Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Telepsychology. Show all posts
Showing posts with label Telepsychology. Show all posts

Sunday, November 20, 2022

Telehealth is here to stay. Psychologists should equip themselves to offer it.

Hannah Calkins
The Monitor On Psychology
Vol. 53 No. 7, Print version: page 30

Telehealth continues to play a significant role in the health care industry. However, psychologists who offer both in-person and virtual services are poised to meet increased demand for flexible, accessible mental health care.

In 2020, psychologists responded to the onset of the COVID-19 pandemic by making a nearly universal pivot to telehealth. This rapid and widespread adoption was largely enabled by the federal government’s declaration of a public health emergency (PHE), which prompted several significant policy changes that made telehealth more feasible for both patients and providers.

Yet in the following year, an APA survey found that 50% of psychologists had moved to offering both in-person and virtual services to their patients, up from 30% in 2020. Additionally, Pew Research Center data showed that 25% of adults with ­low incomes do not own smartphones, and 40% of this group do not have broadband internet or computers at home, signaling significant concerns about telehealth equity.

This means that psychologists should prepare for a hybrid future in which they deliver services via both modalities.

“Telehealth is here to stay. In-person isn’t going away,” said Robin McLeod, PhD, a licensed psychologist and president and chief business development officer at Natalis Psychology in St. Paul, Minnesota. “I believe it is vital for most psychologists to be able and willing to provide both options for patients. It just makes good business sense.”

Meeting demand for telehealth

Like many other providers, those at McLeod’s large practice made a quick pivot to virtual care during the pandemic and now offer hybrid options.

“[Our] providers have returned to providing in-person care, which many of our patients welcomed,” said McLeod. “However, most every provider in our organization continues to provide telehealth services for those clients who prefer that.”

Similarly, Zixuan Wang, PsyD, of Encounter Psychotherapy in Gaithersburg, Maryland, also has a robust hybrid practice. However, prior to spring 2020, she had never seriously considered offering telehealth.

“I am so appreciative that technology has enabled us to provide telehealth services, as they have been proven to be effective and beneficial for so many people who need care,” she said.

Wang and McLeod’s stories are scaled-down versions of the broader narrative of telehealth during the pandemic: Rapid and sustained implementation out of necessity has led to a permanent change.

Thursday, August 6, 2020

Five tips for transitioning your practice to telehealth

Five tips for transitioning your practice to telehealthRebecca Clay
American Psychological Association
Originally posted 19 June 20

When COVID-19 forced Boston private practitioner Luana Bessa, PhD, to take her practice Bela Luz Health online in March, she was worried about whether she could still have deep, meaningful connections with patients through a screen.

To her surprise, Bessa’s intimacy with patients increased instead of diminished. While she is still mindful of maintaining the therapeutic “frame,” it can be easier for everyday life to intrude on that frame while working virtually. But that’s OK, says Bessa. “I’ve had clients tell me, ‘It makes you more human when I see your cat jump on your lap,’” she laughs. “It has really enriched my relationships with some clients.”

Bessa and others recommend several ways to ensure that the transition to telehealth is a positive experience for both you and your patients.

Protect your practice’s financial health

Make sure your practice will be viable so that you continue serving patients over the long haul. If you have an office sitting idle, for example, see if your landlord will renegotiate or suspend lease payments, suggests Kimberly Y. Campbell, PhD, of Campbell Psychological Services, LLC, in Silver Spring, Maryland. Also renegotiate agreements with other vendors, such as parking lot owners, cleaning services, and the like.

And since patients can’t just hand you or your receptionist a credit card, you’ll need to set up an alternate payment system. Campbell turned to a credit card processing company called Clover. Other practitioners use the payment system that’s part of their electronic health record system. Natasha Holmes, PsyD, uses SimplePractice to handle payment for her Boston practice And Still We Rise, LLC. Although there’s a fee for processing payments, an integrated program makes payment as easy as clicking a button after a patient’s session and watching the payment show up at your bank the next day.

The info is here.

Monday, July 20, 2020

Seven Tips for Maintaining the Frame in Online Therapy

Clifford Arnold & Thomas Franklin
Psychiatric News
Originally published 25 June 20

While we are in the midst of a pandemic, teleconferencing technology can be a source of both stability and insecurity in the therapeutic relationship; on the one hand, it confers the near-miraculous ability to remain connected at a safe distance, while on the other hand it upends the basic conditions under which therapy takes place, like simply being in the same room together.

