitting protected health information or other sensitive information via the public internet, AES encryption or a virtual private network (VPN) shall be used to secure the transmission.

9. Special Focus: Administrative Issues

Here, we delve more deeply into the responsibilities of administration in telehealth.

Diverse Responsibilities and Solutions

Responsibilities: Where telehealth is concerned, policies, staff training, and technological investment must be brought to bear in order to meet the responsibilities inherent in electronic communications. These include: 1) prevention of security breaches by hackers (acquisition of information, hoaxes, and installation of viruses), 2) prevention of boundary crossing or ethical lapses by employees, and 3) prevention of criminal mischief by employees.

Threats: The outcomes that such efforts attempt to thwart include: 1) threats to the safety or well-being of patients or staff, 2) unauthorized release of private health information such as psychotherapy notes or client identities, 3) posting of information that would reflect negatively on the organization, and 4) noncompliance with legal and regulatory requirements.

Integration: Telehealth is, in part, such an intrinsic aspect of the electronic infrastructure of an office or organization, that all decisions regarding computer, communications, and data management must consider any effects that they may have on telehealth performance or policies, and vice versa.

It is outside the scope of this course to provide an adequate training on computer security and records management, but some details will be provided shortly. For now, note that the kinds of measures being used include:

Password protection

Shredding (or wiping) of electronic data (meaning complete erasure)

Secure storage of data including back up data

Off-site storage to prevent data loss

File encryption

Auditing and monitoring of employee activity

Monitoring and managing the company's (or professional's) online reputation

Effective integration requires that IT staff, marketing professionals, and other consultants be up-to-date, competent, and specialized.

Small-timers: Even solo practitioners need to use most of the above mentioned measures and technologies, though not with all the same requirements imposed on large organizations. Practitioners must go through a process of learning, self-assessment, setting objectives, selecting and acquiring tools, implementing the chosen solutions, and monitoring the results. They should lean heavily on the best sources of information and advice in order to avoid wasting time or making poor choices. A CEU course on HIPAA is highly recommended. If the provider can afford it, utilizing a consultant may save time. National organizations have regular articles on these subjects.

Policy Development

When employees are the problem: There are many examples of healthcare organization staff violating ethical boundaries. Sometimes this is well intentioned and accidental, as in the case of a physician that unintentionally provided too much information about a case when writing about healthcare experiences on Facebook. This made it possible to identify a patient. Clear policies and staff training can help to reduce such incidents.

Policies developing--the case of social media: A survey of organizations regarding their policies concerning use of social media indicates that companies are aware of a surge in social media use, and are recognizing that social media can play an important role in their marketing efforts. Part of this awareness is of the threats that social media use can pose to the organization, employees, and patients. However, as of 2011, the survey found that 45% of organizations did not have policies pertaining to social media. Only 31% had specific policies. (Health Care Compliance Association and Society of Corporate Compliance and Ethics, 2011) The report indicates that a minority of organizations has formal monitoring. Instead most default to reacting to incidents as they occur.

Private practice policies: In some areas there may be laws requiring informed consent to include written policies. In any case, they can be useful to prevent misunderstandings or even liability. See the sample form ("Generic Private Practice Policies for Tele-Mental Health") provided as an appendix to this course. It includes suggestions for customizing it to your practice.

Security Measures

Introduction

In this section, we will cover some fundamental guidelines and concepts for security measures that can help the professional meet their responsibilities for compliance with laws, regulations, and ethics. This is not a complete list of measures, and the situation is changing constantly. Some are not entirely telehealth-specific, but are related to electronic aspects of client privacy.

Password Protection

Passwords are a common means of guarding against unauthorized access to data and functions of computers and networks. When people log in to an online email site such as Hotmail or Google Mail, they must supply a user name and password in order to gain access. The professional must have a password that is sufficiently long and unpredictable that it can thwart unauthorized people from "hacking" their account. They must also keep whatever record they maintain of their passwords secure. At the same time, it is necessary to have someone authorized and able to access data in case of illness when that data is needed for professional reasons. There is a great deal of information available online as to current standards for passwords, password management, and other security measures.

Other things that can be password protected are the initial access to your computer after turning it on, re-accessing the computer after stepping away or allowing the screen saver to activate, access to specific programs, files, or directories, and online accounts. How to Create and Store Secure Passwords

You should use the following guidelines in creating passwords:

Do not use the same password for multiple accounts, except perhaps for accounts which, if breached, would not produce much harm.

Use at least eight characters.

Use various types of characters: upper case, lower case, numbers, and symbol characters such as the ampersand.

Do not use full words, names, meaningful numbers such as birthdays, or patterns of numbers or letters such as 123456.

For your most sensitive accounts, change passwords periodically.

Do not allow your browser or other software to automate filling in your passwords except for less sensitive accounts or where you have a computer safe from theft. Even so, you must be prepared to change any such passwords if the computer is compromised or stolen.

Since you probably can't remember all your passwords, you must have a way to refer to them. Many people use a booklet or removable thumb drive. However, you must remember to hide the source away properly, and to have back up in case of loss. If lost, you will need to change the pass words, at least for sensitive accounts. For added security, you can use a program to encrypt your passwords. Some allow online storage for a mobile solution.

Firewalls

Firewalls protect computers and networks from unauthorized access from persons using the Internet to hack computers. In other words, they keep persons or programs outside the network from getting in. Any competent IT (information technology) professional charged with maintaining a computer network. Computers and the devices that connect them to the Internet (routers or modems) have firewalls that must be configured properly.

Shredding

When users delete files such as documents, these files actually remain on the hard drive until they are written over by other data. This may take a long time. Programs have been designed to wipe (or shred) files so that they cannot be retrieved.

Back Up

Loss of data can be costly and compromise clinical care. Individuals and organizations must have proper back up policies, practices, and equipment. This can be as simple as having a schedule for burning files to media such as disks or external hard drives that are kept in secure locations. Users must be sure than any storage of data onto other computers is HIPAA compliant. For example, there is "cloud" storage, which means that the data is uploaded via the Internet to an organization's computers intended for this purpose. These are not necessarily sufficiently secure. Encryption is a means of gaining added security for all these measures.

Encryption

Encryption scrambles data so completely that it is nearly impossible to unscramble without a software "key" that unlocks the encryption. There are various encryption programs and strategies. There are free encryption programs, and a great deal of useful information about this online. Some programs actually keep the data that is used encrypted, not just the backup data. Modern encryption is highly secure. Security breaches are unlikely to come through a hacker breaking encryption.

Reputation Management

Professionals, organizations, and specialized services perform monitoring of the Internet to identify threats to the reputation of the professionals or organization. This can be done passively and with no financial investment by setting up alerts with Google. These can include variations on names such as the professional's name, the business' name, and even topics that the user wants to monitor.

