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ACKNOWLEDGEMENTS

TheAmericanTelemedicineAssociation(ATA)wishestoexpresssincereappreciationtotheATATelementalHealthPracticeGuidelinesWorkGroupandtheATAStandardsandGuidelinesCommitteefortheirinvaluablecontributionsintheresearch,writinganddevelopmentofthefollowingguidelines.

PracticeGuidelinesForVideo-basedOnlineMentalHealthServices

(AlphabeticalOrder)

PracticeGuidelinesWorkGroupChair:CarolynTurvey,PhD,AssociateProfessor,DepartmentofPsychiatry,UniversityofIowa,ATATelementalHealthSIGChairWorkGroupMembersMireanColeman,LICSW,CT,ClinicalSocialWorker,NationalAssociationofSocialWorkersOranDennison,SeniorSoftwareArchitect,AlaskaNativeTribalHealthConsortiumKennethDrude,PhD,Psychologist,BoardMember,OhioBoardofPsychologyMarkGoldenson,CEO,BreakthroughPhilHirsch,PhD,ChiefClinicalOfficer,HealthLinkNowBobJueneman,ChiefScientist,Spyrus,Inc.GregM.Kramer,JD,PhD,ClinicalPsychologist,NationalCenterforTelehealthandTechnology|T2|DavidD.Luxton,PhD,ResearchPsychologist,ProgramManagerResearch,OutcomesandInvestigations|ROI|,NationalCenterforTelehealthandTechnology|T2|MarleneM.Maheu,PhD,TeleMentalHealthInstitute,Inc.TaniaS.Malik,JD,FounderandPresidentofCOPETodayMattC.Mishkind,PhD,ResearchPsychologist,ProgramLead,TelehealthProgram|THP|,NationalCenterforTelehealthandTechnology|T2|,JointBaseLewis-McChord,Tacoma,WA

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TerryRabinowitz,MD,DDS,Professor,DepartmentsofPsychiatryandFamilyMedicine,UniversityofVermontCollegeofMedicine,Director,DivisionofConsultationPsychiatryandPsychosomaticMedicineandDirectorofTelemedicine,FletcherAllenHealthCareLisaJ.Roberts,PhD,GlobalClinicalInnovationsandSalesManager,ViterionTeleHealthcare,abusinessofBayerHealthcareThomasSheeran,PhD,ME,AssistantProfessor(Research),RhodeIslandHospital,TheWarrenAlpertMedicalSchoolofBrownUniversity,AdjunctAssistantProfessor,InstituteofGeriatricPsychiatry,WeillCornellMedicalCollegeJayH.Shore,MD,MPH,AssociateProfessor,DepartmentofPsychiatry,SchoolofMedicine,CommunityandBehavioralHealth,ColoradoSchoolofPublicHealthCentersforAmericanIndianandAlaskaNativeHealth,UniversityofColoradoAnschutzMedicalCampusPeterShore,PsyD,AssistantProfessorofPsychiatry,OregonHealth&ScienceUniversity,DirectorofTelehealth,VANWHealthNetwork(VISN20),DepartmentofVeteransAffairs,AdjunctAssistantProfessor,InstituteofGeriatricPsychiatry,WeillCornellMedicalCollegeFrankvanHeeswyk,CTO&VPTechnicalServices,OntarioTelehealthNetworkBrianWregglesworth,DirectorofProductDevelopment,AlaskaNativeTribalHealthConsortiumPeterYellowlees,MBBS,MD,ProfessorofPsychiatry,UCDavis,DirectoroftheHealth,InformaticsGraduateProgram,UCDavis,Sacramento,CAMurrayL.Zucker,MD,RegionalMedicalDirector,SanFrancisco,OptumOtherContributorsDavidKaplan,PhD,ChiefProfessionalOffice,AmericanCounselingAssociationJoelYager,MD,Chair,SteeringCommitteeonPracticeGuidelines,AmericanPsychiatricAssociationATAStandardsandGuidelinesCommitteeChair:ElizabethA.Krupinski,PhD,Professor&ViceChairofResearch,DepartmentofMedicalImaging,UniversityofArizonaStandardsandGuidelinesCommitteeMembersNinaAntoniotti,RN,MBA,PhD,DirectorofTelehealth,MarshfieldClinicTeleHealthNetwork