When striving for continuity in the transition from in-person to online therapy, a possible pitfall is to conserve the verbal elements of therapy and ignore the rest. This is counterproductive since the nonverbal aspects of therapy have an arguably greater impact on patients, and without them words can be ineffectual. The set of nonverbal conditions that engender trust, confidence, and security in patients and allow the words of therapy to be effective is called the therapeutic frame. The following tips are meant to help maintain the therapeutic frame during this precarious time, specifically in the transition from the office to the screen.

1. Create some distance: One way to preserve a familiar and comfortable frame is to observe personal space online as one would in the office. It would feel awkward, intrusive, and exhausting to sit four feet away from a patient and stare directly into her face for an hour straight in the office, yet we do that regularly online. Perhaps we are compensating for feeling distant in other ways or perhaps we simply can’t see or hear very well. It’s ok to back up, and some technological modifications can help (see tip #3). The extra space might allow both parties to feel less self-conscious and more at ease, less focused on maintaining a perfect affect and more on the therapy.

2. Body language matters: Here’s another reason to back off the camera a bit: Expanding the field of vision to include not just facial expressions but also upper-body language (for example, hand gestures, posture, distance modulation) has been shown to increase empathy measures, according to David T. Nguyen and John Canny in the article “More Than Face-to-Face: Empathy Effects of Video Framing.” Experiment with this. Sit back, expand the visual frame, move, and gesture as you would in person—find what feels connective and go with it. In addition to camera distance, the angle matters too; if the lens is positioned at a height lower than your eyes it may appear to your patients that you are looking down on them. Stack some books under your monitor to avoid the impression of being overbearing or aloof.

The info is here.

Tuesday, April 7, 2020

Four pieces of ethical advice for practitioners during COVID-19

Four pieces of ethical advice for practitioners during COVID-19Rebecca Schwartz-Mette
APAservices.org
Originally posted 2 April 20

Are you transitioning to full-time telepsychology? Launching a virtual classroom? Want to expand your competence in the use of technology in practice? You can look to APA’s Ethics Committee for support in transforming your practice. Even in times of crisis, the Ethical Principles of Psychologists and Code of Conduct (hereafter “Ethics Code” or “Code;” 2002, Amended June 1, 2010 and Jan. 1, 2017) continues to guide psychologists’ actions based on our shared values. Here are four ways to practice in good faith while meeting the imminent needs of your community:

Lean in

Across the nation, rather than closing their practices and referring out, psychologists are accepting the challenge to diligently obtain training and expand their competence in telepsychology. Standard 2.02, “Providing Services in Emergencies,” allows psychologists to provide services for individuals for whom other services aren’t available through the duration of such emergencies, even if they have not obtained the necessary training. The Ethics Committee supports those psychologists working in good faith to meet the needs of patients, clients, supervisees and students.

Get training and support

Take advantage of the APA’s new (and often free) resources to develop and expand your competence, in line with Standard 2.03, “Maintaining Competence.” Expand your network by connecting with colleagues who can provide peer consultation and supervision to support your efforts.

Consider referrals

The decision to transition to telepsychology may not be for everyone. Competency concerns, lack of access to technology, and specific needs of particular clients may reflect good reasons to refer to practitioners who can provide telepsychology. Psychologists should assess each client’s needs in light of their own professional capacities and refer to others who can provide needed services in line with Standard 10.10(c), “Terminating Therapy.”

Take care of yourself

Psychologists are human and can feel lost in the ambiguity of this unprecedented time. It is your ethical mandate to also care for yourself. Practicing accurate self-assessment, leaning on colleagues when needed, and taking time to unplug from the news and practice to recharge helps to prevent burnout and is entirely consistent with 2.06, “Personal Problems and Conflicts.” Make self-care a verb and connect with your community of psychologists today.

Friday, August 31, 2018

What you may not know about online therapy companies

Pauline Wallin
The Practice Institute
Originally posted August 19, 2018

Here is an excerpt:

In summary, while platforms such as Talkspace and BetterHelp provide you with ready access to working with clients online, they also limit your control over your relationships with your clients and in how you work with them.