This is a subject worthy of further research, because there are various strategies to choose from, and because it is a rapidly developing area. Example strategies include responding to negative articles or posts (submissions of comments or brief articles) online, soliciting positive comments from people familiar with the professional or organization, and producing positive articles or posts. Where information is untrue and harmful, legal action may be the appropriate solution. Posts that violate website policy may be taken down. Websites post their policies for this kind of situation. However, don't expect a post to be deleted just because you don't like it.

Where a client posts accusatory or negative information, the professional is bound by confidentiality not to reveal information about the client. Without verification, the post may not be coming from the person, but may be from an imposter.

In such situations, legal advice is needed to determine whether to respond, and what response is appropriate. Public accusations are not the same as a legal action in which the therapist is permitted to acknowledge the fact of the individual having been a client in order to mount a defense or pursue a debt.

Billing and Authorization for Payment

Billing is likely to have electronic aspects, regardless of whether there is telehealth activity taking place outside of billing. HIPAA covers the matter of maintaining confidentiality of identifying information. Where credit card payments are concerned, the professional can arrange for the service be identified as something other than psychotherapy (such as "Consult"), and that the business name used for this purpose be something other than one that implies mental health services. This is because various bank and processor staff will see the data. It may even be that the individual would not want their spouse to know that the consultation is for.

The professional's policies should clearly indicate under what circumstances billable hours or sessions will accrue. Will the client be charged if they follow up via email with additional questions? What about a five-minute emergency call between sessions? What about fifteen minutes? What if there are three of them? What accountability does the professional accept if the session is cut short by an outage?

The practitioner must be certain what media will be covered by payers such as insurance companies. Medicare began allowing online videoconferencing as of 2001 (Maheu, 2001). Authorization for mental health services using telehealth is expanding.

Copy Machines: Surprise!

Copy machines may store thousands of documents on hard drives. This poses a tremendous security risk, especially when the machine is sold. The documentation may not adequately explain this. Organizations and practitioners must make sure that the machine is set up properly in order to prevent this. A copy machine that is not treated with the same security measures as files (in terms of being locked away) is a HIPAA violation if it is retaining images of personal health data such as client records.

Work Station Responsibility

Staff must not leave their computer work stations or laptops unattended without signing out, or someone else may use their identity to search client records without authorization or engage in other mischief. Staff are fired for unauthorized medical record access. There are many incidents of staff being unable to resist the temptation because of a personal connection or because of the notoriety of a patient.

IT Support and Configuration

Even solo practitioners can develop relationships with consultants or affordable support services. The time involved in troubleshooting technical problems can be far out of proportion to the cost of using a service. Organizations are likely to have full-time staff for such support.

The National Association of Social workers (2012) suggests a number of possible changes to settings for Skype that most therapists would need a consultant to assist with. The more esoteric suggestions, such as registry changes pertaining to Skype may not be necessary for a practitioner that exercises consistent cautions such as not downloading files that are not confirmed as appropriate. Also, some of these measures may restrict important and legitimate activities. For example, preventing file downloads via Skype may not be practical.

Cultural and Linguistic Competence

Incentives and obligations: Telehealth providers must be concerned with issues of culture, class, and language, because one of the incentives for telehealth being the need to reach persons with poor access to mental health services.

Reasons for poor access may include poverty and rural living, and the areas needing access may be high in persons with limited English language and with significant differences in culture from those designing or providing telehealth services. Ethnic and racial minority populations are much less likely to have good access to quality mental health services. (Wells, Klap, Koike, and Sherbourne, 2001; Harris, Edlund, and Larson, 2005).

Systems thinking: From a systems perspective, one of the needs in this regard is to recognize the obstacles to receiving telehealth services that affect these populations. Systems and interventions must be designed with these realities in mind, and be customized to the specific populations and regions in question.

Cultural competency is an important part of our ethical standards, and refers to our need to understand those with whom we work. According to Castro, Proescholdbell, Abeita, and Rodriguez (1999) cultural competence is the capacity of a service provider or an organization to understand and work effectively in accordance with the cultural beliefs and practices of persons from a given ethnic/racial group.

Warning: Maheu (2001) warns that clinical care that fails to incorporate such knowledge is likely to fall outside the standard of care because, in part, it can impair informed consent, assessment, communication and education with clients, and the relationship and collaboration needed for direct care.

Thus, according to Taylor, Symonette, and Singleton (2009), "it is important to be aware of cultural beliefs and communication nuances among minority groups, as they are important components for practitioners to incorporate during online counseling sessions." and "a culturally engaged practitioner always considers a clients cultural background and experiences, which may influence the utilization of E-therapy as a relevant form of treatment for substance abuse."

Infrastructure development: In some scenarios, an organization is responsible for providing the infrastructure necessary for telehealth services. For example, an employer may contract with a managed care firm to cover employees in an under-served area. Federal grantees have been tasked with developing large-scale projects in under-served areas with high minority populations. One example is a program that includes telepsychiatry in southeast Georgia. (Diamand, Ellis, Marcin, Mawis, Nagrampa, Nesbitt, 2004) Such development should be undertaken with a good understanding of the populations to be served. Measures should be taken to ensure cultural relevance.

The appendix "HHS Material on Cultural Competence" provides background on the issues that must be managed in this area.

Appendix 1. Ethical Framework for the Use of Technology in Mental Health (Online Therapy Institute)

This set of guidelines is compiled from those offered by National Board of Certified Counselors (NBCC), the American Counseling Association (ACA), the International Society for Mental Health Online (ISMHO) and the British Association for Counseling and Psychotherapy (BACP) at the time of publication.

The guidelines are provided under a Creative Commons license at http://onlinetherapyinstitute.com/ethical-training/ (accessed 6/28/2012, 2009 version)

A competent practitioner working online will always adhere at least the following minimum standards and practices in order to be considered to be working in an ethical manner.

Practitioners have a sufficient understanding of technology.

Technology basics are required for practitioners who choose to deliver therapeutic services via technology. Practitioners will possess a basic understanding of technology as the technology relates to delivery of services

Encryption: Practitioners understand how to access encrypted services to store records and deliver communication. Records storage can be hosted on a secure server with a third-party, stored on the practitioners hard drive utilizing encrypted folders or stored on an external drive that is safely stored.

Backup Systems: Records and data that are stored on the practitioners hard drive are backed up either to an external drive or remotely via the Internet.

Password Protection: Practitioners take further steps to ensure confidentiality of therapeutic communication and other materials by password protecting the computer, drives and stored files or communication websites.

Firewalls: Practitioners utilize firewall protection externally or through web-based programs.

Virus Protection: Practitioners protect work computers from viruses that can be received from or transmitted to others, including clients.

Hardware: Practitioners understand the basic running platform of the work computer and know whether or not a clients hardware/platform is compatible with any communication programs the practitioner uses.

Software: Practitioners know how to download and operate software and assist clients with the same when necessary to the delivery of services.