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DavidBrennan,MSBE,Director,TelehealthInitatives,MedStarHealthAnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineJerryCavallerano,PhD,OD,StaffOptometrist,AssistanttotheDirector,JoslinDiabetesCenter,BeethamEyeInstituteCindyK.Leenknecht,MS,APRN-CS,CCRP,TelehealthProjectCoordinator-MontanaPediatricProject,St.VincentHealthcare/PartnersinHealthTelemedicineNetworkHelenK.Li,MD,AdjunctAssociateProfessor,UniversityofTexasHealthScienceCenterLouTheurer,GrantAdministrator,BurnTelemedicineProgram,UniversityofUtahHealthSciencesCenterJillM.Winters,PhD,RN,PresidentandDean,ColumbiaCollegeofNursing,Milwaukee,WI

ATAStaffJordanaBernard,MBA,SeniorDirectorProgramServicesGaryCapistrant,MA,SeniorDirectorPublicPolicyJonathanD.Linkous,CEOMaureenMcGrath,MA,DirectorProgramServices

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PracticeGuidelinesforVideo-BasedOnlineMentalHealthServices

TableofContents

Preamble 6Scope 7Introduction 7PracticeGuidelinesforVideo-BasedOnlineMentalHealthServices 9 a.ClincialGuidelines 9 b.TechnicalGuidelines 16 c.AdministrativeGuidelines 19Appendix:References 20

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Preamble

TheAmericanTelemedicineAssociation(ATA),withmembersfromthroughouttheUnitedStatesandthroughouttheworld,istheprincipalorganizationbringingtogethertelemedicinepractitioners,healthcareinstitutions,vendorsandothersinvolvedinprovidingremotehealthcareusingtelecommunications.ATAisanonprofitorganizationthatseekstobringtogetherdiversegroupsfromtraditionalmedicine,academia,technologyandtelecommunicationscompanies,e-health,alliedprofessionalandnursingassociations,medicalsocieties,governmentandotherstoovercomebarrierstotheadvancementoftelemedicinethroughtheprofessional,ethicalandequitableimprovementinhealthcaredelivery.ATAhasembarkedonanefforttoestablishpracticeguidelinesandtechnicalstandardsfortelemedicinetohelpadvancethescienceandtoassuretheuniformqualityofservicetopatients.Theseguidelines,basedonclinicalandempiricalexperience,aredevelopedbyworkgroupsthatincludeexpertsfromthefieldandotherstrategicstakeholdersanddesignedtoserveasbothanoperationalreferenceandaneducationaltooltoaidinprovidingappropriatecareforpatients.TheguidelinesandstandardsgeneratedbyATAundergoathoroughconsensusandrigorousreview,withfinalapprovalbytheATABoardofDirectors.Existingproductsarereviewedandupdatedperiodically.Thepracticeofmedicineisanintegrationofboththescienceandartofpreventing,diagnosing,andtreatingdiseases.Accordingly,itshouldberecognizedthatcompliancewiththeseguidelineswillnotguaranteeaccuratediagnosesorsuccessfuloutcomeswithrespecttothetreatmentofindividualpatients,andATAdisclaimsanyresponsibilityforsuchoutcomes.Theseguidelinesareprovidedforinformationalandeducationalpurposesonlyanddonotsetalegalstandardofmedicalorotherhealthcare.Theyareintendedtoassistpractitionersinprovidingeffectiveandsafemedicalcarethatisfoundedoncurrentinformation,availableresources,andpatientneeds.Thepracticeguidelinesandtechnicalstandardsrecognizethatsafeandeffectivepracticesrequirespecifictraining,skills,andtechniques,asdescribedineachdocument,andarenotasubstitutefortheindependentmedicaljudgment,training,andskilloftreatingorconsultingpractitioners.Ifcircumstanceswarrant,apractitionermayresponsiblypursueacourseofactiondifferentfromtheguidelineswhen,inthereasonablejudgmentofthepractitioner,suchactionisindicatedbytheconditionofthepatient,restrictionsorlimitsonavailableresources,oradvancesininformationortechnologysubsequenttopublicationoftheguidelines.Nonetheless,apractitionerwhousesanapproachthatissignificantlydifferentfromtheseguidelinesisstronglyadvisedtoprovidedocumentation,inthepatientrecord,thatisadequatetoexplaintheapproachpursued.Likewise,thetechnicalandadministrativeguidelinesinthisdocumentdonotpurporttoestablishbindinglegalstandardsforcarryingouttelemedicineinteractions.Rather,theyare