Before signing on with such platforms, read the terms of service thoroughly. Search online for lawsuits against the company you're considering working with, and read reviews that are not on the company's website.

Also, talk with the risk management consultant provided by your malpractice insurer, who can alert you to legal or ethical liabilities. For your maximum legal protection, hire an attorney who specializes in mental health services to review the contract that you will be signing. The contract will most likely be geared to protecting the company, not your or your license.

The info is here.

Tuesday, March 21, 2017

Ethical concerns for telemental health therapy amidst governmental surveillance.

Samuel D. Lustgarten and Alexander J. Colbow
American Psychologist, Vol 72(2), Feb-Mar 2017, 159-170.

Abstract

Technology, infrastructure, governmental support, and interest in mental health accessibility have led to a burgeoning field of telemental health therapy (TMHT). Psychologists can now provide therapy via computers at great distances and little cost for parties involved. Growth of TMHT within the U.S. Department of Veterans Affairs and among psychologists surveyed by the American Psychological Association (APA) suggests optimism in this provision of services (Godleski, Darkins, & Peters, 2012; Jacobsen & Kohout, 2010). Despite these advances, psychologists using technology must keep abreast of potential limitations to privacy and confidentiality. However, no scholarly articles have appraised the ramifications of recent government surveillance disclosures (e.g., “The NSA Files”; Greenwald, 2013) and how they might affect TMHT usage within the field of psychology. This article reviews the current state of TMHT in psychology, APA’s guidelines, current governmental threats to client privacy, and other ethical ramifications that might result. Best practices for the field of psychology are proposed.

The article is here.

Sunday, August 16, 2015

Ethical Practice in Telepsychology

By Nicholas Gamble, Christopher Boyle and Zoe A Morris
Special Issue: Telepsychology: Research and Practice
Volume 50, Issue 4, pages 292–298, August 2015

Objective

Telepsychology has the potential to revolutionise the provision of psychological service not only to those in remote locations, or with mobility issues, but also for those who prefer flexible access to services. Rapid developments in internet communications technology have yielded new and diverse methods of telepsychology. As a result, ethical regulatory and advisory guidelines for practice have often been developed and disseminated reactively. This article investigates how the core ethical principles of confidentially, consent and competence are challenged in telepsychological practice.

Method

Through the application of existing ethical standards, advances in communications technology are considered and their ethical use in psychological contexts explored.

Conclusion

It is expected that psychologists will have basic competencies for the use of everyday technology in their practice. However, the use of internet communications technology for telepsychology has created new opportunities and challenges for ethical practice. For example, telepsychology is geographically flexible, but there can be privacy concerns in cross-border information flow. Psychologists who engage in telepsychology require a particularly thorough understanding of concepts such as data mining, electronic storage, and internet infrastructure. This article highlights how existing technology and communication tools both challenge and support ethical practice in telepsychology in an Australian regulatory context.

The entire article is here.

Saturday, April 11, 2015

Telepsychology, Telehealth, & Internet-Based Therapy

From Ken Pope's site

I gathered the following resources to help therapists, counselors, and other clinicians to keep abreast of the rapidly evolving professional guidelines, research, treatments, innovations, and practices in the areas of telepsychology, telehealth, internet-based therapy.

I've divided the resources into 3 sections:

1) Links to 24 sets of professional guidelines that focus on telepsychology, online counseling, internet-based therapy, etc.

2) Citations for 51 recent (i.e., published in 2013-2015) articles

3) State Psychology Board Telepsychology Laws, Regulations, Policies, & Opinions--This third section was generously compiled by psychologist Kenneth R. Drude, and I am indebted to him for his kind offer to post it here.

The resource page is here.

I will link it in the Guides and Guidelines section of this site.

Tuesday, October 21, 2014

College Counseling Centers Turn to Teletherapy to Treat Students for Anxiety

By Jared Misner
Sunoikisis via the Chronicle of Higher Education
Posted September 26, 2014

At the University of Florida, students struggling with anxiety can visit its counseling center and, after an initial, in-person consultation with a counselor, can elect to start a seven-week program called Therapist Assisted Online. The program works like an online course, complete with videos and online activities. Once a week, students meet with their specific counselor, one on one, through a videoconference for 10 to 15 minutes to discuss their anxiety.