Third-party services: Practitioners utilize third-party services that offer an address and phone number so that contact is possible via means other than email. This offers a modicum of trust in the third-party utilized for such services as backup, storage, virus protection and communication.

Practitioners work within their Scope of Practice.

Scope of Practice indicates the specific area to which a practitioner may practice. Scope of practice in many geographic areas also defines where a practitioner may practice; whether the practitioner may practice across various geographical boundaries and within what parameters a practitioner may practice. Practitioners also follow local and regional laws and codes of ethics as applicable.

Understanding of boundaries and limitations of ones specific discipline: Practitioners understand which assessments and interventions are allowed within their specific discipline. For instance, career counselors who have no training in mental health issues generally do not provide psychotherapy services.

Understanding of specific laws or ethics within ones own discipline or geographic location: Practitioners understand the limits set forth by laws or ethics within the applicable geographic location. For instance, in the United States, Licensed Professional Counselors cannot call themselves Psychologists, and in the UK the term Chartered Psychologist is reserved by law for use only by those with proper recognition from the appropriate authorities. Certain states dictate what a practitioner can be called due to the implementation of Title laws. Practice laws may prevent a licensed practitioner from interpreting certain personality tests in one state, yet the same practice may be accepted under Practice law in another state.

Respect for the specific laws of a potential clients geographic location: Practitioners understand that different geographic regions may offer additional limits to practice, particularly with regard to jurisdiction. For instance, a counsellor in the UK should be cognizant of the laws of a client who resides in a U.S. state such as California in which the law prohibits consumers residing in California from engaging in counseling from a practitioner who is not licensed in California.

Practitioners seek out training, knowledge and supervision.

Training, knowledge and supervision regarding mental health and technology is paramount to delivering a standard of care that is considered best practice within ones geographic region and within a global context. Practitioners are encouraged to demonstrate proficiency and competency through formal specialist training for online work, books, peer-reviewed literature and popular media. Clinical and/or peer supervision and support are mandated for practitioners who cannot practice independently within a geographic region and is highly recommended for all practitioners.

Formal Training: Practitioners seek out sufficient formal training whenever possible through college, university or private settings. Formal training is displayed on the practitioners website.

Informal Training: Practitioners seek out continuing education and professional development and conferences, conventions and workshops.

Books: Practitioners read books written by the general public and professionals.

Peer-reviewed Literature: Practitioners read peer-reviewed literature that includes the latest theories and research.

Popular Media: Practitioners are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of mental health and technology on the popular culture.

Clinical/Peer Supervision: Practitioners seek clinical supervision whenever the practitioner cannot practice independently within his or her geographic location. Clinical and/or peer supervision is sought by all practitioners who deliver services via technology. Clinical and peer supervision is delivered either face-to-face or via encrypted methods.

Example Topics of study related to Training, Knowledge and Supervision (not an exhaustive list):

Online Therapy

Online Clinical Supervision

Online Peer Supervision

Avatar Therapy

Cyberpsychology

Text-based Therapy

Telehealth

Behavioral Telehealth

Telepsychiatry

Internet Addictions

Social Media

Mixed Reality

Online Relationships

Second Life

Online Peer Support

SMS Text Messaging

Virtual Worlds

Virtual Reality

Mental Health and Technology

Practitioners display pertinent and necessary information on Websites.

Websites provide access to information for the general public, potential clients, clients and other professionals.

Crisis Intervention Information: People may surf the internet seeking immediate help. Practitioners display crisis intervention information on the home page. Practitioners understand that people in crisis may visit the website from anywhere in the world. Offering global resources such as Befrienders International or The Samaritans is the best course of action.

Practitioner Contact Information: Practitioners offer contact information that includes email, post address and a telephone or VOIP number. While it is not recommended that post addresses reflect the practitioners home location, clients should have a post address for formal correspondence related to redress, subpoenas or other mailings requiring a signature of receipt. Practitioners state the amount of time an individual may wait for a reply to email or voice mail. Best practice indicates a maximum of two business days for therapeutic inquiries.

Practitioner Education, License and/or Certification Information: Practitioners list degrees, licenses and/or certifications as well as corresponding numbers. If the license, certification board, or professional body offers a website that allows the general public to verify information on a particular practitioner the license and certification listings should link directly to those verifying body websites. Practitioners consider listing other formal education such as college or university courses, online continuing education and professional development courses, and conference/convention attendance directly related to mental health and technology.

Terms of Use and Privacy Policy: Terms of Use, often all or in part, synonymous with a practitioners informed consent, is available on the website either as a page on the website or a downloadable document. The practitioners privacy policy is also available in the same way and offers information about if or how email addresses, credit card information and client records are used, shared or stored. Practitioners must ensure that they comply with the requirements of the Data Protection Act and other aspects of applicable law, and in the United States, practitioners display the Notice of Privacy Practices to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that are required for patient consent in the geographic location of the practitioner should be posted on the website as well.

Encrypted Transmission of Therapeutic and Payment Information: Practitioners offer secure and encrypted means of therapeutic communication and payment transactions. Email and Chat programs whether embedded within the practitioner site (private practice or e-clinic) or utilizing 3rd party platforms such Hushmail or Cryptoheaven are explained on the website. Payment methods are explained as well through merchant information or information provided by the practitioner.

Practitioners conduct an initial Intake and Screening process.

The initial screening and intake process begins with the potential client's first contact. The practitioner implements formal and informal measures for screening a client's suitability for delivery of mental health services via technology.

Client's Technology Skills: Practitioners screen potential client's use of technology through questions at the outset. Questions include but are not limited to an inquiry about the client's experience with online culture e.g. email, chat rooms, forums, social networks, instant messaging and online purchasing, mobile texting, VOIP or telephones. Practitioners ensure that the client's platform is compatible with the varying programs and platforms the practitioner may utilize during the course of therapy.

Client's Language Skills: Practitioners screen for language skills from the initial contact through the first few exchanges. Assessing for language barriers, reading and comprehension skills as well as cultural differences is part of the screening process. Text-based therapy may also involve screening for keyboarding proficiency.

Presenting Issue, Client Identity and Clinical Concerns: Practitioners screen to ensure the presenting issue is within the scope of practice and knowledge base of the practitioner. Screening around issues of suicidality, homicidality and immediate crisis are formally addressed through an intake questionnaire or first exchange. Practitioners incorporate a mechanism for verifying identity of clients by asking for a formal identification number such as Driver's License or other satisfactory method. The client must not be anonymous, offering at a minimum: first and last name, home address, and phone number for emergency contact. Minors must be identified through parental consent. If client identity is not required, such as is the case with crisis hotlines and triage settings, limitations of the service are stated clearly. Other concerns regarding mental stability are addressed- e.g. client currently hallucinating or delusional; actively using drugs and alcohol so that insight-oriented interventions would not be suitable; and any other medical or physical issues that might impede the intervention or require a different method of delivery, e.g. disability that impairs typing, rendering a chat exchange cost-prohibitive. Any assessment instruments that are utilized should be approved for online or computer-assisted use according to the test author/publisher.

