Technology has undoubtedly changed the way the world does business. For psychologists, electronic tools can open up a new realm, enabling them to reach more patients regardless of geographic location or diagnosis. Before engaging in telepsychology, however, practitioners need to understand the issue of licensing, security and privacy and reimbursement.
Ben Johnson, Ph.D., ABPP, clinical assistant professor at The Warren Alpert Medical School of Brown University and clinical psychologist and director of RICBT, Cognitive Behavioral Therapy and Coaching, conducts some of his therapy sessions via telephone, which he says allows the practitioner to communicate consistently and helps keep the client accountable for his behavior.
“If I can help someone in crisis get on track with a 15-minute phone call rather than wait a week for an appointment, it’s a good thing,” he says. “Patients are extremely appreciative of engaged and available clinicians.”
More in the technology realm is the patient portal Johnson launched in January, 2014. While this electronic tool, which requires a unique username and password, allows patients to check appointments and update demographic and insurance information, it also serves as a vehicle for distance therapy. Practitioners can post symptom-oriented measures for a number of conditions including sleep disorders, anxiety and others on the portal.
“The patient fills it out and the clinician evaluates it and talks about it at the next session,” he says. “This becomes part of the electronic medical record and a talking point.”
Additionally, patients can type out their goals and upload them to the portal, which aids with tasks and homework. “It makes everything efficient,” Johnson says.
For psychologists licensed to practice in multiple states, telepsychology can become an important aspect of their practices. James M. Claiborn, Ph.D., ABPP Counseling Psychology, ACT, practices in South Portland, Maine but also is licensed in N.H., N.Y. and Delaware.
For the last couple of years, he has used VSee, a secure, no-cost video conferencing application that is HIPAA compliant. With a specialty in obsessive-compulsive disorder, he is able to offer therapy to a wide range of clients, regardless of geographic location. “I work with people who have difficulty finding appropriate care,” he notes.
Claiborn also runs an email-based support group for patients with OCD. “I view this differently than the video sessions. I am presenting myself as an authority on the topic, not engaging in a therapeutic relationship,” he says.
Before incorporating telepsychology in a practice, Claiborn advises clinicians to “do a lot of thinking, reading and continuing education work.” He emphasizes that psychologists should take each case on an individual basis and understand client needs and evolving social expectations and norms.
Practitioners also need to be thoughtful when it comes to security and privacy. “You need to balance caution and the limits of risk management with helping clients,” Johnson says.
When Roberta Tsukahara, Ph.D., P.A., planned a move from Texas to Maine she knew she would conduct sessions via video and consulted with the American Psychological Association and the two state boards to ensure that she was following the law. “You have to be sure that wherever you are sitting, you are in compliance,” she says.
After obtaining her Maine license, Tsukahara researched applications and also chose VSee as the best option. Before implementing this technology, she amended her client agreement to reflect her restrictions regarding social media connections as well as the parameters within which she would use the technology.
Tsukahara finds that using video to treat clients has enabled her to maintain a steady income stream, as well as flexibility and convenience for both her and her clients.
Reimbursement has never been an issue for Tsukahara, since she accepts only private pay clients. “My long distance clients use PayPal via my Web site,” she says. “After they pay, I send them a paid invoice from QuickBooks via email with ‘done by VSee’ in the memo line.”
But for Claiborn, who does accept insurance, reimbursement depends on the insurer. If the carrier approves the telehealth session, he will code the service appropriately, using a Maine-specific modifier. However, when the health insurance company refuses to pay for telepsychology, Claiborn works out other arrangements with the client.
The Veterans Administration has been using telehealth for patients with mental health diagnoses since 2002, according to Judy Audette, RN, MSN, telehealth coordinator at the White River Junction (WRJ) VA Medical Center in Rutland, Vermont. She says that providers are able to connect over a secure video stream with veterans in clinics and VA centers across the country, as well as in skilled nursing facilities and, in some cases, veterans’ homes.
This fiscal year, VA providers at WRJ saw 1,118 patients through telehealth; last year there were 513 encounters, according to Audette.
Ken Major, Psy.D., evidence-based psychotherapy telemental health psychologist at the WRJ VA Medical Center, was hired as part of the national VA evidence-based psychotherapy for PTSD Initiative, which was launched in 2010. “Evidence supports the fact that you reach more people and are able to deliver front-line therapy,” he says.
Given the geographic challenges – he says 36 percent of veterans live in remote areas – Major does not often have an in-person encounter with the veteran before beginning telemental health sessions. However, he sees no detrimental effect on outcomes. “In terms of outcomes, the VA sets the foundational aspect of rolling out services as an institution and [for me] as an individual provider,” he says.
After conducting hundreds of hours of telemental health, Major believes this form of therapy experience is as good as face-to-face. “Patient feedback indicates that it’s nice to meet in person, but [not doing so] is no barrier to getting better and forming an alliance, feeling safe and welcome, which are common factors in psychotherapy,” he emphasizes. “In fact, four people who had suffered traumatic experiences early in life said the telemental health approach was superior to face-to-face. They felt it was far less threatening and very empowering.”
Lynn Bufka, Ph.D., assistant executive director for practice research and policy at APA, says, “We do know that electronic interactions work from controlled studies. We urge psychologists to consider using a technology interface.”
APA guidelines on the use of telepsychology can be found at: http://www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf. State-by-state regulations can be accessed at the following link: http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf
By Phyllis Hanlon