All That Glitters is Not Gold
While many online companies offer exciting online therapy jobs, many of their platforms lack the ability for clinicians to meet their own professional legal and ethical obligations. Upon close examination, it is clear that their legal offices have written employment or service agreements that squarely place all responsibility for the interaction on the shoulders of the practitioner. Some online therapy companies even ask the clinician to “indemnify” them against any “clinician wrongdoing.” After all, they are hiring licensed professionals who should know their duties, right?
The truth is, most clinicians are untrained and therefore unaware of the procedures or tools needed to work responsibly online. By working for some of these companies, they are allowing their employers to limit their abilities. Meanwhile, they are fully responsible for working with unscreened, online clients and patients who could be seriously mentally ill — and therefore potentially lethal. Some of these uninformed clinicians operate with little knowledge of the client on one end and no emergency support systems on the other. They may violate licensure requirements, informed consent requirements, and much more.
Indeed, these companies are surfacing everywhere. One of our TeleMental Health Institute trainees reported receiving more than a dozen such letters in the last year. Many such professionals have been coming to our presentations, training and courses with a wide variety of questions about online therapy employers who connect them to consumers via the Internet. Many therapists are intrigued by the opportunities but confused about responsibilities and/or limited in time to research the issues. They seek our consultation to get quick responses to specific questions. As a result, I’ve examined related online therapy employment or service agreements as well as the “terms and conditions” of services offered to consumers.
How Many Online Therapy Companies are Failing to Follow Best Practices?
Many. Conduct an online search for “online therapy” or “online counseling” to see how many online therapists are:
- offering anonymous care, which precludes the ability for licensed professionals to report when required by law
- operating over state lines without mentioning the need to obtain licensure in the foreign state(s) or countries
- offering professional services to populations that have not been assessed, so for example, the clinician trained in general issues may be facing a geriatric situation with a complex family and medical history
- offering services with no screening procedures aside from asking them to click a box to indicate they are over 18 years of age
- offering easy answers to a wide range of problems with no formal intake procedures but without asking for histories, medications taken, or collaboration with other treating professionals
- offering professional services without informed consent that covers the risks and benefits, such as educating the client, mandated reporting, suicide and homicide procedures and safety plans
- offering professional services without triage to clinicians who are legally licensed and properly trained
- offering professional services without emergency backup in the local community
Each of the actions identified above represents a failure to follow best practices for behavioral telehealth, telemental health, telepsychiatry, telepsychology, or distance counseling.
27 Questions You Can Ask Online Therapy Employers
To make it easier for you to understand how to evaluate companies offering online therapy jobs, the TeleMental Health Institute is happy to offer the following list of questions as a community service. They are designed for you to send to all potential behavioral telehealth, telemental health, text therapy or online therapy employers. These same questions can be used with telephone-based therapy employers. If a company gets squeamish at the prospect of your asking these questions, move on. As professionals it is our responsibility to choose technologies that enhance our work, rather than simply be the workhorses for make-money-fast business models that leave us and our patients at undue risk.
To find a good fit for you and your work, ask any one or combination of these questions:
- Who on your team has credentials in telemental health or behavioral telehealth best practices?
- Do you have any clinical research supporting your approach to telemental health?
- Does your system ask consumers to fully identify themselves or do you allow anonymity?
- What should I do in your network if I have a clinical emergency (i.e., suicidal, homicidal, abuse reporting)? What is the process that you have developed to handle such reporting through your platform? Has this process been reviewed by industry leaders or ethics boards of various professionals associations? Has it been tested and proven bug free?
- How do I complete an informed consent process using your system? What are consumers told about how I will handle their emergencies or my mandate to report them for reasonable suspicion of abuse?
- How do I know where someone is geographically when they contact me? Do I have to ask them?
- Are all your systems compliant with federal and state transactions, privacy and security standards (HIPAA and HITECH in US, PIPEDA in Canada)? Does your interface (audio, video, text messaging, email, etc.) offer “audit trails” and “breach notification tools” as required by HIPAA? Are you creating any form of digital footprint of my communications with specific individuals? Where will my notes or comments about any individual be stored? Will you give me a Business Associate’s Agreement (BAA) for the services you are offering me in your company? Who else will see what consumers have communicated through your company?
- Are you collecting “big data” or other types of data through your company? If yes, is that area compliant with all federal and state laws of relevance? Will you attest to your claims in this regard?
- Will you indemnify me against all your actions if something is wrong with not only your security requirements, but also your business model?
- Do you have insurance to protect me if your systems fail and there is a privacy, security or transmission breach?
- What type of agreement do you ask consumers to sign before they connect with me?
- How do I know where to refer in a client or patient’s local communities if local support is needed, as with mental health emergencies? What am I supposed to do if they tell me they are in the midst of a suicidal attempt but located in another state?
- Will I be given their phone numbers in case your digital connection fails at an inopportune time in my contact with a consumer?
- What are consumer expectations of my availability? Will they be routed to someone else?
- Will I have access to notes from other clinicians if the consumers I have served get routed to someone else in your system in my absence?
- What’s your policy about responding to subpoenas requesting any data from your company about the people I see through your platform?
- What will consumers get to see about me through your company? Do I get to edit that information whenever I choose?
- How can I be sure that I am speaking to the person whose account is being used to access me? For example, do you offer “authentication” tools so I know I am not violating the account owner’s privacy by speaking to a family member pretending to be the client?
- How can I pre-screen your consumers? How can I be sure that the person you are routing to me through your platform is only dealing with issues for which I am clinically, legally and ethically prepared?
- Are you counting on my malpractice insurance policy to cover all my liabilities if we get sued?
- Do you offer insurance against my reputation being harmed by being in association with your group if something goes wrong?
- Do you offer insurance against your system failing to provide the service you promise when I’m in the middle of working with a vulnerable client or patient in an emergent situation? Are you asking me to “indemnify” you against all my liabilities if something goes wrong?
- Who pays for services through your system? If insurance is billed, who is responsible to complete the notes, render a diagnosis and CPT code? How are these processes streamlined to save time and yet be accurate? Can I double check your attempts to collect reimbursement for my services whenever I want?
- If I am allowed to connect to foreign states and countries through your platform, will you help me determine how I can be compliant with all their legal requirements, including licensure, informed consent and mandated reporting?
- If I am not certified in telepractice, how do you help me gain expertise in any legal, ethical or clinical areas required for responsible telepractice?
- Will you try to stop me from working for other online therapy companies in your “service agreement?”
- How else do you protect me as a licensed clinician whose #1 duty is to “do no harm” to the people I serve?
There are plenty of companies who have done an excellent job of preparing online platforms that will protect you and those you serve. We have been approached by a number of them who need trained clinicians. If you are looking for legal and ethical online therapy job, complete a detailed profile our new employment and credentialing service at ProviderPanel.com and we’ll get back to you ASAP. When you are contacted by any potential employer with an online therapy job, be sure to ask them the above questions, and listen carefully to the answers they give. If you’d also like to know how to minimize your risk and also practice from home, see this recorded webinar. Broader certification is also available here.
Are You a Reputable Online Therapy Company?
If you are a company either delivering or seeking to deliver behavioral services online, contact us for enterprise discounts to help your workforce be in compliance with behavioral telehealth best practices . Thousands of responsible professionals from all 50 United States and 39 countries have already trained in our systems at the Telebehavioral Health Institute. Many are looking for employment with legal and ethical employers like you.