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resultoftheaccumulatedknowledgeandexpertiseoftheATAworkgroupsandintendedtoimprovethetechnicalqualityandreliabilityoftelemedicineencounters.Thetechnicalaspectsofandadministrativeproceduresforspecifictelemedicinearrangementsmayvarydependingontheindividualcircumstances,includinglocationoftheparties,resources,andnatureoftheinteraction.Thispracticeguidelinesdocumentfocusesontelementalhealthservicesdeliveredinreal-timeusinginternet-basedvideoconferencingtechnologiesthroughpersonalcomputersandmobiledevices.TheseguidelinesserveasacompaniondocumenttoATA’sPracticeGuidelinesforVideoconferencing-basedTelementalHealth,adocumentadoptedin2009thatfocusesonreal-timevideoconferencing-basedtelementalhealthservicesdeliveredusingtechnologiesotherthantheInternet.

Scope

Thescopeoftheseguidelinescoverstheprovisionofmentalhealthservicesprovidedbyalicensedhealthcareprofessionalwhenusingreal-timevideoconferencingservicestransmittedviatheInternet.Othercertifiedprofessionalsmaytakeguidancefromtheseguidelines,butthecurrentversiontargetsthepracticeofbehavioralhealthbylicensedhealthcareprofessionals.Theguidelinespertaintotelementalhealthconductedbetweentwoparties,anddonotaddressconcernsrelatedtomultipointvideoconferencing.Theseguidelinesincludetelementalhealthserviceswhentheinitiating,receiving,orbothsitesareusingapersonalcomputerwithawebcamoramobilecommunicationsdevice(e.g.,“smartphone”,laptop,ortablet)withtwo-waycameracapability.Theseguidelinesdonotaddresscommunicationsbetweenprofessionalsandclientsorpatientsviatexting,e-mail,chatting,socialnetworksites,online“coaching”orothernon-mentalhealthservices.Thisdocumentcontainsrequirements,recommendations,oractionsthatareidentifiedbytextcontainingthekeywords“shall,”“should,”or“may.”“Shall”indicatesarequiredactionwheneverfeasibleandpracticalunderlocalconditions.Theseindicationsarefoundinboldthroughoutthedocument.“Should”indicatesanoptimalrecommendedactionthatisparticularlysuitable,withoutmentioningorexcludingothers.“May”indicatesadditionalpointsthatmaybeconsideredtofurtheroptimizethetelementalhealthcareprocess.

Introduction

TelementalhealthisoneofthemostactivetelemedicineapplicationsrenderedintheUnitedStates.Telementalhealthisanintentionallybroadtermreferringtotheprovisionofmentalhealthandsubstanceabuseservicesfromadistance.MentalhealthisparticularlysuitedtotheuseofadvancedcommunicationtechnologiesandtheInternetfordeliveryofcare.Byusingadvancedcommunicationtechnologies,mentalhealthprofessionalsareabletowidentheirreachtopatientsinacost-effectivemanner,amelioratingthemal-distributionofspecialtycare.

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Establishingguidelinesfortelementalhealthimprovesclinicaloutcomesandpromotesinformedandreasonablepatientexpectations.ATAhasdevelopedcorestandardsfortelemedicineoperationsthatprovideoverarchingguidanceforclinical,technicalandadministrativestandards(http://www.americantelemed.org/practice/standards/ata-standards-guidelines/core-standards-for-telemedicine-operations).(1)Thisdocumentprovidesfurtherguidanceontheclinical,technical,administrativeaswellasethicalissuesasrelatedtoelectroniccommunicationbetweenprofessionalsandpatientsusingadvancesininternet-basedvideoconferencingtechnologiesandtheresultingtreatmentmodels.TheseguidelinesalsoserveasacompaniondocumenttoATA’sPracticeGuidelinesforVideoconferencing-basedTelementalHealth,adocumentthatfocusesonreal-time,videoconferencing-basedtelementalhealthservicesdeliveredusingmethodsotherthantheInternet(2,3)andappliestothegroupsandservicesdescribedtherein.OtherprofessionalorganizationsintheUSandabroadhavepublishedguidelinesfortheprovisionofmentalhealthcareutilizingthedesktopandmobileinternet-basedcommunicationtechnologies.(4-7)Whenguidelines,positionstatements,orstandardsfromanyprofessionalorganizationorsocietyexist,mentalhealthprofessionalsshouldalsoreviewthesedocumentsand,asappropriate,incorporatethemintopractice.Internet-basedTelementalHealthModelsofCareTodayToday,mentalhealthprofessionalsareusinginexpensivetechnologiesavailablethroughtheproliferationofpersonalcomputers,theInternet,mobiledevicesandvideoconferencingsoftwaretoprovidementalhealthservices.Forexample,manymentalhealthprofessionalsareusingwidelyavailable,commercialsoftwaredownloadedfromtheInternettoprovidecaredirectlytoapatient’shomeorothernon-institutionalsetting.Internet-basedwebsitescanserveasaconduitorportalformentalhealthprofessionalsandpatientsseekingtreatmentonline.Mentalhealthprofessionalscansignupwithoneormoreweb-basedcompaniesandprovideaprofessionalprofilethatcanbeviewedonlinebyprospectivepatients.Patientsfindsuchsitesbysearchingonlineorthroughwordofmouth.Inbothofthesemodelsofcare,telementalhealthservicesaredelivereddirectlytothepatient.Thus,methodstoensurepatientsafetyandprivacyaswellasidentityverificationofbothprofessionalsandpatientscanbeimplemented.Inotherscenarios,mentalhealthservicesareoutsourcedtocompanieswhocontractwithhospitalsorotherinstitutionsinneedofsuchresources.Inturn,somecompaniesalsocontractwithoutsideprofessionalstoprovidetelementalhealthcareusingtechnologymaintainedandprovidedbythecompany.Thisisarapidlygrowingandevolvingfieldandtherisksandbenefitsoftelementalhealthservicesdeliveredusingvideoconferencingtechnologiesarenotwidelydiscussedoraddressedinformaltrainingofmentalhealthpractitioners.Therefore,thoughtfulelucidationofthekey