Practitioners offer an Informed Consent process.

The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information is accessible via the practitioners website. The informed consent process includes a formal acknowledgement from the client to the practitioner. This acknowledgement is received via encrypted channels. Informed Consent content is revisited during the course of therapy as necessary and beneficial.

The following topics are addressed within Informed Consent:

Possible Advantages and Disadvantages of Online Therapy: Information is disseminated about the pros and cons of online therapy including such disadvantages as lack of visual and auditory cues and the limitations of confidentiality via technology, and advantages that include easy scheduling, time management and a no need to incur transportation costs.

Confidentiality and Technology

Encryption: An explanation about the use of encryption for therapeutic exchanges and lack of encryption if/when unencrypted methods (standard email, forum posts, mobile telephone, SMS texting, social networking) are used for issues such as appointment changes and cancellations.

Therapist as Owner of the Record: Unless otherwise specified through law in the practitioners geographic location, the therapist remains the owner of the therapeutic record including all transcripts, notes and emails. The client is informed that posting direct information about the therapist or verbatim information from sessions is prohibited.

File Storage Procedures: The client is informed about how records are stored (web-based, third party or hard-drive/external drive) and for how long the records are maintained. All procedures conform to the standards laid down in applicable law and as required by any relevant authority (such as professional body) and, at least, include encryption and password protection and a commitment to destroy all records after a given period as required by law/regulation/best practice.

Privacy Policy: The practitioner's privacy policy is also included in the Informed Consent process including information about how email addresses, credit card information and client records are used, shared or stored. In the United States, practitioners must include the Notice of Privacy Practices to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that are required for patient consent in the geographic location of the practitioner are included in the Informed Consent process.

Other Informed Consent Issues

Practitioner's Geographical Jurisdiction: The physical location of the practitioner is offered in the Informed Consent and if the practitioner is licensed within a specific jurisdiction, the Informed Consent states client understands services are rendered under the laws or jurisdiction of the relevant country, state or region.

How to Proceed during a Technology Breakdown: The client is informed about how to proceed if a technology breakdown occurs during a session, e.g. If we disconnect, try to reconnect within 10 minutes. If reconnection is not possible, email or call to reschedule an appointment.

Emergency Contact: Practitioners offer specific information about who to contact in case of an emergency and set specific rules about emergency emails that the practitioner may not be privy to e.g. (suicidal emails in the middle of the night, threatening posts on a support forum). Practitioners research local resources within the client's geographic area as emergency backup resources.

Cultural Specifics that May Impact Treatment: Practitioners discuss varying time zones, cultural differences and language barriers that may impact the delivery of services. Practitioners should also ensure at or prior to the start of therapy, that the client's expectations of the service being offered (such as the meaning of the term counselling etc.) is sufficiently close to their own understanding and should take into account that different cultures around the world can have very different understandings of these matters.

Dual Relationships: Practitioners discuss with clients the expected boundaries and expectations about forming relationships online. Practitioners inform clients that any requests for friendship, business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored to preserve the integrity of the therapeutic relationship and protect confidentiality. If the client has not been formally informed of these boundaries prior to the practitioner receiving the request, the practitioner will ignore the request via the social media site and explain why in subsequent interaction with the client.

Insurance, Subsidy or Reimbursement Information: If the client resides in a geographic area that generally accepts insurance or other forms of reimbursement for therapy services, the practitioner informs the client of this information. Conversely, services delivered via technologies that are not covered at all or at the same rate, the practitioner informs the client of this information also.

Appendix 2. Generic Private Practice Policies for Tele-Mental Health

Note: The more people get used to telehealth, the less you need sections such as 4, 5, and 6. Select from this appendix and streamline according to your judgment and clientele.

Note: This can be incorporated into your existing policy statement or exist as a separate policy statement, signed separately.

Note: this policy is based on a review of recommendations and other literature. It has not been reviewed by an attorney or national organization. It does not constitute legal advice. It can only serve as a guide in preparing your own policies.

POLICIES These are my policies regarding communication by phone and other electronic means. It includes policies on our between-session contacts.

Telemedicine Policies (Electronic Communications)

Messages and Privacy

I check messages (**how often) on weekdays and (**how often) on weekends.

I usually respond within (**time period) but there are circumstances that may delay a response. If I do not respond, please try again in case there was a technical problem.

Preserve your privacy: Unless you take special measures, email and text messages have more risk to privacy than phone or VoIP (such as Skype). If you elect to use less secure methods, avoid revealing sensitive information. For email, use a provider with SSL (HTTPS).

Emergencies

In an immediate or life-threatening emergency such as suicidal feelings, go to an emergency room or dial 911. If you are safe enough to talk about it with me instead, (**state emergency contact policy).

(Note: This is for providers in California, so adapt this according to the laws in your state. )

Services via Electronic Communication:

Mental health services through electronic communication (such as Skype) are telemedicine according to California law.

1. You will not lose the right to treatment or benefits if you decide not to accept telemedicine services.

2. Your confidentiality limits and protections (see Privacy Policy Note: this directs the client to your existing privacy policy for your practice) are not to be changed as a result of using telemedicine. However, there are risks to privacy of electronic communications. Please discuss any concerns with me. I will do my best to inform you of the risks to privacy.

3. Your rights and ability to your records are the same, regardless as to whether they were generated through telemedicine. (See Policies on access to records.) Note: this directs the client to your existing policy on records.

4. Telemedicine has benefits and risks or disadvantages. So long as I have your permission, I will work with you to use any telemedicine methods that can provide you with benefits such as saving time and travel. I will work with you to avoid disadvantages such as too much risk to your privacy or using electronic communication when a face-to-face visit appears to be necessary. Assessment and treatment may be improved through face-to-face interaction for some situations.

5. Note: Optionally, add any comments about specific media that you may rely on with some clients, such as video conference calls. Do you have any policies specifically on that? Specifically, do you do sessions by phone or VoIP? Do you have different rates for such contacts.

6. It is important to understand that at times, email communication or cell phone communication including text messages content between you and your therapist maybe misinterpreted due to lack of eye contact, vocal tone, and attending to facial expressions between client and therapist. If you are unsure about the intent or content of an email or the intent of the therapist via cell or phone conversations, you are encouraged to discuss concerns, questions and ask for clarification.

7. Between sessions, additional telephone contacts may be billed by the hour if they exceed five minutes. They should only be for exceptional situations such as a crisis. This does not apply to calls regarding scheduling. Note: Modify this according to your availability, and indicate your rates.

8. Email contact can be used for scheduling only. (Note: modify this if you use this or other media besides phone or Skype for therapeutic purposes. Include rates.)

