TBHI Q&A #21: When should an initial telehealth assessment be performed in person?
While practitioner reluctance is understood to be the biggest barrier to telehealth, research about attitudes is quite limited. It is the hypothesis of this article that the lack of awareness of the evidence to support telehealth assessment is a large contributor to the overall reluctance of practitioners.1 For instance, a common concern expressed by clinicians is the thought of working with an actively suicidal or homicidal patient through telehealth. A related concern involves the liability incurred when offering text-based or even video-based care to everyone with a keyboard and a credit card. After all, any one of those people could carry one or more serious diagnoses, be under or overly-medicated, and be under or over-reporting symptoms, including suicidality or homicidality. Yet even with these concerns, most clinicians offering telehealth services underestimate how many laws and ethical codes are directly relevant to their online practices.2
The ability to conduct an accurate assessment of an online client/.patient is another big concern. As with any patient assessment, the main clinical concerns involve the possibilities that the assessment is inaccurate and assessment then leads to results that are given far too much weight. The more disordered the individual is, and/or the most severe the repercussions of such testing, the more difficult it is for a responsible clinician to render a correct diagnosis through telehealth. The truth is that any clinician is limited by the inherent inaccuracies of technology chosen; the pathology and current stressors experienced by the individual being assessed; as well as the reality of the rules of state and ethical codes that dictate proper professional behavior.
In many cases, regular intake does not involve a formal assessment instrument, but rather, a clinical interview. Most practitioners are trained to use all senses when conducting such an interview, including vision (seeing the client/patient complete the intake form, hygiene, appearance); sound (voice amplitude and other vocalizations such a huffing, puffing, mumbling), gait (walking into the room and navigating the chair), olfactory (excessive perfume or cologne, alcohol, foul breath, being unwashed) and more. In those cases, the clinician needs to be fully aware of the limitations of their technical environment and fully document why and how they have bridged the gap between the in-person experience and that digital environment. For example, the clinician may be able to document the successful completion of telehealth courses addressing the issues of telepresence and how to bridge these gaps with evidence and competency-based assessment techniques.3Such training can also have helped them develop appropriate guidelines for screening. More specifically, such screening is dependent on the setting as well as the diagnosis of the client/patient. The more severely disordered that client/patient, the more a controlled setting may be necessary. Examples of such settings include locked psychiatric units, detox facilities and/or correctional facilities. The clinician in training for telehealth also may want to consider whether or not they are delivering care in a way that involves an infrastructure that supports safety when developing their screening guidelines. If they choose to work with people who struggle with the more severe disorders such as active addictions, suicidal homicidal impulses, extreme anxiety or psychosis, or the more serious characterological disorders such as borderline personality disorder, psychopathy or narcissistic personality disorder, they need to seek careful training to prevent unexpected events.
Suggestions for Conducting Formal Telehealth Assessments
A range of formal testing instruments are available for clinical care, from simple questionnaire-type instruments such as the MAST or Beck Depression Inventory (BDI) to more complex neuropsychological tests such as the Halstead Reitan. However, if a clinician chooses to use these or any other standardized assessment instruments, the suggestions below may need to be considered before offering assessment through telehealth systems:
- Is the clinician authorized to use these instruments offline? Just because a “therapy platform” makes tests available to a clinician, that clinician’s training and licensure determine their legal authority administer, interpret and share results of any particular test. Be leery of some online employers who in the spirit of “disruption” downplay the skills required for test administration.
- Has the clinician made a diligent attempt to obtain needed information before using a formal testing instrument for telehealth services? He or she may want to ask the testing houses or test developer which of their tests are validated for online administration, limitations, norms, etc. Write to the testing houses or test developer to create a document trail — don’t just call.4
- Consider the differences between each of the factors below:
- computerized administration of a test that is developed specifically for digital use
- the clinician’s mastery of the test materials and their administration through telehealth, such as using a validated protocol of telehealth-based cognitive assessment of dementia4
- the ethical requirements for test administration, interpretation and sharing of results, whether or not one is working in telehealth5
Telehealth Assessment Challenges
Let’s bring telehealth assessment challenges to life:
Imagine a teenager walking into a room where his Mom is taking the MMPI at her computer. Imagine her allowing him to look over her existing answers to get his feedback, despite strict instructions to complete the test in privacy. Imagine him persuading his Mom that some of her answers are incorrect. Can you imagine that this Mom would then be persuaded to alter at least some of her answers if she was not under your watchful eye for the entire patient assessment process Next, the clinician may want to consider exactly how they’re going to interpret and share results through telehealth.
Let’s take telehealth assessment challenges a few steps further:
- The thoughtful clinician considering telepractice may want to imagine how to disengage from someone who clearly is not appropriate for their online practice. This problem is pervasive in many online therapy platforms, where the platform introduces the independent contracted professional (using a 1099 process for tax purposes) while saddling those clinicians with the limitations of the platform to approximate in-person care. Aside from the puffery offered by many online platform developers/owners, what are the clinical responsibilities of the licensed clinician? How can a clinician disengage from an inappropriate client/patient in a way that one’s licensing board members would approve without creating liability for abandonment?
- What if the formal telehealth assessment results reveal a serious underlying psychotic process in addition to the outward symptoms of anxiety and depression? What could a responsible telehealth clinician tell the online client/patient during the sharing of test results? When would the clinician decide that giving online test results is inappropriate? How could the clinician best handle that situation?
- By getting enough training to be able to anticipate and avert such difficult situations, the responsible clinician also prepares for scenarios that are unexpected, but possible. For example, how could a telepractitioner legally and ethically handle confrontation by an agitated spouse who barges in and insists on hearing the test results during a video session with the client/patient? Or one that listened to the information about test results from their living room on his Bluetooth, then calls the clinician to demand clarification?