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issuesandthepotentialsolutionsareneededtobetterinformthosewhowanttopracticeresponsibly.

PracticeGuidelinesforVideo-basedOnlineMentalHealthServices

a.ClinicalGuidelines

A.ProfessionalandPatientIdentityandLocationAtthebeginningofavideo-basedmentalhealthtreatment(i.e.,notateverysubsequentencounterunlesscircumstanceswarrantre-verification)withapatient,thefollowingessentialinformationshallbeverified:

1.ProviderandPatientIdentityVerification

Thenameandcredentialsoftheprofessionalandthenameofthepatientshallbeverified.Forserviceswiththepatientataremotehealthcareinstitution,theverificationofbothprofessionalandpatientmayoccuratthehostclinic.Whenprovidingprofessionalservicestoapatientinasettingwithoutanimmediatelyavailablementalhealthprofessional,thetelehealthprovidershallprovidethepatient(orlegalrepresentative)withhisorherqualifications,licensureinformation,and,whenapplicable,registrationnumberandwherethepatientcanverifythisinformation.Patientsshallprovidetheirfullname.ProfessionalsmayaskpatientstoverifytheiridentitymoreformallybyshowingagovernmentissuedphotoIDonthevideoscreenorbyusingasmartcard.

2.ProviderandPatientLocationDocumentation

Thelocation(s)wherethepatientwillbereceivingservicesbyvideoconferencingshallbeconfirmedanddocumentedbytheprovider.Inaddition,thelocationoftheprovidermayneedtobedocumented,especiallyincaseswheresuchdocumentationisneededfortheappropriatepaymentofservices.However,itisnotnecessaryforthementalhealthprovidertorevealtheirspecificlocationtothepatient,especiallyiftheproviderislocatedathomeatthetimeoftheservice.

Verificationofproviderandpatientlocationiscriticalforfourkeyreasons:

a. Theprofessionalshallcomplywiththerelevantlicensinglawsinthejurisdictionwheretheproviderisphysicallylocatedwhenprovidingthecareandwherethepatientislocatedwhenreceivingcare.Note,intheUnitedStatesthejurisdictional

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licensurerequirementisusuallytiedtowherethepatientisphysicallylocatedwhenheorsheisreceivingthecare,notwherethepatientlives.(8)

b. Theemergencymanagementprotocolisentirelydependentuponwherethepatientreceivesservices.Onceagain,wherethepatientresidesisonlyrelevantifthatisalsowhereheorsheisreceivingcare.

c. Mandatoryreportingandrelatedethicalrequirementssuchasdutytonotifyaretiedtothejurisdictionwherethepatientisreceivingservices.

d. Insomecases,providerpaymentamountsaretiedtowheretheproviderandpatientarelocated.

Whenpatientsarereceivingtelementalhealthservicesatanaccreditedhealthcenter,theemergencymanagementandreportingprotocolsshallbecoordinatedwiththeremotehealthcenterinaccordancewithapplicablejurisdictionallawandlicensingrequirements.