9. If you frequently contact your therapist via email or phone outside of your normal session, it is important to understand that your therapist will bill you for a portion of his or her time, based on his or her regular hourly rate as agreed upon. As the therapist sees numerous clients per week, the therapist may receive numerous emails and calls each week from many clients.

Note: Other topics to consider for this policy statement, if not covered in your existing policies, follow. Some of these topics may be part of your verbal interaction, depending on the kind of clients you see.

The possibility of an increased session frequency or level of care for clients that turn out to need more. Whether you can accommodate this. That you will provide referral or attempt to assist the client in locating a higher level of care. That a high level of between-session contacts may indicate a need for a higher level of care.

That it is not a good idea to share information such as recordings of calls or text from messages with others, because it compromises the client's privacy and could be regretted later because of the inability to control the materials once they are out of the client's control. It can also be taken out of context and damage the therapists reputation. It may be a cause to terminate treatment.

Your signature below indicates only that you understand the information and policies. Please discuss any questions or insights you have to your satisfaction before signing.

Note: Many therapists also state that the signature indicates that the client agrees with the policies and will abide by them.

Name and signature blanks go here in the same format as your other documents.

Appendix 3. HHS Material on Cultural Competence
Introduction The following material is a well-cited explanation of cultural competence issues from HHS. (Taylor, Symonette, & Singleton, 2009) - RY
Keys to Cultural Competence

Beliefs and attitudes about particular groups of people usually dictate individuals behavior toward that group, regardless of the accuracy of the perception (HHS, 2001). Mistrust of the medical community has been documented repeatedly, according to the Epidemiologic Catchment Area study conducted in the early 1980s (HHS, 2001). In the study, nearly 50 percent of the African Americans surveyed reported a fear of receiving mental health treatment, compared with 20 percent of whites. Current-day discrimination and racism coupled with historical mistreatment are real barriers that may contribute to a lack of trust toward mental health treatment and the medical community (HHS, 2001).

In addition, a 1999 study funded by the Kaiser Family Foundation reported similar findings within minority populations. Results indicated that 12 percent of African Americans and 15 percent of Latinos, vs. 1 percent of whites, believed that they had received substandard medical care because of their race (HHS, 2001). Data from the Commonwealth Fund Minority Health Survey (1997) reported that 43 percent of African Americans and 28 percent of Latinos, compared with 5 percent of whites, perceived they were treated poorly by a health care professional because of their race and cultural background (HHS, 2001). Likewise, immigrants and refugees are also leery of the U.S. health care system. Consequently, the delivery of mental health and substance use disorder treatment services for undocumented people is in jeopardy because this population fears deportation and mistreatment (HHS, 2001). Few research studies examine the link between effective culturally competent substance abuse treatment services through electronic modalities for minority individuals. Sanchez-Page (2005) identifies and addresses four counseling inadequacies in delivering culturally appropriate mental health treatment online. Lack of culturally suitable evaluation tools. Researchers and practitioners should design culturally suitable evaluation tools to measure the benefits of E-therapy compared with face-to-face counseling among minority populations and their white counterparts. Lack of awareness about communication styles. Practitioners must understand the important impact of cultural communications styles among minority populations and how the absence of verbal and nonverbal cues associated with online counseling may negatively influence the relationship between the practitioner and client. Limited access to technology in communities of color. Poverty and disproportionate access to technology within communities of color limit the use of E-therapy as a mainstream counseling option for minority groups. Consequently, further research is required to examine the usefulness of electronic therapy among minority populations. Lack of culturally appropriate online interventions. Develop culturally appropriate online interventions that address the cultural beliefs and practices of individuals from specific ethnic/racial groups (Castro et al., 1999). By effectively addressing important cultural factors, clinicians may begin cultivating the opportunity to advance the integration of E-therapy among underrepresented and underserved populations (Sanchez-Page, 2005). Stigma

Members of minority communities often have critical views about mental illness (HHS, 2001).

In these communities, individuals who suffer from mental illness are often ostracized and subjected to shame and embarrassment by family members (HHS, 2001). Documenting the intensity of this stigma is difficult because minority groups are reluctant to address issues related to mental illness and substance abuse (HHS, 2001). Few cross-cultural studies have examined the relationship between race and mental illness. Zhang, Snowden, and Sue (1998) conducted a study comparing Asian Americans and whites living in Los Angeles. Data indicated that more than twice the number of whites (25 percent) would consider talking about their mental health challenges with a friend, compared with 12 percent of Asians. Study reports also showed that only 4 percent of Asian respondents would seek assistance from a mental health professional, compared with 26 percent of white respondents. Thirteen percent of white participants found it acceptable to discuss mental distress with a doctor, compared with only 3 percent of the Asian participants found it acceptable (HHS, 2001).

In the 1970s, the National Opinion Research Center began to evaluate societal views of mental illness. This extensive analysis initiated the 1996 General Social Survey (HHS, 2001), which gauged respondents personal opinions about mental illness when presented with various short stories depicting people diagnosed with mental illness. Study results indicated that respondents labeled people with mental illness as a menace and unfit to handle personal responsibilities. Intense criticism was aimed at individuals with substance abuse problems and schizophrenia. However, researchers observed that neither the race of neither the respondents nor of the individuals portrayed in the short stories factored into the stigma associated with mental illness (HHS, 2001). On the other hand, a second study assessing public bias toward individuals with mental illness captured how different ethnic groups respond to people with mental illness (HHS, 2001). After interacting with individuals diagnosed with mental illness, Native Americans and whites reported a greater tolerance of people with mental illness, while African Americans, Latinos, and Asians reported less tolerance. The self-worth of family members and individuals diagnosed with mental illness is directly affected by the stigma of being labeled crazy. Often, the intense stigma attached to mental illness prevents people, particularly those within minority groups, from receiving treatment for mental illness. However, cultural sensitivity and acknowledgement of cultural stigma associated with receiving mental health and substance abuse treatment services is helpful when relating to minority clients (HHS, 2001).

Embracing Diversity

Integrating fundamental parts of ethnic group culture, including styles of communication, value systems, historical background, and religious and traditional beliefs, are believed to increase the use of mental health services among minority clients. Researchers recognize that by adapting mental health treatment services to a client's familiar culture, potentially significant treatment outcomes may be realized (HHS, 2001). During the last decade, practitioners and other mental health care professionals began emphasizing the importance of delivering culturally competent mental health services while encouraging buy-in from minority consumers, families, and communities. For example, a noted culturally appropriate 21mental health care service delivery model designed for children and adolescents with severe emotional disabilities concentrates on the strengths of ethnic groups culture for effective service delivery (Cross, Bazron, Dennis, and Isaacs, 1989). Principal components involved in adapting this mental health care service delivery model include policy, training, resources, practice, and research. Linguistic competence is equally significant in developing culturally appropriate treatment services. The National Center for Cultural Competence at Georgetown University defines linguistic competence as the capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. Linguistic competency requires organizational and provider capacity to respond effectively to the health literacy needs of populations served (The National Center for Cultural Competence, 2006). For example, the bilingual website Amigos utilizes an electronic psychoeducational tool to help minorities access health-related resources (Guanipa, Nolte, and Lizarraga, 2002). Providing availability to computers, and educating the targeted community about mental health care and multiculturalism, was the objective of establishing Amigos. By implementing electronic modalities similar to the Amigos program, minority groups may cautiously utilize culturally and linguistically competent mental health and substance abuse treatment services. Continuing research by practitioners and further development of culturally appropriate online interventions may encourage the use of E-therapy by minority populations.

