Teletherapy & Telehealth Best Practices – How to Know if You Are Compliant

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What Are Telehealth Best Practices Versus Telehealth Competencies?

Telehealth best practices are often defined as the ‘best way’ to identify, collect, evaluate, document, disseminate, and implement the delivery of care to improve health outcomes. Telehealth competencies, on the other hand, are the building blocks of best practices. They involve an analysis and use of relevant knowledge, skills, and attitudes needed to demonstrate best practices.
As healthcare professionals and their groups worldwide consider their future with telehealth service delivery, it may be time to take inventory of telehealth best practices, along with the telehealth building blocks that comprise telehealth competencies. In doing so, a few common questions inevitably arise, including how administrators, as well as professionals, might evaluate their competence in using best practices in telehealth. They would perhaps be more apt to consider these questions, which also relate to telehealth best practices and competencies:

  • On a day-to-day level, what are the best practices for when a new intake goes awry and I find myself in troubled waters without the stability and predictability of a brick-and-mortar practice?
  • What are the payors doing? How can I support myself with telehealth alone? How can I legitimately market myself without breaking any rules?
  • After years of experience, which telehealth competencies do I still need to develop to follow telehealth best practices?

How Many Telepractitioners or Teletherapists Use Telehealth Best Practices?

Research in the area of professional behavior related to telehealth is scarce. Most of our national professional associations don’t have hard data on telehealth utilization, and most professionals don’t belong to or respond to professional associations to respond to their surveys. My own research into the best practices of psychologists in the years 2000 or 2018 do not seem particularly relevant, given the massive influx of practitioners who jumped online in a matter of a few quicks days in February of 2019. However, if those numbers are in any way reflective of the current state of affairs, we can expect that licensing boards are going to have their hands full in the next few years as they attempt to support while redressing the errant telehealth practices of their licensees.
In another article published this week,
Whatever telehealth challenges experienced during the pandemic, it may be time to take inventory to identify strengths as well as deficiencies. As outlined by J. Perle in a survey of 404  psychologists, counselors, therapists, social workers:

Education is required to understand not just the technologies, but the practices (e.g., ethical, legal, safety planning), differences from face-to-face care, and workflows. Given the need for rapid transition due to COVID-19, it is unclear how providers are prepared for the integration of telehealth with their traditional practices.

An example of the type of rigor suggested by published telebehavioral health competencies can be seen in Table 1 of the 2018 article, An Interprofessional Framework for Telebehavioral Health Competencies. As suggested in the middle column labeled “Proficient” in that Table taking the time to note any strengths or weaknesses may leave the average clinician worried that they are operating blindfolded in some way. As Perle concludes in his 2022 article,

…a significant portion of providers can be viewed as having gained information that guided ethical, legal, and safe clinical services. Nevertheless, with consideration of the breadth and duration of the educational activities pursued, many providers would likely still benefit from additional education to foster a more complete understanding of the new telehealth competencies.

it may be obvious to the reader that having gained some information is not the same as having developed competencies or adhering to best practices when choices seem limited and time is limited. Overconfidence about telehealth competence is rampant in the field. We at TBHI Telehealth.org evidence-based teletherapy training, and find that even the hardiest of clinicians buckle when faced with a pre-test of 25 common teletherapy scenarios. Of the 797 clinicians who voluntarily completed our telehealth professional training pre-test since February 2019, only 19 (3.14%) passed with a score above 80%. No one achieved a 95 or 100% score, despite that the test items have been validated and are pinned to the published competencies . Published competencies that inform the pre-test are: 
Clinical practice, either in-person or online, is not easy. However, even the most serious challenges can be overcome by developing technology-specific clinical competencies. To illustrate this point, the next section is provided for the reader to consider a behavioral therapist’s ability to defend their current teletherapy activities if required by a licensing board investigation.

What Can Go Wrong in Teletherapy?