Ininstanceswherethementalhealthprofessionalisprovidingservicestopatientsinsettingswithoutclinicalstaffimmediatelyavailableand/ortopatientsthatchangelocationsoverthecourseoftreatment,theyshoulddiscusstheimportanceofconsistencyinwherethepatientchoosestoreceivecareasitistiedtoemergencymanagement.Thoughpatientswhochangelocationsmaylikelyremaininthesamestate,theymaychangecities,whichwillimpactemergencymanagementprotocolsrelatedtopoliceinterventionandlocationoflocalemergencyroomswillingtoevaluatepotentiallylethalpsychiatricissues.

3.ContactInformationVerificationforProfessionalandPatient

Thecontactinformationforbothproviderandpatientshallbeverified.Thisshallincludegatheringtelephoneandmailcontactinformationforboththeproviderandpatientandmayalsoincludecontactinformationthroughelectronicsourcessuchasemail.

4.VerificationofExpectationsRegardingContactBetweenSessions

Reasonableexpectationsaboutcontactbetweensessionsshallbediscussedandverifiedwiththepatient.Atthestartofthetreatment,thepatientandprovidershoulddiscusswhetherornottheproviderwillbeavailableforphoneorelectroniccontactbetweensessionsandtheconditionsunderwhichsuchcontactisappropriate.Theprovidershouldprovideaspecifictimeframeforexpectedresponsebetweensessioncontacts.Thisshouldalsoincludeadiscussionofemergencymanagementbetweensessions.

b.PatientAppropriatenessforVideoconferencing-basedTelementalHealth

Todate,nostudieshaveidentifiedanypatientsubgroupthatdoesnotbenefitfrom,orisharmedby,mentalhealthcareprovidedthroughremotevideoconferencing.Recentlarge

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randomizedcontrolledtrialsdemonstrateeffectivenessoftelementalhealthwithmanysmallertrialsalsosupportingthisconclusion.(9-11)Regardingspecificsubgroups,suchaspatientswithpsychoticorphobicdisorders,onereviewbySharpetal.(12),foundnoevidenceforinferiorityofvideoconferencingtelementalhealthforpatientswithpsychosis.Dongieretal.(13)comparedin-personversusvideoconferencinginterviewsinpsychoticpatientsandconcludedthateventhosewithdelusionspertainingtotheTV,respondedappropriatelytovideoconferencinganddidnotincorporatetheirexperienceintotheirdelusionalsystem.Bouchardetal.(14)foundvideoconferencingtreatmenteffectiveforagoraphobiaandpanicdisorder.AppropriatenessofVideoconferencinginSettingswhereProfessionalStaffarenotImmediatelyAvailable

Mentalhealthprofessionalsshouldconsiderthepatients’expectationsandlevelofcomfortwithhome-basedcaretodeterminetheappropriatenessofusingvideoconferencinginthissetting.(15)Provisionoftelementalhealthservicesinprofessionallyunsupervisedsettingsrequiresthatthepatienttakeamoreactiveandcooperativeroleinthetreatmentprocessthaninin-personsettings.(15,16)Determiningwhetherapatientcanhandlesuchdemandsmaybemoredependentonthepatient’sorganizationalandcognitivecapacities,thanondiagnosis.Whenthepatientislocatedoutsideaninstitutionallocation,thepatient(guardianorcaretaker)isresponsibleforsettingupthevideoconferencingsystemathisorhersite,maintainingtheappropriatecomputersettings,andestablishingaprivatespace.Inaddition,evenwithestablishmentofacommunitybasedemergencymanagementprotocol,suchasthatdescribedintheEmergencyManagementsectionofthisdocument,patientcooperationiscriticalforeffectivesafetymanagementinsettingswhereaprofessionalisnotimmediatelyavailable.Determiningpatientappropriatenessforvideoconferencing-basedtelementalhealthservicesshould,inadditiontoconsideringthepatient’sabilitytopotentiallybenefitfromthem,relyontheprofessional’sassessmentofthepatient’sabilitytoarrangeanappropriatesettingforreceivingvideoconferencingservicesandthepatient’scontinuedcooperativenessregardingmanagingsafetyissues.Professionalsshouldalsoconsidersuchthingsaspatient’scognitivecapacity,historyregardingcooperativenesswithtreatmentprofessionals,currentandpastdifficultieswithsubstanceabuse,andhistoryofviolenceorself-injuriousbehavior.Professionalsshallconsidergeographicdistancetothenearestemergencymedicalfacility,efficacyofpatient’ssupportsystem,currentmedicalstatus,andpatient’sgenerallevelofcompetencearoundtechnologywhendeterminingpatientappropriatenessforvideoconferencing.Professionalsshouldevaluatethepotentialforriskfactorsorproblemsatthestartofprovidingvideoconferencingservicesinsettingswhereaprofessionalisnotimmediatelyavailable.Inaddition,evaluationofappropriatenessofvideoconferencingcareshouldcontinuethroughoutthetreatmentincludingmonitoringofsymptomsandpatientcooperativenessinassumingthe