Summary

- Developing and testing the effectiveness of culturally appropriate online substance abuse treatment interventions requires buy-in from minority consumers, families, communities, and mental health professionals.

- Therapists should recognize that the historical discrimination that minority groups have experienced in encounters with the medical community and the resulting feelings of mistrust from these encounters may influence the willingness of individuals to seek mental health and substance abuse treatment.

- Poverty and limited access to technological resources may influence the utilization of E-therapy as a mainstream counseling option within some minority groups. In addition, consider that standard substance abuse curricula and general interventions may not necessarily provide the best treatment strategies for minority communities.

- Practitioners must recognize and emphasize the importance of providing culturally competent treatment services and integrate fundamental components of ethnic group culture, including communication styles and religious and traditional beliefs.

Integrating these cultural components may increase the use of mental health services among minority clients.

Appendix 4. California Board of Psychology: Information on Telepsychology

http://www.psychboard.ca.gov/consumers/telepsych.shtml

From time to time the board becomes aware of articles or information that would be educational and informative to licensed psychologists and the consumers of psychological services. In such cases, the board will attempt to bring this information to licensees and consumers, provided the necessary authorizations for publication can be obtained. In the posting of any information on its web site, the board will maintain sole discretion as to what information is posted.

The following information regarding telepsychology has been excerpted with the permission of the primary author from "Regulation of Telepsychology: A Survey of State Attorneys General" by Gerry Koocher & Elisabeth Morray. Professional Psychology: Research and Practice, October, 2000, vol. 31, issue #5, pages 503-508.

In light of the survey data obtained in this research, the authors offer the following regarding telepsychology:

1. Before engaging in the remote delivery of mental health services via electronic means, practitioners should carefully assess their competence to offer the particular services and consider the limitations of efficacy and effectiveness that may be a function of remote delivery.

2. Practitioners should consult with their professional liability insurance carrier to ascertain whether the planned services will be covered. Ideally, a written confirmation from a representative of the carrier should be obtained.

3. Practitioners are advised to seek consultation from colleagues and to provide all clients with clear written guidelines regarding planned emergency practices (e.g., suicide risk situations).

4. Because no uniform standards of practice exist at this time, thoughtful written plans that reflect careful consultation with colleagues may suffice to document thoughtful professionalism in the event of an adverse incident.

5. A careful statement on limitations of confidentiality should be developed and provided to clients at the start of the professional relationship. The statement should inform clients of the standard limitations (e.g., child abuse reporting mandates), any state-specific requirements, and cautions about privacy problems with broadcast conversations (e.g., overheard wireless phone conversations or captured Internet transmissions).

6. Clinicians should thoroughly inform clients of what they can expect in terms of services offered, unavailable services (e.g., emergency or psychopharmacology coverage), access to the practitioner, emergency coverage, and similar issues.

7. If third parties are billed for services offered via electronic means, practitioners must clearly indicate that fact on billing forms. If a third-party payer who is unsupportive of electronic service delivery is wrongly led to believe that the services took place in vivo as opposed to on-line, fraud charges may ultimately be filed.

Appendix 5. APA Statement on Services by Telephone, Teleconferencing, and Internet (1997, Superseded, not in use)

NOTE: This has been superseded, but is an interesting document in that it directly addresses ethics issues in terms of telehealth media. - RY

http://www.apa.org/ethics/education/telephone-statement.aspx

A statement by the Ethics Committee of the American Psychological Association

The American Psychological Association's Ethics Committee issued the following statement on November 5, 1997, based on its 1995 statement on the same topic.

The Ethics Committee can only address the relevance of and enforce the "Ethical Principles of Psychologists and Code of Conduct" and cannot say whether there may be other APA Guidelines that might provide guidance. The Ethics Code is not specific with regard to telephone therapy or teleconferencing or any electronically provided services as such and has no rules prohibiting such services. Complaints regarding such matters would be addressed on a case by case basis.

Delivery of services by such media as telephone, teleconferencing and internet is a rapidly evolving area. This will be the subject of APA task forces and will be considered in future revision of the Ethics Code. Until such time as a more definitive judgment is available, the Ethics Committee recommends that psychologists follow Standard 1.04c, Boundaries of Competence, which indicates that "In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm." Other relevant standards include Assessment (Standards 2.01 -2.10), Therapy (4.01 - 4.09, especially 4.01 Structuring the Relationship and 4.02 Informed Consent to Therapy), and Confidentiality (5.01 - 5.11). Within the General Standards section, standards with particular relevance are 1.03, Professional and Scientific Relationship; 1.04 (a, b, and c), Boundaries of Competence; 1.06, Basis for Scientific and Professional Judgments; 1.07a, Describing the Nature and Results of Psychological Services; 1.14, Avoiding Harm; and 1.25, Fees and Financial Arrangements. Standards under Advertising, particularly 3.01 - 3.03 are also relevant.

Psychologists considering such services must review the characteristics of the services, the service delivery method, and the provisions for confidentiality. Psychologists must then consider the relevant ethical standards and other requirements, such as licensure board rules.

(This policy statement was issued under the 1992 Ethics Code. The 2003 Ethics Code supersedes the 1992 version of the Ethics Code. Therefore, this statement is considered inactive.)

Appendix 6. California Business and Professions Code Section 2290.5 (As revised by the Telehealth Advancement Act of 2011)

Note: This is considered to be model legislation addressing telemedicine. - RY

2290.5. (a) For purposes of this division, the following definitions shall apply:

(1) "Asynchronous store and forward" means the transmission of a patient's medical information from an originating site to the health care provider at a distant site without the presence of the patient.

(2) "Distant site" means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.

(3) "Health care provider" means a person who is licensed under this division.

(4) "Originating site" means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.

(5) "Synchronous interaction" means a real-time interaction between a patient and a health care provider located at a distant site.

(6) "Telehealth" means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.

(b) Prior to the delivery of health care via telehealth, the health care provider at the originating site shall verbally inform the patient that telehealth may be used and obtain verbal consent from the patient for this use. The verbal consent shall be documented in the patient's medical record.

(c) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.

(d) This section shall not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.