That means students visit the counseling center only once and can do the rest from the comfort of their dormitory room. “They like the idea of being at home,” Brian C. Ess, a counselor at Florida’s Counseling and Wellness Center, says.

The entire article is here.

Please visit the Ethics and Psychology podcasts for Episodes 15 and 16, which addresses Ethics and Telepsychology.

Monday, September 15, 2014

Episode 15: Ethics and Telepsychology (Part 1)

Ethics and Telepsychology involves the rise of technology in the healthcare sector.  There are about 21 states that mandate insurance companies cover telehealth services.  John is joined by Dr. Marlene Maheu, trainer, author, researcher, and the Executive Director of the TeleMental Health Institute, Inc., where she has overseen the delivery of professional training in telemental health to more than 5000 professionals in 39 countries since 2010.  John and Marlene discuss the supporting research for telepsychology and its limitations; practitioner competencies; reimbursable, evidence-based models for telepsychology; and limitations with telepsychology.

At the end of this podcast, the listener will be able to:

1. Outline the general research findings on the usefulness of telepsychology,
2. Describe requirements of competent telepsychology practice,
3. List at least four reimbursable, evidence-based models for legal and ethical telepractice.

Click here to earn one APA-approved CE credit


Or listen directly below



Resources for Episode 15



by Marlene Maheu, Myron L. Pulier, Frank H. Wilhelm and Joseph P. McMenamin 

Bibliography from TeleMental Health Institute, Inc.

Marlene Maheu SlideShare

Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: Predictors of treatment completion and outcome and comparison to treatment delivered in person. Behavior Therapy, 42, 276-283. 
doi: 10.1016/j.beth.2010.07.005

Harris, E., & Younggren, J. N. (2011). Risk management in the digital world.
Professional Psychology: Research and Practice, 42, 412-418.
doi: 10.1037/a0025139

Thursday, March 27, 2014

Best practices for remote psychological assessment via telehealth technologies

By David Luxton, Larry Pruitt, and Janyce Osenbach
Professional Psychology: Research and Practice, Vol 45(1), Feb 2014, 27-35.
doi: 10.1037/a0034547
Special Section: Telepractice

Abstract

The use and capabilities of telehealth technologies to conduct psychological assessments remotely are expanding. Clinical practitioners and researchers need to be aware of what influences the psychometric properties of telehealth-based assessments to assure optimal and competent assessments. The purpose of this review is to discuss the specific factors that influence the validity and reliability of remote psychological assessments and to provide best practices recommendations. Specific factors discussed include the lack of physical presence, technological issues, patient and provider acceptance of and comfort with technology, and procedural issues. Psychometric data regarding telehealth-based psychological assessment and limitations to these data, as well as cultural, ethical, and safety considerations are discussed. The information presented is applicable to all mental health professionals who conduct psychological assessment with telehealth technologies.

The entire article is here, behind a paywall.

The Use of Telepsychology in Clinical Practice: Benefits, Effectiveness, and Issues to Consider

By Nicole Godine and Jeffrey Barnett
International Journal of Cyber Behavior, Psychology and Learning
DOI: 10.4018/ijcbpl.2013100105

Abstract

The use of various technologies in the practice of psychology has increased greatly in recent years in concert with increases in the use of these technologies in the lives of most individuals. E-mail, text messaging, chat rooms, and the Internet have greatly changed how many individuals communicate and maintain relationships. The psychotherapy relationship is no exception. The scope and practice of telepsychology, the use of the Internet and other technologies in the provision of psychological services, is reviewed along with relevant research that supports their use in the treatment of a wide range of conditions and disorders. Clinical, ethical, and legal issues and challenges are addressed and recommendations for the effective and appropriate use of these technologies in psychological practice are provided.

Article Preview

Mental health services can be delivered by e-mail, real-time chat, telephones, videoconferencing, cell phones, and websites (Grohol, 2003; Smith & Allison, 1998; Stamm, 2003; VandenBos & Williams, 2000). Synchronous modalities of communication, in which participants communicate in real time, include online chat, telephones, cell phones, and videoconferencing. Videoconferencing is a “technological procedure that allows individuals to see and hear each other on a computer monitor or video screen in real time” (Germain, Marchand, Bouchard, Drouin, & Guay, 2009, p. 42). It is different from real-time chat, telephone conversations, and cell phone conversations in that videoconferencing allows users to view and speak to each other in real time, whereas chat, telephones, and cell phones only allow the users to speak to each other (not view each other) in real time. Asynchronous forms of communication, in which there is a delayed response time, include e-mail, websites (which might be simply informational, or might offer contact with a mental health professional through e-mail), and text messaging via cell phones.