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responsibilitiesinherentinremotecare.Theconsentprocessshallincludediscussionofconditionsofparticipationaroundsessionmanagementsothatifaprofessionaldecidesapatientcannolongerbemanagedthroughdistancetechnology,thepatientisawarethatservicesmaybediscontinuedifnolongerappropriate.c.InformedConsentAthoroughinformedconsentatthestartofservicesshallbeperformed.Theconsentshouldbeconductedwiththepatientinreal–time.Local,regionalandnationallawsregardingverbalorwrittenconsentshallbefollowed.Ifwrittenconsentisrequired,thenelectronicsignatures,assumingtheseareallowedintherelevantjurisdiction,maybeused.Theprovidershalldocumenttheprovisionofconsentinthemedicalrecord.Theconsentshouldincludeallinformationcontainedintheconsentprocessforin-personcareincludingdiscussionofthestructureandtimingofservices,recordkeeping,scheduling,privacy,potentialrisks,confidentiality,mandatoryreporting,andbilling.Inaddition,theinformedconsentprocessshouldincludeinformationspecifictothenatureofvideoconferencingasdescribedbelow.Theinformationshallbeprovidedinlanguagethatcanbeeasilyunderstoodbythepatient.Thisisparticularlyimportantwhendiscussingtechnicalissueslikeencryptionorthepotentialfortechnicalfailure.Keytopicsthatshallbereviewedinclude:confidentialityandthelimitstoconfidentialityinelectroniccommunication;anagreeduponemergencyplan,particularlyforpatientsinsettingswithoutclinicalstaffimmediatelyavailable;processbywhichpatientinformationwillbedocumentedandstored;thepotentialfortechnicalfailure,proceduresforcoordinationofcarewithotherprofessionals;aprotocolforcontactbetweensessions;andconditionsunderwhichtelementalhealthservicesmaybeterminatedandareferralmadetoin-personcare.d.PhysicalEnvironmentBoththeprofessionalandthepatient’sroom/environmentshouldaimtoprovidecomparableprofessionalspecificationsofastandardservicesroom.Effortsshallbemadetoensureprivacysoclinicaldiscussioncannotbeoverheardbyothersoutsideoftheroomwheretheserviceisprovided.Ifotherpeopleareineitherthepatientortheprofessional’sroom,boththeprofessionalandpatientshallbemadeawareoftheotherpersonandagreetotheirpresence.Seatingandlightingshouldbetailoredtoallowmaximumcomforttotheparticipants.Bothprofessionalandpatientshouldmaximizeclarityandvisibilityofthepersonattheotherendofthevideoservices.Forexample,patientsreceivingcareinnon-traditionalsettingsshouldbeinformedoftheimportanceofreducinglightfromwindowsorlightemanatingfrombehindthem.Bothproviderandpatientcamerasshouldbeonasecure,stableplatformtoavoidwobblingandshakingduringthevideoconferencingsession.Totheextentpossible,thepatientandprovidercamerasshouldbeplacedatthesameelevationastheeyeswiththefaceclearlyvisibletotheotherperson.

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e.CommunicationandCollaborationwiththePatient’sTreatmentTeamProfessionalsshallacknowledgethatoptimalclinicalmanagementofpatientsdependsoncoordinationofcarebetweenamultidisciplinarytreatmentteam.Thisshallbediscussedwithallpatients.However,patientsmayhavespecificprivacyconcernsaboutreleaseofinformationaboutmentalhealthtreatmenteventootherhealthprofessionalsprovidingservicestothemandtheseconcernsshallberespected.Forpatientswhoagreetocoordinationofcare,telementalhealthprofessionalsshouldarrangeforappropriateandregularprivatecommunicationwithotherprofessionalsinvolvedincareforthepatient.Moreover,professionalsconductingtelementalhealthtopatientsinsettingswithoutclinicalstaffimmediatelyavailableareencouragedtodevelopcollaborativerelationshipswithlocalcommunityprofessionals,suchasapatient’slocalprimarycareprovider,astheseprofessionalsmaybeinvaluableincaseofemergencies.f.EmergencyManagementProvidingmentalhealthcaretopatientsusingvideoconferencinginvolvesparticularconsiderationsregardingpatientsafety.Therearealsoadditionalconsiderationswhenprovidingcaretopatientsinsettingswithoutstaffimmediatelyavailable.(17)Belowareissuesthatshouldbeconsideredinbothtypesofpracticefollowedbyseparatesectionsforemergencymanagementforsupervisedandunsupervisedsettings.

