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Why Online Practice Can be Harmful — Part II

Online Practice

In this article, we’ll consider the differences between traditional and exclusively Internet-based practice, and the repercussions these differences might have for the professional. As we discussed in Why Online Practice Can Be Harmful — Part I, working in traditional telehealth systems alleviates many of the risks inherent to telemental health and any other form of virtual practice. Client/patient intake, assessment and history are often conducted by a team of professionals. Working online in a small group or independent practice is quite another story. We’ll now look at the differences in more detail.

Traditional Behavioral Telehealth  — Client/Patient Experience

Working in traditional behavioral or telemental health settings affords many benefits for risk management. Team members include the clinician, but can also include administrative assistants, nurses or physician assistants and information technology (IT) team members. Each of these professionals has the opportunity to make chart notations about their experience of the client/patient.  Intake forms are completed in the waiting room, often under the watchful eye of an administrative assistant. Nurses often take vital signs and comments are entered into the patient record. Physicians, nurse practitioners or their representatives are responsible for management of the case. HIPAA requirements are explained and the patient consents to treatment. Release forms are signed and messages are sent to other involved health professionals.

Once the determination is made that a substance abuse, behavioral or mental health consult is needed, the client/patient is educated, often by a technical or other assistant. Information is shared about how the technology and support systems work, what they can expect, who they will see for their video consult and why. Proper expectations are set for the consult with a behavioral specialist, who is at a computer that might be hundreds of miles away. An appointment is set, often on another day. The client/patient returns to the clinic for that appointment with the behavioral specialist. Everyone involved understands mandated reporting and emergency treatment protocols. Such backup is available within the client/patient’s local community with pre-identified personal or response teams.

Traditional Behavioral Telehealth — Practitioner’s Experience

On the clinician’s side, the professional is credentialed, trained in how to keep the client/patient record, and also trained in how to use the technology. Practitioners often don’t need to be trained in the legal issues, because their institution handles requirements such of making sure the technology is HIPAA compliant, proper intake forms are signed, releases are sent, etc. Those legal requirements, for which they must exert effort, are understood and formally accepted in an agreement with the healthcare facility.

Both treatment protocols and technology protocols are understood by the clinician and carefully monitored by quality control staff. Mechanisms for mandated reporting are established and well-tested. Malpractice insurance is in place and has the advantage of a large system selecting the plan, a legal team to interpret its coverage, and the clout of the large organization is readily available to force payment of benefits when in question. There usually is a support team on standby to handle any unexpected technical failures with the video or other technology. Emergency back-up staff and processes are identified and available for unexpected emergencies.

The system works well. Scientific documentation for the effectiveness of using such professionals and video-based systems is well established. This large, interlocking system of checks and balances affords the practitioner many assurances and peace of mind when embarking on innovative forms of practice via technology.

Independent, Small Group and Clinic Practitioners

On the other hand, the experience of many independent or small group and clinic practitioners can be quite different. These professionals do often not have an in-house system of checks and balances when working online. They have to cover all the bases, including:

Following all relevant state and ethical requirements

  • authentication of the consumer
  • establishing geographic location of all involved parties
  • intake/assessment
  • technology-related informed consent
  • understanding, developing and following appropriate protocols for both the technical and clinical interventions
  • consumer education and management
  • proper documentation and
  • emergency planning/intervention

Just as when a practitioner uses a telephone company to connect with a consumer, a professional using any video platform without the aid of a support staff at a distant site is responsible nonetheless. Such professionals need to understand how to handle all the required elements of a professional relationship and protect that client/patient from harm online — and all without assistance from supportive staff, large structures  and the training afforded by such systems.

The Problem — Lack of Information

On the Internet, many practitioners are not only uncredentialed, many don’t know where to go to get credentialed. Training is a serious problem. Many don’t have any training to handle the many events that can easily go wrong online with a behavioral or mental health practice. Many don’t know how to conduct a legal informed consent process, a distant intake or assessment. They often don’t how where to find protocols for telemental health care or how to adapt what they find to their own clinical populations.They often don’t know how to anticipate emergencies, prevent them or rally a local backup team when an emergency appears. Many also don’t know how to properly bill for their services. They have not studied the many models for successful practice in over a dozen settings supported by the evidence base, and don’t comprehend how to deliver comparable services to their own specialty populations.

The Solution — Training is Available to Remedy the Gaps

How this new breed of practitioner fares without guidance and the advantage of the evidence base is questionable. For example, if a patient arrives to an in-person session and smells of alcohol or has not bathed in weeks, the clinician’s intake process is likely to differ substantially from an intake with a well-groomed, alert and sober client/patient. Likewise, a tremor in someone’s hand can often be noticed upon the clinician’s shaking hands prior to entering an office. Noting a hand tremor requires active inquiry when working online. If a new client/patient stumbles into a brick-and-mortar office, the clinician might be expected to conduct a gait analysis, that is, ask them to walk from one end of the office to the other to assess gait. Online, the gait analysis also needs to be actively pursued, because most clients/patients are seated at their monitors upon initial contact.

Many professionals seeking to work online often have good intentions, but misunderstand limitations imposed by licensure, assessment or reporting requirements. They often are unaware that it is their responsibility to know how regulations differ from state-to-state and internationally. They may not understand how much education the client/patient needs to make the contact without interruption, their expectations, and how to cover all that ground when online and charging a consumer by-the-minute for their services. They may agree to operate without the benefit of a full intake, informed consent or emergency backup when their state law mandates that they cover all these bases, and much more.

While the telephone or online platforms such as Helpouts are easy to use, delivering health care that is legal or ethical via these platforms isn’t quick, easy or intuitive for most professionals.

These Limitations Can Be Easily Overcome

Most professionals delivering mental health services in the United States do not work in well-established health care facilities with the needed systems in place to deliver telehealth. The worrisome reality of this professional community is that they:

  • haven’t yet undergone graduate or professional training (CE or CME training) related to technology in delivering behavioral or mental health care
  • belong to professional membership groups that haven’t yet identified needed competencies for such training
  • are licensed by state regulatory boards that are still struggling to develop their own internal policies (Many have not developed pages such as this one posted online by the Board of Behavioral Sciences in California years ago.)

Despite how burdensome these issues may seem, solutions have been developing for over six decades in the scientific literature. Found mostly in the medical literature, these evidence-based resources can be readily understood by the practitioner who looks carefully. Regulatory precedent abounds, professional associations worldwide already have produced insightful standards and guidelines. (For a professional training program designed to expedite your absorption of key fundamentals and manage your risk while earning CEs and CMEs from the comfort of your home or office via a sophisticated eLearning platform, look at our TMHI Certificate Program.)

In Why Online Practice Can Be Harmful–Part I, we reviewed the some of the consumer protection issues that are relevant to working online. In our next section, Why Online Practice Can Be Harmful Part III, we focus on the role of professional associations and how they can help with the adoption of new technologies to meet consumers online.

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