The entire article is here, behind a paywall.

Thursday, November 7, 2013

“HIPAA-COMPLIANT” Texting of PHI: The Good. The Bad. The Ugly.

By Alaap Shah and Ali Lakhani
TechHealth Perspectives
Originally published October 14, 2013

Here is an excerpt:

Currently, there is a great deal of uncertainty around whether “HIPAA-compliant” texting of ePHI can be accomplished.  Even greater confusion exists around whether certain texting platforms themselves can be “HIPAA-compliant”.  Before you start to send ePHI via text message, there are a number of issues to consider.

The entire article is here.

Monday, June 24, 2013

Five Ethical Mistakes To Avoid with Clients on the Internet

This is a brief overview of common mistakes to avoid with online psychotherapy.  If nothing else, this short video should help a psychologist contemplating providing online psychotherapy services.





From the Australian Counseling Association.

Saturday, May 25, 2013

VETS Act Expands Veterans Access to Care, Protects Patient Safety

The American Telemedicine Association strongly supports the proposed Veterans E-Health and Telemedicine Support Act (H.R. 2001,) lauding it as a key step in improving healthcare quality by minimizing regulatory barriers for interstate telemedicine.

Press Release
The American Telemedicine Association
Originally published May 16, 2013

The American Telemedicine Association voices its strong support for the new Veterans E-Health and Telemedicine Support Act (H.R. 2001) as one key step in lowering regulatory barriers to 21st century healthcare. The bi-partisan bill, introduced by Representatives Charles Rangel (D-NY) and Glenn Thompson (R-PA) and cosponsored by 21 Members of Congress, would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license.

This bill, known as the VETS Act, builds on the unanimous congressional enactment of the 2011 STEP Act (Servicemembers' Telemedicine and E-Health Portability Act,) which provides a similar provision for healthcare providers in the U.S. Department of Defense. A similar licensing rule for patients and providers of Medicare, Medicaid and other major federal health programs was included in a comprehensive telemedicine bill submitted by Rep. Mike Thompson (D-CA) in December 2012.

“These bills are a simple way, while preserving the states’ role to license, to address shortages of medical specialists, to improve patient access to the best qualified physicians, and to accommodate mobile Americans and multi-state health plans,” said Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association. “They accommodate both patient choice and patient safety. We would like to see a similar act for all federal patients and providers.”

Presently, most providers who practice interstate telemedicine must be licensed both where the patient and provider are physically located. Such regulation increases the cost of healthcare and is an artificial barrier, favoring the business interests of local physicians over patient choice. Some state medical boards are even imposing stricter licensing requirements for telehealth providers than they do for in-person care, such as requiring a prior face-to-face examination for each and every case.

“Access to quality healthcare is, ultimately, the foremost safety issue for the patient,” concluded Linkous. “It’s time that we allow patients to make an appointment and see a qualified licensed health provider regardless of where the patient or provider is located."

About the American Telemedicine Association

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, ATA is headquartered in Washington, DC.

For more information visit http://www.americantelemed.org.

Friday, December 7, 2012

Arizona studies envision telemedicine on smartphones


By: Lorri Allen
Cronkite News Service
Originally published: Nov 21, 2012


Until now, telemedicine has largely involved capital-intensive studios and cameras isolated to one area of a hospital. But the Mayo Clinic and a University of Arizona center dedicated to telemedicine are pioneering work aimed at moving care to smartphones.

That means practicing medicine in remote and underserved communities will become cheaper, quicker and more effective, according to Dr. Bart Demaerschalk, a neurologist at Mayo Clinic Hospital.

"What we're attempting to do is to make it even easier for the clinical specialist to insert themselves in a virtual manner for the patient in the remote environment," he said. "A mobile device should fulfill that goal."

Dr. Ronald Weinstein, director of the Arizona Telemedicine Program, sees it as a natural progression.