1.EducationandTraining

Professionalsshouldreviewtheirdiscipline'sdefinitionsof"competence"priortoinitiatingtelementalhealthpatientcaretoassurethattheymaintainbothtechnicalandclinicalcompetenceforthedeliveryofcareinthismanner.Professionalsshallhavecompletedbasiceducationandtraininginsuicideprevention.Thedepthoftrainingandthedefinitionof“basic”aresolelyattheprofessional’sdiscretion.

2.JurisdictionalMentalHealthInvoluntaryHospitalizationLaws

Eachjurisdictionhasitsowninvoluntaryhospitalizationandduty-to-notifylawsoutliningcriteriaanddetainmentconditions.Professionalsshallknowandabidebythelawsinthejurisdictionwherethepatientisreceivingservices.

3.PatientSafetywhenProvidingServicesinaSettingwithImmediatelyAvailable

Professionals

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Whenaprofessionalseesapatientviapersonalcomputerand/ormobiledeviceoutsideofthepatient’shome(e.g.,localclinic,community-basedoutpatientclinic,schoolsite,library)orotherfacilitywherededicatedstaffmaybepresent,itmaybeimportantthattheprofessionalbecomefamiliarwiththefacility’semergencyprocedures.Insomecases,thefacilitywillnothaveproceduresinplace.Insuchcases,theprofessionalshouldcoordinatewiththedistantsiteclinictoestablishbasicprocedures.Thebasicproceduresmayinclude:1)identifyinglocalemergencyresourcesandphonenumbers;2)becomingfamiliarwithlocationofnearesthospitalemergencyroomcapableofmanagingpsychiatricemergencies;and3)havingpatient’sfamily/supportcontactinformation.Theprofessionalmayalsolearnthechosenemergencyresponsesystem'saverageresponsetime(30minutesvs.5hours)andthecontactinformationforotherlocalprofessionalassociations,suchasthecity,countyorstate,provincialorotherregionalprofessionalassociation(s)incasealocalreferralisneededtofollow-upwithalocalprofessional.

4.PatientSafetywhenprovidingServicesinaSettingwithoutImmediatelyAvailable

ProfessionalStaff

Fortreatmentoccurringwherethepatientisinasettingwithoutclinicalstaff,theprofessionalmayrequestthecontactinformationofafamilyorcommunitymemberwhocouldbecalleduponforsupportinthecaseofanemergency.Thispersonwillbecalled“thePatientSupportPerson”anindividualselectedbythepatientInthecaseofanemergency,theprofessionalmaycontactthePatientSupportPersontorequestassistanceinevaluatingthenatureofemergencyand/orinitiating9-1-1fromthepatient’shometelephone.(17).

5.PatientSupportPersonandUncooperativePatients

Itispossiblethatapatientwillnotcooperateinhisorherownemergencymanagement,whichunderliesthepracticeofinvoluntaryhospitalizationinmentalhealthcare.ProfessionalsshouldbepreparedforthisaswellasthepossibilitythatPatientSupportPersonsalsomaynotcooperateifthepatientsthemselvesareadamantthattheydonotwanttoseekemergencycare.Therefore,anyemergencyplanshallincludelocalemergencypersonnelandknowledgeofavailableresourcesincaseofinvoluntaryhospitalization.

6.Transportation

Asvideoconferencing-basedtelementalhealthhasdeveloped,inpart,toincreaseaccesstopatientsingeographicallyremoteareas,itisexpectedthattheremaybebarrierstotransportationtolocalmentalhealthservices.Inlightofthis,theprofessionalshallknowanylimitationsthepatienthasintermsofself-transportingand/oraccesstotransportation.Strategiestoovercometheselimitationsinlightofanemergencyshall

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bedevelopedpriortostartingtreatmentforpatientsinsettingswithoutstaffimmediatelyavailable.

