Psychotherapy technology has been rapidly developing for several years now, and few things shift as fast as tech. To help catch us all up, I have compiled updated information on a few tech topics of interest to psychotherapists.
The Year of Telemental Health
It’s probably fair to dub 2017 the year of telemental health. I give it this moniker because of the numerous different advances and changes that came together to make it a big year for the expansion of this therapy medium.
The U.S. federal government started putting significant funding into videoconferencing-based telemental health services in the early 21st century. At the time, it was primarily an effort to find ways to provide care for people in rural areas where access to care was low (and in many ways that is still the primary aim of those programs.) The promising results of this research have been manifest for many years in the ways that Medicare reimburses for certain telemental health services when provided to people in these more remote areas. Even now, Medicare continues to reimburse for these services in Health Provider Shortage Areas (Centers for Medicare and Medicaid Studies, 2016).
In 2017, we are now seeing greater overall rates of reimbursement from private third-party payers. Telemental Health expert Marlene Maheu, as interviewed by Barbara Griswold, states that “telehealth parity is now mandated by more than half of the 50 United States” (Griswold, 2016). It is also my anecdotal experience, from speaking with colleagues all over the country, that psychotherapists in many regions are finding that insurance companies that did not previously cover telemental health services have started doing so recently. Not all of them report this, and many still report being denied coverage, but coverage certainly seems to be growing.
There are a number of reasons why insurance companies would want to cover telemental health. Certainly one reason is that it holds some promise to improve outcomes with lower costs. Another important reason, however, is its growing popularity.
With so many people asking for telemental health services, it is no surprise that companies continue to pop up with the business model of connecting clients with licensed therapists who perform services by telemental health. Many well-reputed companies currently exist that perform this service.
Licensed psychotherapists with the skills and interest to work via secure videoconferencing can literally sign up with a company, do some orientation and training, and then start receiving referrals from that company. This did not start being true in 2017, but the availability of these services continues to rapidly expand this year.
Astute readers will note that I referred to the idea of “well-reputed” companies that provide these services. Some companies, possibly in the name of innovation, jump into the market without fully addressing the ethical, legal, and/or clinical implications of their business models. Most companies, however, are conscientious about doing things in an ethical and legal manner. Here are some examples of things to look for in telemental health companies to make sure they meet your legal, ethical, and clinical needs:
- Does the company ask you to perform services in a way you know to be unethical or illegal? For example, do they ask you to work across state lines in an illegal manner (e.g., without proper licensure)? If you are not sure, always consult with knowledgeable colleagues before proceeding.
- Do company officials have access to client information that they should not have access to? Once again, consult when you are not sure.
Some further reading from APA and Practice Central can be found in the Resources section below. Once again, most telemental health companies run ethical and clinically viable businesses that meet high standards. I simply urge you to do your basic due diligence when deciding on which companies with which to work.
Telemental Health Training and Certification
An often-raised question is one of whether training or certification in telemental health is necessary. Certainly all telemental health professionals need to be competent in their chosen delivery medium, but there remains the question of what competencies are needed before performing telemental health services.
The APA’s Guidelines for the Practice of Telepsychology (2013) do address the question of competence. Here is a relevant quote from Guideline 1:
Psychologists who utilize or intend to utilize telecommunication technologies when delivering services to clients/patients strive to obtain relevant professional training to develop their requisite knowledge and skills. Acquiring competence may require pursuing additional educational experiences and training, including but not limited to, a review of the relevant literature, attendance at existing training programs (e.g., professional and technical) and continuing education specific to the delivery of services utilizing telecommunication technologies.
Many psychotherapists struggle to determine precisely what competencies they need to gain before performing telemental health services. For this reason alone, getting formal training may be appropriate for many psychotherapists. A number of training programs exist, and the Resources section of this article has some further information.
As for certifications, the Distance Credentialed Counselor (DCC) is currently offered by the Center for Credentialing and Education (CCE.) CCE is also moving towards offering a new credential called the Board Certified Telemental Health Provider (BC-TMHP.) Taking a look at the BC-TMHP training syllabus can provide some guidance on the standard competencies that are seen as necessary for telemental health practice. It is also wise to study the telemental health-related guidance published by the American Telemedicine Association. The Resources section has links to all these items.
Net Neutrality and Psychotherapists
While net neutrality is a political issue, it is also a technical issue that may be vital to the future of psychotherapy because it can impact the availability of cloud-based services. This includes services we use to deliver telemental health services.
Net neutrality is a nerdy topic, which is likely why it has taken so long to gain significant public recognition. To describe it briefly: Net neutrality is the principle that everything that is connected to the Internet has the same priority as everything else that is connected to the Internet.
So right now, because of net neutrality laws, Dr. Smith’s practice website gets the same priority, in terms of Internet speed and accessibility, as Google.com. Without net neutrality laws, Internet service provider companies would have the ability to require that Dr. Smith pay a premium to keep her website fast for all visitors.
Much more pertinent to psychotherapy is that if Dr. Smith wishes to provide online therapy services, her videoconferencing provider could potentially be required to pay extra fees to avoid artificial slowing of its Internet connections. Anyone who has performed online therapy over a bad Internet connection knows how vital a good connection is to ensuring ethical and effective practice. So the video company would certainly pay the extra fees, which would then be passed on to Dr. Smith, and then to her clients. Comcast, which controls much of the Internet in the U.S., has indicated it is likely to implement these kinds of policies if net neutrality laws are repealed. At the time of writing, for example, Netflix already pays a premium to Comcast despite the existence of net neutrality laws (Brodkin, 2014).