"Telemedicine is rapidly evolving into being next-generation or even a generation beyond by going to mobile health or e-health, and the concept du jour is that the smartphone is the telemedicine workstation," he said.

That's happening at Benson Hospital, where health care workers use Skype on iPads to save time.

"It's very low-cost and it's to facilitate communication between our ER docs and admissions," said John Roberts, information technology director.

The entire story is here.

Thursday, October 18, 2012

Phone Therapy Is Effective, Increases Access And Potentially Decreases Costs

Medical News Today
Originally published October 2, 2012


A new study reveals that cognitive therapy over the phone is just as effective as meeting face-to-face. The research was published in the journal PLoS ONE.

Researchers at the University of Cambridge together with the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care (NIHR CLAHRC) and NHS Midlands & East also found that providing talking therapy over the phone increases access to psychological therapies for people with common mental disorders and potentially saves the NHS money.

For the study, data from 39,000 patients in seven established Improving Access to Psychological Therapies (IAPT) services (an initiative which aims to expand the availability of psychological therapies) in the East of England were used to compare Cognitive Behavioural Therapy (CBT) delivered face-to-face versus over the phone. For all but an infrequent, identifiable clinical group with more severe illness, therapy over the phone was as effective as face to face, and the cost per session was 36.2% lower.


Thursday, August 9, 2012

Guidelines for the Practice of Telepsychology

GUIDELINES FOR THE PRACTICE OF TELEPSYCHOLOGY

(Draft – Released for public comment on July 27, 2012)

Introduction
Definition of Telepsychology
Operational Definitions
Need for the Guidelines
Development of the Guidelines
Guideline 1: Competence of the Psychologist
Guideline 2: Standards of Care in the Delivery of Telepsychology Services
Guideline 3: Informed Consent
Guideline 4: Confidentiality of Data and Information
Guideline 5: Security and Transmission of Data and Information
Guideline 6: Disposal of Data and Information and Technologies
Guideline 7: Testing and Assessment
Guideline 8: Interjurisdictional Practice
Conclusion
References

These guidelines are designed to address the developing area of psychological service provision
commonly known as telepsychology. Telepsychology is defined, for the purpose of these
guidelines, as the provision of psychological services using telecommunication technologies as
expounded in the “Definition of Telepsychology.” The expanding role of technology in the
provision of psychological services and the continuous development of new technologies that
may be useful in the practice of psychology present unique opportunities, considerations and
challenges to practice. With the advancement of technology and the increased number of
psychologists using technology in their practices, these guidelines have been prepared to educate
and guide those who engage in the practice of telepsychology.

The proposed Guidelines are here.

In order to comment on these proposed guidelines, click here.

Technological Imperative

By Pat DeLeon
Posted with permission


One direct consequence of the advent and steadily increasing presence of technology within the health care arena will be the need for psychology to finally seriously address the issue of licensure mobility. The Department of Veterans Affairs (VA) recently announced its plan to increase veterans’ access to mental health care by conducting more than 200,000 clinic-based, telemental health consultations by mental health specialties this fiscal year. Earlier the VA indicated that it would no longer charge a copayment when veterans receive care in their homes from VA health professionals using video conferencing. The Secretary: “Telemental health provides Veterans quicker and more efficient access to the types of care they seek. We are leveraging technology to reduce the distance they have to travel, increase the flexibility of the system they use, and improve their overall quality of life. We are expanding the reach of our mental health services beyond our major medical centers and treating Veterans closer to their homes.” Since the start of the VA Telemental Health Program, VA has conducted over 550,000 patient encounters.

The Fiscal Year 2013 budget request for the Office of Rural Health Policy, which is located within the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, notes that there has been a significant Departmental focus on rural activities for over two decades. Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities. There are nearly 50 million people living in rural America who face ongoing challenges in accessing rural health care. Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts. Rural areas also continue to suffer from a shortage of diverse providers for their communities’ health care needs and face workforce shortages at a greater rate than their urban counterparts. Of the 2,052 rural counties in the nation, 77 percent are primary care health professional shortage areas (HPSAs), where APA’s Nina Levitt reports that psychologists are eligible for the National Health Service Corps Loan Repayment Program which places health professionals in underserved rural communities. 