(e) All laws regarding the confidentiality of health care information and a patient's rights to his or her medical information shall apply to telehealth interactions.

(f) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.

(g) (1) Notwithstanding any other provision of law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.

(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).

(3) For the purposes of this subdivision, "telehealth" shall include "telemedicine" as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.

Appendix 7. Resources Directory

PsychIN Directory: Tele-Mental Health

http://www.psychinnovations.com/tele_mental_health_telehealth

Annotated directory of tools for research and reference now includes annotated, categorized tele-mental health resources including turnkey solutions. Organizations (Some have publications and forums)

Ethics, American Counseling Association

http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx

Page lists articles on ethical issues that include telehealth. Appears to be updated regularly. Includes their code of ethics.

International Association of CyberPsychology, Training, and Rehabilitation

http://iactor.ning.com/

iACToR is the official voice and resource for the international community using advanced technologies in prevention, therapy, training, education, and rehabilitation. Our mission is to bring together top researchers, policy makers, funders, decision-makers and clinicians, pooling collective knowledge to improve the quality, affordability, and availability of existing healthcare.

Ultimately, through international collaboration with the most eminent experts in the field, we are working to overcome obstacles and increase access to top-quality healthcare for all citizens. By enhancing public awareness of the possibilities that technology offers, we move toward changing and improving healthcare as it currently exists.

TeleHealth.net

http://telehealth.net

Evidence-Based Practice for Telemental Health, July 2009

http://www.americantelemed.org/files/public/standards/EvidenceBasedTelementalHealth_WithCover.pdf

Alternate URL:

http://virtualservices.kansasworks.com/About/Documents/Telemental%20Health2.pdf

Telemental Health SIG

http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3326

The Telemental Health Special Interest Group includes administrators, clinicians, and information technology professionals. Its goal is to enhance and support the use of technology in the delivery of mental health services, and its mission is to promote dialogue between mental health practitioners, to improve the understanding and use of telehealth applications in the delivery of mental health services, and to provide guidance to the ATA Board of Directors regarding telemental health

ATA Wiki

http://wiki.americantelemed.org/

Online Therapy Institute

http://www.onlinetherapyinstitute.com

Has broad spectrum of resources and articles. Includes ethical frameworks and a social network that is free to join.

Offers training.

Verifies websites so that individuals and businesses can demonstrate to their audience that their website is ethical and in compliance with what OTI considers to be best practice.

Telehealth

http://www.selfhelpmagazine.com/ppc/telehealth.php

Telehealth issues and resources for professionals.

American Telemedicine Association

http://www.americantelemed.org/

"The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world. Established in 1993 as a non-profit organization and headquartered in Washington, DC, membership in the Association is open to individuals, healthcare institutions, companies and other organizations with an interest in promoting the deployment of telemedicine throughout the world. ATA is governed by a Board of Directors, which is elected by the association's membership."

The Center for Telehealth & E-Health Law

http://www.ctel.org/

Provides consultation, services, and online articles and resources.

"CTeL is the only organization that provides legal and regulatory expertise on emerging telehealth issues. CTeLs Board of Directors is comprised of leading experts with years of experience in telehealth issues, such as: credentialing and privileging, e-prescribing, Federal Communications Commission (FCC) and telecommunication matters, physician and nurse licensure, and Medicare and Medicaid reimbursement."

APA Rural Health Resources

http://www.apa.org/practice/programs/rural/resources.aspx

Includes section on telehealth

ISMO

https://www.ismho.org/home.asp

We are an international community exploring and promoting Mental Health in the digital age. Our members include students, teachers, researchers, clinical practitioners, and others interested in using Internet technologies to sustain positive mental health. We meet online to discuss current issues and collaborate on projects to further our mission.

Ohio Psychological Association

Lots of links to materials.

http://www.ohpsych.org/commtech.aspx

TelePsychology.net

http://www.telepsychology.net/

Telepsychology Guidelines, Ethics and Continuing Education

California Board of Psychology: Information on Telepsychology

http://www.psychboard.ca.gov/consumers/telepsych.shtml

"From time to time the board becomes aware of articles or information that would be educational and informative to licensed psychologists and the consumers of psychological services. In such cases, the board will attempt to bring this information to licensees and consumers, provided the necessary authorizations for publication can be obtained."

Citations Laws, Legislation

California Business and Professions Code 2290.5 (2011). (Revised by the Telehealth Advancement Act of 2011.)

Telehealth Advancement Act of 2011.

Other Citations

Alemi, F., Stephens, R., Parran, T., Llorens, S., Bhatt, P., Ghadiri, A., et al. (1994). Automated monitoring of outcomes: Application to treatment of drug abuse. Medical Decision Making, 14, 180 187.

American Psychiatric Association. (Undated). Telepsychiatry. Accessed at: http://www.psych.org/Departments/HSF/UnderservedClearinghouse/Linkeddocuments/telepsychiatry.aspx

American Psychological Association. (2010). Telehealth 50-state review. Practice Directorate, Legal & Regulatory Affairs. Accessed 6/24/2012 at http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf

American Psychological Association. (2007). APA Resource Document On Telepsychiatry Via Videoconferencing. Accessed at: http://www.psych.org/psych_pract/tp_paper.cfm

American Psychological Association. (2007). APA Statement on Services by Telephone, Teleconferencing, and Internet. Accessed at http://www.apa.org/ethics/education/telephone-statement.aspx

American Psychological Association. (2011). Reimbursement for telehealth services. APA Practice Update, March, Accessed at: http://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx

Barak, A., Hen, L., Meyran, B. and Na'ama, S. (2008). A Comprehensive review and a meta-analysis of the effectiveness of internet based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/4), 109-160. doi: 10.1080/15228830802094429. URL: http://construct.haifa.ac.il/~azy/B401-MetaAnalysisInterventionsBarak.pdf

Bauer, K. (2009). Healthcare ethics in the information age, in Luppicini, R., and Adell, R. Handbook of Research on Technoethics. Hershey, New York: Information Science Reference, p. 170.

Blascovich, J. and Bailenson, J. (2010). Infinite reality: Avatars, eternal life, New Worlds and the Dawn of the Virtual Revolution. New York: Harper Collins Publishers. California Board of Psychology. (2011). Information on Telepsychology. Accessed at: http://www.psychboard.ca.gov/consumers/telepsych.shtml

Castro, F. G., Proescholdbell, R. J., Abeita, L., and Rodriguez, D. (1999). Ethnic and cultural minority groups. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook. New York: Oxford University Press.

Copeland, J. and Martin, G. (2004). Web-based interventions for substance use disorders: A qualitative review. Journal of Substance Abuse Treatment, 26, 109-116.

Crowell, C. R., Narvaez, D., and Gomberg, A. (2009). Moral Psychology and Information Ethics: Psychological Distance and the Components of Moral Behavior in a Digital World. In Handbook of Research on Technoethics. Hershey, New York: Information Science Reference, p. 700.