- What if the person becomes suicidal upon hearing the conclusions? Would the clinician be liable if the client/patient made an attempt on their life? What would the test developer have to say about the validity of the telehealth procedures used with their test instrument? How would an attorney defend such a clinician if they were charged with malpractice? Which state law could have been violated and which professional ethical code section could be involved?
The point is that some assessment requirements can easily be met online while others are quite a bit more difficult if not impossible, particularly with seriously mentally ill or intoxicated individuals. Some intake/assessment processes have a telehealth research basis of support but are only appropriate if the clinician follows the researched protocol.6 Some popular employers with unorthodox services may be proliferating, but they are not yet validated and therefore, can leave the client/patient as well as the clinician in hot water if something goes wrong.7 In telehealth, being “creative” on the fly could quickly become problematic for the private practitioner as well as the unwitting clinician who chooses to offer “distruptive” services through unproven technologies with a poor evidence base.
Yes, telehealth can replace in-person care in many ways, but it simply isn’t evolved enough to correctly, responsibly serve all people as well as in a highly controlled, brick-and-mortar offices. If a clinician is guessing at the answers to the questions above rather than able to identify specific, peer-reviewed articles to support their procedures using telehealth, focused research/study is warranted. To see some of the data available for such a case, research the assessment literature;8,9,10, 11,12 consider getting specific telehealth training to conduct proper screening, documentation, and legally and ethically compliant practices.
In summary, the experienced clinician will consider that telehealth cannot yet be all things to all people — no matter what some clinicians would like to believe. Some assessment are still best conducted in-person. Meanwhile, if any form of assessment is involved, it is the job of the responsible professional to have thought through all services offered to the public and considered what telehealth can and can’t do for each person in front of them. He or she will do well to stick to evidence-based screening protocols and/or assessment instruments and processes. If not, they may need to offer general telehealth services with very well screened populations, develop strong and reliable support systems in case of emergency and wait for the research to lead the way.13
Your comments are invited. Please feel free to provide links to peer-reviewed publications to support your views.
Telehealth Assessment References and Footnotes
1 Callan, J. E., Maheu, M. M., & Bucky, S. F. (2017). Crisis in the behavioral health classroom: enhancing knowledge, skills, and attitudes in telehealth training. Career paths in telemental health, 63-80.
2 Glueckauf, Robert L.; Maheu, Marlene M.; Drude, Kenneth P.; Wells, Brittny A.; Wang, Yuxia; Gustafson, David J.; Nelson, Eve-Lynn. Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, Vol 49(3), Jun 2018, 205-219.
4 Develop a document trail to put into a “defensible file” as taught in many of the TBHI online telehealth courses.
5 Hannah E Wadsworth, Kaltra Dhima, Kyle B Womack, John Hart, Myron F Weiner, Linda S Hynan, C Munro Cullum, Validity of Teleneuropsychological Assessment in Older Patients with Cognitive Disorders, Archives of Clinical Neuropsychology, Volume 33, Issue 8, December 2018, Pages 1040–1045, https://doi.org/10.1093/arclin/acx140
6 For example, think about the APA code section related to testing (administration, interpretation, giving results, etc.). Go to Section 9 of that document. The clinician is obligated to think about those or similar requirements for delivering test results with a severely disordered client/patient, whether it is online or in traditional settings. If online, they may or may not be able to prevent a client/patient from immediately leaving the session, or worse case — engaging in harmful behavior. Giving test results is challenging enough in a traditional in-person practice setting. A clinician who isn’t fully prepared can be treading on very thin ice when announcing undesirable news to clients/patients online.
7 Maheu, M., Pulier, P., Wilhelm, F., McMenamin, J., & Brown-Connolly, N. (2004). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Erlbaum.
8 Consider that just two years ago, the American Psychological Association responded to a CMS inquiry about the appropriateness of online patient assessment for Medicare reimbursements by stating that they were not in support of CMS offering reimbursement for telehealth-based assessment. Their published reason for doign so was that important cues would be missing in telehealth-based assessment. This conclusion, however, was reached after speaking with leaders in neuropsychology but not telehpsychology (personal communication, Randy Phelps, 2017).
9 Review the An Interprofessional Framework for Telebehavioral Health Competencies, published in 2017 by the Coalition for Technology in Behavioral Science (CTiBS). See the first domain, Clinical Evaluation and Care. Maheu M. M., Drude, K., Hertlein K., Lipshutz, R., Wall, K., Long, R., Hilty D. M., (2017). An Interprofessional Framework for Telebehavioral Health Competencies. Journal for Technology in Behavioral Science, 1(4).
10 Hilty D. M., Maheu M. M., Drude, K., Wall, K., Long R, Hertlein K, Luoma, T. (2017). The Need for Telebehavioral Health Competencies: An Approach Based On Competency Frameworks And Common Themes Across Fields. Journal for Technology in Behavioral Science, 1(1).
11 Write to the TBHI contact desk and ask for their psychological assessment reference list. TBHI is honored to share them with its community at no cost.
12 A chapter on assessment can be found in Luxton, D., Nelson, E. & Maheu, M. (2016). Telemental Health Best Practices. Washington, DC: American Psychological Association.
13 On a personal note, I know that the waiting is ridiculously painful. I’ve waited 25 years for my colleagues to finally take telehealth seriously. As the evidence base grows, legal and ethical reform is happening. For evidence of that growth, see the TBHI page of current telebehavioral health-related ethical standards and guidelines and the TBHI bibliography page with more than 1000 searchable research articles. More directly, in 2018, I gave an invited workshop related to telehealth and neuropsychological assessment to NAN, the National Academy for Neuropsychology. I am now invited to address this issue of psychological assessment through telehealth at the American Psychological Association in August of 2019.