HRSA’s Telehealth Grants initiative is designed to expand the use of telecommunications technologies within rural areas, seeking to link rural health practitioners with specialists in urban areas, thereby increasing access and the quality of healthcare provided. Telehealth offers important opportunities to improve the coordination of care in rural communities by linking its providers with specialists and other experts not available locally. The strengthening of a viable rural health infrastructure is viewed as critical for long-term success, including facilitating distance education experiences. The budget request for the office of rural health office once again proposed $11.5 million, which has subsequently been approved by the Senate Appropriation Committee, and thus allows the continuation of the Licensure Portability Grant initiative, in order to assist states in improving clinical licensure coordination across state lines. This particular initiative builds on HRSA’s 2011 Report to Congress indicating: “Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country…. Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of health professionals. ” 

For some colleagues, and particularly for those who are not comfortable with fundamental change, the relationship between telemental health and licensure mobility might seem to be a tenuous one. And yet, we would suggest that they are intimately linked. The public policy rationale for professional licensure is to protect the public from untrained and/or unethical practitioners, not to enhance the status or economic well-being of the profession. Historically, and we would expect for the foreseeable future, licensure decisions and qualification criteria have been made at the individual state level, where each of the professions plays a major role in determining its requirements for membership and its scope of practice, albeit through the political process. Within the federal system the governing statutes and implementing regulations generally require licensure in at least one state (regardless of practitioner geographical location) and facility approval (i.e., being credentialed). As improvements in technology allow for increasingly higher quality utilization, the congressional committees with jurisdiction have been systematically “cleaning up” potential lingering statutory restrictions. And, at both the state and federal level, expanding reimbursement paradigms are evolving. APA estimates that 13 states now require private sector insurance companies to pay for telehealth services. Over the years, we have not been aware of any objective evidence which suggests that the quality of care being provided via telehealth is in any way compromised. To the contrary, as the VA, the Department of Defense (DoD), and the federal criminal justice system are demonstrating, access has been significantly enhanced and new state-of-the-art clinical protocols have been developed and implemented. 

A First Hand View -- From Tripler Army Medical Center: “I joined the Telebehavioral and Surge Support (TBHSS) Clinic in February, 2011 during its infancy. At that time, the program was fully staffed with providers and support staff, making us 24 strong. TBHSS provides healthcare access by connecting eligible beneficiaries to providers who are able to indentify and treat their clinical needs. These services are provided through secured video technology which allows accessibility from remote locations worldwide. I was very excited to have the opportunity to work in a clinic that has the ability to reach out to those off island, typically in areas where the demand for services is far greater than that of the availability. To date, the clinic has been able to support Alaska, Texas, Korea, Japan, Okinawa, and American Samoa, as well as various sites on the island of Oahu and in the Continental United States. As a provider, it was refreshing to be able to provide multiple services such as therapy, consultation, administrative evaluations, and both neuropsychological and psychological assessments. In addition, we provided surge support during different points within the ARFORGEN cycle whenever there was a need for augmented behavioral health resources. In February, 2012 I was fortunate to be commissioned in the USPHS as a Lieutenant (0-3) and detailed to Tripler. As a clinical psychologist, I was able to utilize all the skills within the Department of Psychology that I acquired from my time at TBHSS. Recently, I had the honor to be promoted to the position of Clinical Director of TBHSS. Returning back to my roots has been exciting as I get to work with individuals who have a passion and commitment to serve service members and their families. My journey as a clinical psychologist civilian contractor to active duty clinical director has just begun and I am looking forward to the ongoing relationships that the TBHSS team forges with the different regions” [Sherry Gracey, Lt. USPHS]. 

ASPPB: We were very pleased to learn from Steve DeMers that the Association of State and Provincial Psychology Boards (ASPPB) was successful in its application this year for one of the licensure portability grants issued by HRSA. ASPPB will receive approximately $1 million over the next three years to provide support for state psychology licensing boards addressing statutory and regulatory barriers to telehealth, focusing upon continuing the development and implementation of its Psychology Licensure Universal System (PLUS) initiative. As an integral means of addressing the present barriers associated with telepsychology, ASPPB has developed an on-line application system, the PLUS, that can be used by any applicant who is seeking licensure, certification, or registration in any state, province, or territory in the United States or Canada that participates in the PLUS program. This also enables concurrent application for the ASPPB Certificate of Professional Qualification in Psychology (CPQ) which is currently accepted by 44 jurisdictions and the ASPPB Interjurisdictional Practice Certificate (IPC). All information collected by the PLUS is deposited and saved in the ASPPB Credentials Bank, a Credentials Verification & Storage Program (The Bank). This information can then be subsequently shared with various licensure boards and other relevant organizations. Therefore, streamlining future licensing processes. 