Diamand, R. J., Ellis, J., Marcin, J. P., Mawis, R., Nagrampa, E., Nesbitt, T. S. (2004). Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community. Pediatrics, 113(1), 1-6.

Demetriou, A. J., American Bar Association, Health Law Section. (2008). Report to the house of delegates, August. Accessed at www.abanet.org/health/04_government_sub/media/116B_Tele_Final.pdf

Field, M. J. (1996). Telemedicine: A guide to assessing telecommunications in health care. Institute of Medicine, Committee on Evaluating Clinical Applications of Telemedicine.

Fenichel, M. (2000). Online therapy. Accessed at: http://www.fenichel.com/OnlineTherapy.shtml

Folen, R. A., Jones, S. L., Stetz, M. C., Edmonds, B., and Carlson, J. (2010). The role of telehealth in treating military personnel. National Register of Health Service Providers in Psychology, Fall. URL: http://www.nationalregister.org/trr_fall10_folen.html accessed 7/27/2010.

Fox, F. (2011). The Social Life of Health Information. Pew Internet & American Life Project. Accessed at http://www.pewinternet.org/Data-Tools/Get-the-Latest-Statistics/Latest-Research.aspx

Grady B., Myers K., Nelson E. (2009). Evidence-based practice for telemental health. American Telemedicine Association. URL: http://www.americantelemed.org/files/public/standards/EvidenceBasedTelementalHealth_WithCover.pdf accessed 6/28/2012.

Greysen, S. R., Kind, T., and Chretien, K. C. (2010). Online professionalism and the mirror of social media. Journal of General Internal Medicine, 25(11), 1227 1229.

Hailey, D., Roine, R., and Ohinmaa, A. (2008). The effectiveness of telemental health applications: A review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 53(11), 769-778.

Health Care Compliance Association and Society of Corporate Compliance and Ethics. (2011). Social Media and Compliance: A survey by the Health Care Compliance Association & the Society of Corporate Compliance and Ethics. Accessed at: http://www.hcca-info.org/staticcontent/2011SocialMediaSurvey_report.pdf

Hesse, B. W., O'Connell, M., Augustson, E. M, Chou, W. S., Shaikh, A. R., Rutten, L. F. (2011). Realizing the promise of web 2.0: Engaging community intelligence. Journal of Health Communication. 16(1).

International Society for Mental Health Online. 2000. Suggested Principles for the Online Provision of Mental Health Services 2000. v 3.11. Accessed at https://www.ismho.org/suggestions.asp

Labardee, L. (2009). Online Counseling Crosses the Chasm. EAP Digest, Summer. URL: http://www.onlinetherapyinstituteblog.com/wp-content/uploads/2009/08/eapsummer091.pdf accessed 6/28/2012.

Maheu, M. M. (2012). 50 + video teleconferencing companies claiming HIPAA-compliance or offering "business associate" agreements. Telemental Health Institute. URL: http://telehealth.org/video accessed 7/5/2012.

Maheu, M. M., Pulier, M. L., Wilhelm, F. H., McMenamin, J., and Brown-Connolly, N. (2005). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Erlbaum.

Maheu, M. M., Whitten, P., & Allen, A. (2001). E-health, telehealth, and telemedicine: A guide to start-up and success. San Francisco: Jossey-Bass Inc.

McCullagh, D. (2010). Report: Feds to push for Net encryption backdoors. CNet News, 9/27. Accessed at: http://news.cnet.com/8301-31921_3-20017671-281.html#ixzz1MypW461V if

McCullagh, D. (2009). Judge orders defendant to decrypt PGP-protected laptop. CNet News, 2/26. Accessed at: http://news.cnet.com/8301-13578_3-10172866-38.html

Miller, S. R. (2011). Report details health care data theft. South Florida Business Journal, 2/23. Accessed at: http://www.bizjournals.com/southflorida/news/2011/02/23/report-details-health-care-reform-theft.html

Mills, E. (2010). Study: Medical identity theft is costly for victims. CNet News, 3/3. Accessed at http://news.cnet.com/8301-27080_3-10460902-245.html

Morgan, S. and Polowy, C. I. (2012). Social Workers and Skype, Part II, Telemental Health Law. NASW Legal Defense Fund. URL: https://www.socialworkers.org/ldf/legal_issue/2012/Apr2012.asp?back=yes#.T7uWbkOT0Eg.email

National Association of Social Workers. (2012). Social workers and Skype, part I. URL: https://www.socialworkers.org/ldf/legal_issue/2011/112011.asp?back=yes accessed 6/17/2012

National Association of Social Workers and Association of Social Work Boards. (2007). Standards for Technology and Social Work Practice. Accessed at http://www.socialworkers.org/practice/standards/NASWTechnologyStandards.pdf

Ohio Psychology Association. (2011). The Ethical Practice of Telepsychology Webinar, Accessed at: http://www.ohpsych.org/homestudies.aspx

Madden, M. (2008). Digital Footprints. Pew Internet and American Life Project. Accessed June 20, 2010 at: ttp://www.pewinternet.org/Presentations/2008/Digital-Footprints.aspx.

Ragusea, A. S., and VandeCreek, L. (2003). Suggestions for the ethical practice of online psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40, 94 102.

Sengupta, S. (2011). Half of America Is using social networks. New York Times Bits Blog, 8/26. URL: http://bits.blogs.nytimes.com/2011/08/26/half-of-america-is-using-social-networks/ Accessed 6/29/2012.

Smith, A. (2011). Why Americans Use Social Media. Pew Internet. URL: http://pewinternet.org/Reports/2011/Why-Americans-Use-Social-Media/Main-report.aspx accessed 12/29/2012.

Taylor, E., Symonette, E., and Singleton, E. (2009). Considerations for the provision of e-therapy. Center for Substance Abuse Treatment. U.S. Department Of Health And Human Services, Substance Abuse and Mental Health Services Administration.

TelePsychology.net. (2011). Home Page. Accessed at: www.telepsychology.net

Vallejo, M. A., Jordon, C. M., Diaz, M. I., Comeche, M. I., and Ortega, J. (2007). Psychological assessment via the internet: A reliability and validity study of online (vs. paper-and pencil) versions of the General Health Questionnaire-28 (GHQ-28) and the Symptoms Check-List-90-Revised (SCL-90-R). Journal of Medical Internet Research, 9, 1 10.

Wells, K., Klap, R., Koike, A., and Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158, 2027-2032.

Yellowlees, P., Shore, J., and Roberts, L. (2010). Practice guidelines for videoconferencing-based telemental health. American Telemedicine Association, Telemental Health Standards and Guidelines Working Group. Accessed at: http://www.americantelemed.org/files/public/standards/PracticeGuidelinesforVideoconferencing-Based%20TelementalHealth.pdf

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