First, let’s compare in-person treatment to online treatment. When working through video, the therapist is most often limited to seeing only the person’s face and upper torso, much unlike being in-person, where it is easy to see someone wildly tapping their foot. (Adaptions are available and easily taught to overcome the face and torso limitation, but that is another discussion.) When working through audio-only, a whole different set of unseen, unheard, unexperienced variables can surface. A clinician working with someone by telephone only is limited to what they are told, how it is told, and whatever else can be discerned from background noise. (Again, telepresence issues can be taught and protocols established to maximize therapeutic exchange, but for the most part, there is no evidence to support the belief that most therapists are engaged in these activities with the people they serve.) Text messaging introduces even more limitations, which have been addressed elsewhere.
As a quick exercise, imagine that the average teletherapist today is faced with any of these scenarios listed below. Consider how well equipped you think they are to respond professionally to a client or patient who:

  • Is slightly intoxicated, currently drinking an evening beer(s), and requesting therapy because they are afraid of what they will do to their children.
  • Influenced by someone off-screen and invisible to the teletherapist, but presenting with halting speech and long pauses.
  • Visiting another state, actively suicidal but won’t provide their street address.
  • Creates reasonable suspicion that they are abusing their elderly parent.
  • Gets enraged at the therapist and hangs up after terminating treatment.
  • Sounds quite intoxicated, has a history of opioid abuse, and suddenly becomes non-responsive in session.

The reader is invited to consider how well equipped their colleagues are to appropriately prevent or handle each of the above scenarios. The reader may also want to think about their own competence in these areas, how they would demonstrate telehealth best practices, and document such.

What Is Missing in Telehealth Best Practices?

Without belaboring the point, let us shift to a few other  areas where teletherapy can go wrong and get the reader into hot water:

  • Some teletherapists may be unaware that mandatory reporting laws differ from state to state, including which laws exist or don’t exist in which state and how easy it is to get required information such as required reporting time frames, forms, and processes.
  • Some teletherapists may be unable to see the digital warning signs and, therefore, may react inappropriately when a client is anger-prone or acting out.
  • Some therapists may not have developed a de-escalation protocol on live video to provide structure when the client can see and react to every move they make on camera.
  • Many clinicians are unprepared to prep or actively manage a client or patient in an unsuitable environment or when they push boundaries.
  • Some teletherapists may not know how to maintain the therapeutic bond when working with someone who is provocative, self-pleasuring, or otherwise intentionally causing discomfort to the therapist.
  • They may not know that duty-to-warn laws don’t exist in four US states, where calling the local police and the intended victim could be considered a violation of client privilege.
  • Many clinicians also don’t know that illegally practicing over state lines can nullify their malpractice insurance benefits if faced with a lawsuit.
  • Many therapists are unaware of legal and ethical marketing practices when seriously considering telehealth as a source of income in the future.

Before COVID, the most significant deterrent to telehealth growth was practitioner adoption. Now that COVID led to the forced adoption of telehealth to deliver care, the most significant deterrent to telehealth growth is provider competency. Those who have undergone serious training in telehealth regarding legal or ethical issues are leading the way, and calls for more training are pervasive through the published scientific literature.1, 2, 3

References

  1. Maheu, M. M., & Gordon, B. L. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31(5), 484–489. https://doi.org/10.1037/0735-7028.31.5.484
  2. Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205–219. https://doi.org/10.1037/pro0000188
  3. Maheu, M. M., Drude, K. P., Hertlein, K. M., Lipschutz, R., Wall, K., & Hilty, D. M. (2019). Correction to: An Interprofessional Framework for Telebehavioral Health Competencies. Journal of Technology in Behavioral Science5(1), 79–111. https://doi.org/10.1007/s41347-019-00113-x
  4. Hertlein, K. M., Drude, K. P., Hilty, D. M., & Maheu, M. M. (2021). Toward proficiency in telebehavioral health: Applying interprofessional competencies in couple and family therapy. Journal of Marital and Family Therapy47(2), 359-374
  5. Perle, J. G. (2022). Mental health providers’ telehealth education prior to and following implementation: A COVID-19 rapid response survey. Professional Psychology: Research and Practice.Perle, J. G. (2021). Training Psychology Students for Telehealth: a Model for Doctoral-Level Education. Journal of Technology in Behavioral Science, 1-4.
  6. Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205–219. https://doi.org/10.1037/pro0000188

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