ASPPB is an active participant in the APA/ASPPB/APAIT Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, established by former APA President Melba Vasquez and co-chaired by Linda Campbell (APA) and Fred Millan (ASPPB). The members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice. Several of the meta-issues discussed to date center on the need to reflect broadness of concepts when incorporating telecommunications technologies and to provide guidance on confidentiality and maintaining security of data and information. In addition, a number of meta-issues focus on the critical issue of interjurisdictional practice. The underlying intent behind the proposed guidelines is to offer the best guidance to psychologists when they incorporate telecommunication technologies in the provision of psychological services, rather than be prescriptive. The Task Force met twice in 2011, June of 2012, and plans to meet once more this Fall. Feedback on their recommendations will be sought at the Orlando convention, throughout the APA governance, and continuously from the membership at large. Their goal is to have the guidelines adopted by APA as policy and approved by ASPPB and APAIT sometime in 2013. 

The U.S. Supreme Court: As we all must be aware, this summer the U.S. Supreme Court upheld the underlying constitutionality of the President’s landmark Patient Protection and Affordable Care Act of 2010 (ACA), including it’s far reaching individual mandate provision, by a 5-4 vote. For legal scholars, the most critical issue was probably the Court’s deliberations regarding the federal government’s power to regulate Commerce vs. its power to raise Taxes, as a government of limited and enumerated powers. “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions. 

For health policy experts and practitioners, the Court’s musings on our nation’s health care system makes for particularly intriguing reading. * “Everyone will eventually need health care at a time and to an extent they cannot predict, but if they do not have insurance, they often will not be able to pay for it. Because state and federal laws nonetheless require hospitals to provide a certain degree of care to individuals without regard to their ability to pay, hospitals end up receiving compensation for only a portion of the services they provide. To recoup the losses, hospitals pass on the cost to insurers through higher rates, and insurers, in turn, pass on the cost to policy holders in the form of higher premiums. Congress estimated that the cost of uncompensated care raises family health insurance premiums, on average, by over $1,000 per year.” * “Indeed, the Government’s logic would justify a mandatory purchase to solve almost any problem…. (M)any Americans do not eat a balanced diet. That group makes up a larger percentage of the total population than those without health insurance. The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to purchase insurance…. (T)he annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008. Those increased costs are born in part by other Americans who must pay more, just as the uninsured shift costs to the insured.” * “In enacting [ACA], Congress comprehensively reformed the national market for health-care products and services. By any measure, that market is immense. Collectively, Americans spent $2.5 trillion on health care in 2009, accounting for 17.6% of our Nation’s economy. Within the next decade, it is anticipated, spending on health care will nearly double. The health-care market’s size is not its only distinctive feature. Unlike the market for almost any other product or services, the market for medical care is one in which all individuals inevitably participate.” * “Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid.” 

Bringing Psychology To The Table – State Leadership In Health Care Reform: At this year’s impressive State Leadership conference, Katherine Nordal exhorted our state association leaders to appreciate that: “We’re facing uncharted territory with proposed new models of care delivery. New financing mechanisms that we’re going to have to understand and appreciate, and the ways that they are going to impact practice, whether it’s private practice or institutional practice. We know that the states are in the drivers’ seat, and most of what happens about health care reform is going to happen back home. We know that we can’t do it alone. Our advocacy depends on effective collaborations and effective partnerships. We have to be ready to claim our place at the table. We need to be involved at the ground level. You’ve got to get involved in coalitions. If we don’t participate, then we abdicate our responsibility there and we let other people – physicians, nurses, social workers, MFTs, whoever – define what our future is going to be as a profession. And that’s just not an option for us. If we’re not at the table, it’s because we’re on the menu…. When you get home and you turn your focus to health care reform, I want you to remember that other groups don’t automatically think about psychology and invite us to the table when they’re having these discussions. We have to identify health care reform initiatives that impact psychological practice and our patients and get involved in those in a proactive way. If you wait….” Aloha,