Regardless of how any given psychotherapist views this situation, it is important simply to have awareness of it and take action (or not) with intention. For those who support the repeal of net neutrality, the current presidential administration has indicated they intend to repeal the Federal Communications Commission’s rules on net neutrality. For those who wish to uphold it, the main advocacy groups are the Electronic Frontier Foundation (EFF) and the American Civil Liberties Union (ACLU).
By now, the majority of psychotherapists keep records electronically in some form. Paper records continue to work fine for some psychotherapists who do not have a specific need for electronic records. That could change in the future, but we are not there yet.
One can think of electronic records as having two possible shapes: records kept on the clinician’s own in-house equipment and records kept on “the cloud.” Both are viable ways of keeping records, although many therapists find that cloud-based record-keeping systems provide them with security and usability features that they cannot provide on their own.
It is important that computers, tablets, or smartphones used to store or access records (or other client information) be “full device encrypted” in addition to other standard security measures. Most computers and mobile devices today can be set to use this important and powerful security feature, which can help ensure that you do not have security breaches that need to be reported to clients or government agencies (Office for Civil Rights, n.d.). More information on encrypting your devices can be found in the Resources section below.
When it comes to electronic record-keeping services, one could sort them into two “flavors”: those that are “ONC certified” and those that are not (the “ONC,” Office of the National Coordinator for Health Information Technology, is a subagency of Health and Human Services that oversees health information technology). ONC certification for a system indicates that it offers certain functionality that makes it compatible with the national effort to move toward interoperating “Electronic Health Record” systems. “Electronic Health Records,” as defined by the ONC, help make clients’ health records more portable and increase the availability of epidemiological information for government agencies such as the Centers for Disease Control, among other benefits (“What is an Electronic Health Record?”, n.d.).
An important point is that services that are not ONC certified can offer a level of quality that is equivalent to the ones that are ONC certified. The difference is generally in the kinds of customer needs on which each flavor of system focuses. Most psychotherapists who need an ONC certified system know who they are. They usually need that kind of system because of how they work with Medicare, because they work in an integrated care environment, because their states have specific rules they need to follow, or for other reasons likely obvious to the providers involved. For everyone else, it could be fine to use a system that meets their own practice management needs even if it isn’t ONC certified. If there does arise a general requirement for psychologists to use ONC certified systems in the future, these other record-keeping systems may even pursue ONC certification in order to meet the needs of their customers.
Email and Texting
Any discussion of email and texting in the context of psychotherapy raises obvious questions related to how these methods of communication fit in with effective practice. A fair consideration of the many opinions on this topic is beyond the scope of this article, so I will focus here on the state of secure options for psychotherapists to use.
Easy, secure communication with clients usually means that client and therapist use the same app together. In general, clients who have smartphones can more easily download and install the same apps that their therapists use; clients may not be happy about having to sign up for a new email account to talk to their therapists, but many are willing to install a new app on their phones. Employing a smartphone-based service for HIPAA-secure texting and email can help get clients on board with “the secure stuff.” Additional information can be found in the Resources section below.
It is clear that psychotherapy technology continues to develop at a rapid pace, taking ever greater advantage of the benefits offered by the Internet. The development of new technologies means that keeping our records and communications with clients secure is easier than ever before. It is also easier than ever to get into telemental health with secure and properly-made software tools. At the same time, telemental health competency standards are becoming clearer and more well-established by organizations like the American Telemedicine Association and the Center for Credentialing and Education.
On the other hand, psychotherapists who prefer a “low tech” approach to practice may be able to continue doing so for some time. It is hard to avoid certain electronic things like electronic insurance billing. And it is getting harder and harder to avoid using some kind of email or texting for basic practice management communications. However, people who need psychotherapy come from a variety of places, and there is no sign so far that in-person therapy practice will ever disappear.
- Guidelines from the American Telemedicine Association: http://thesource.americantelemed.org/resources/telemedicine-practice-guidelines
- APA Practice Central article on platforms that offer text therapy: http://www.apapracticecentral.org/update/2015/06-25/text-therapy.aspx
- An APA Psychology Help Center article on telemental health, including quite a few useful research references: http://www.apa.org/helpcenter/online-therapy.aspx
- The CCE page on their upcoming BC-TMHP credential, including a training opportunity: http://www.cce-global.org/Credentialing/BCTMHP
- Some well-regarded telemental health training programs:
- Telemental Health Institute: http://telehealth.org/
- Telehealth Certification Institute: https://telementalhealthtraining.com/
- The Zur Institute’s Telemental Health Program (note: the author of this article is a co-author on some of the Zur Institute’s telemental health courses and receives royalties on their sale): http://zurinstitute.com/certificateintelementalhealth.html
- WIkipedia’s entry on net neutrality: https://en.wikipedia.org/wiki/Net_neutrality
- From the Office of National Coordinator for Health Information Technology (ONC):
- What is an Electronic Health Record?: https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr
- Benefits of Electronic Health Records: https://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs
- Person-Centered Tech article on using full device encryption to protect your client information and prevent breaches: https://personcenteredtech.com/2013/04/05/hipaa-safe-harbor-for-your-computer-the-ultimate-in-hipaa-compliance-the-compleat-guide/
Email and Texting
- Person-Centered Tech article on focusing on secure email and texting options: https://personcenteredtech.com/2016/10/16/even-though-right-hipaa-unencrypted-emails-case-using-secure-email-texting-clients/