The Texas Medical Board reportedly met last Thursday to discuss the much-debated topic of whether or not physicians should be required to meet with patients before prescribing medication. The meeting follows a January 16, 2015 decision by the Board to require that Texas physicians have a “face-to-face visit” with patients. This action by the Board thereby would inhibit the delivery of medical services by Texas-licensed physicians through one of the country’s largest employers of telehealth, Teladoc. The Board explained that their decision was based on their need to protect public health.
Teladoc immediately sought to prevent the decision from taking effect. Four days later, a Travis County judge approved a temporary restraining order, citing that “no imminent peril to public health, safety or welfare exists.” This latest round of decisions follows a heated battle between Texas and Teladocs. Similar battles are taking place in several other states over in-person intake requirements, interjurisdictional licensing and related laws.
Allied Health Licensing Boards & Professional Associations
Many allied health professional boards and professionals are following these events with keen interest, wondering where decision-makers will rest on these pivotal issues for psychology, counseling, social work, behavior analysis, speech pathology, physical therapy, etc. Ethical standards and guidelines issued by leading mental health professional associations regarding telepractice typically do not take a stand for or against a requirement for in-person intakes or assessments.
The American Telemedicine Association has taken the stance that such intakes are unnecessary. The fascinating twist on the issue however, is that most telemedicine does not occur directly between a physician as an independent practitioner and a patient. For decades, the traditional model for telehealth has involved an in-person assessment by a third party, who sees the patient in-person. Whether a nurse who takes vital signs, or a medic who serves in the military, or a “collaborator” who is a para-professional located whereever the patient is in geographic space, an accountable, trained third party is available to outline and present relevant issues for intake and assessment. It therefore is the move away from such a third party that raises concerns for medical as well as behavioral professionals.
The American Psychological Association’s (APA) “Guidelines for the Practice of Psychology” reflects this penchant in Guideline 2, the “Standards of Care in the Delivery of Telepsychological Services”:
When providing telepsychology services, considering client/patient preferences for such services is important. However, it may not be solely determinative in the assessment of their appropriateness. Psychologists are encouraged to carefully examine the unique benefits of delivering telepsychology services (e.g., access to care, access to consulting services, client convenience, accommodating client special needs, etc.) relative to the unique risks (e.g., information security, emergency management, etc.) when determining whether or not to offer telepsychology services. Moreover, psychologists are aware of such other factors as geographic location, organizational culture, technological competence (both psychologist and client/patient), and, as appropriate, medical conditions, mental status and stability, psychiatric diagnosis, current or historic use of substances, treatment history, and therapeutic needs that may be relevant to assessing the appropriateness of the telepsychology services being offered. Furthermore, psychologists are encouraged to communicate any risks and benefits of the telepsychology services to be offered to the client/patient and document such communication. In addition, psychologists may consider some initial in-person contact with the client/patient to facilitate an active discussion on these issues and/or conduct the initial assessment.
The APA statement above gives a clear warning, but apparently leaves the decision about in-person intake and assessment to the clinician. Whether or not clinicians using telehealth systems online are actually conducting the type of intake detailed above remains questionnable. As we’ve seen in some of our recent blog posts, a minimalistic approach to assessment and intervention seems to be proliferating. See Text Messaging for Counseling, Therapy & Crisis Intervention. However, the vast majority of telehealth-related research uses telehealth systems for follow-up only, and not for initial intake.
What do you think of the need for in-person assessments for telemental health?