Intheeventofabehavioraland/ormedicalemergency,thepatient’sPatientSupportPersonshoulddiscusswithemergencypersonnelwhethertheyshouldtransportthepatient.

7.LocalEmergencyPersonnel

Inprovidingcaretopatientsinsettingswithoutprofessionalstaffimmediatelyavailable,determiningdistancebetweenlocalemergencypersonnelinthepatient’scommunityandthepatient’slocationcanshapetheprofessional’sdecisionprocessindeterminingappropriateactions.

Professionalsshallacquiretelephonenumbersforlocalresourcesinthepatient’scommunity.Atthebeginningofeachsession,theprofessionalshallhavethepatient’slocalemergencypersonneltelephonecontactinformationreadilyavailable.Priortoeachsession,theprovidershallalsodeterminethepatient’slocationandwhethertherehavebeenanychangestothepatient’spersonalsupportsystemortheemergencymanagementprotocol.

g.MedicalIssuesIncaseofmedicationsideeffects,elevationinsymptoms,and/orissuesrelatedtomedicationnon-compliance,theprofessionalshouldbefamiliarwiththepatient’sprescriptionandmedicationdispensationoptions.Likewise,whenprescribing,theclinicianshouldbeawareoftheavailabilityofspecificmedicationsinthegeographiclocationofthepatientandthatshouldinformprescribingchoices.Patientsreceivingtreatmentthroughtelementalhealthservicesshouldhaveanactiverelationshipwithaprescribingprofessionalintheirphysicalvicinity.Ifservicesareprovidedinasettingwhereaprofessionalisnotimmediatelyavailable,thepatientmaybeatriskifthereisanacutechangeinhisorhermedicalcondition.Theprofessionalshouldbefamiliarwithwhomthepatientisreceivingmedicalservices.h.ReferralResourcesTheprofessionalshallbefamiliarwithlocalin-personmentalhealthresourcesshouldtheprofessionalexerciseclinicaljudgmenttomakeareferralforadditionalmentalhealthorotherappropriateservices.

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i.CommunityandCulturalCompetencyProfessionalsshallbeculturallycompetenttodeliverservicestothepopulationsthattheyserve.Examplesoffactorstoconsiderincludeawarenessoftheclient’slanguage,ethnicity,race,age,gender,sexualorientation,geographicallocation,andsocioeconomicandculturalbackgrounds.Mentalhealthprofessionalsmayuseonlineresourcestolearnofthecommunitywherethepatientresidesincludinganyrecentsignificanteventsandculturalmoresofthatcommunity.

b.TechnicalGuidelines

Videoconferencingcanbecharacterizedbykeyfeatures:thevideoconferencingapplication,devicecharacteristicsincludingtheirmobility,networkorconnectivityfeatures,andhowprivacyandsecurityaremaintained.Themorerecentuseofdesktopandmobiledevicesrequiresconsiderationofeachofthese.A.VideoconferencingApplicationAll efforts shall be taken to use video conferencing applications that have been vetted and have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose. Video software platforms should not be used when they include social media functions that notify users when anyone on a contact list logs on. Many free video chat platforms include such functionality as a "default setting," which should be changed before providing video-based clinical services. These platforms may also include the capability to create a video chat “Room” that allows others to enter at will. This type of functionality should be disabled. B.DeviceCharacteristicsWhenusingapersonalcomputer,boththeprofessionaldeviceforvideo-transmissionandthepatient’ssiteshould,whenfeasible,useprofessionalgradeorhighqualitycamerasandaudioequipmentnowwidelyavailableforpersonalcomputers.Personalcomputersshallhaveup-to-dateantivirussoftwareandapersonalfirewallinstalled.Providersshouldensuretheirpersonalcomputerormobiledevicehasthelatestsecuritypatchesandupdatesappliedtotheoperatingsystemandthirdpartyapplicationsthatmaybeutilizedforthispurpose.Providerorganizationsshouldutilizemobiledevicemanagementsoftwaretoprovideconsistentoversightofapplications,deviceanddataconfigurationandsecurityofthemobiledevicesusedwithintheorganization.Intheeventofatechnologybreakdown,causingadisruptionofthesession,theprofessionalshallhaveabackupplaninplace.Theplanshallbecommunicatedtothepatientpriorto

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commencementoftreatmentandmayalsobeincludedinthegeneralemergencymanagementprotocol.Theprofessionalmayreviewthetechnologybackupplanonaroutinebasis.Theplanmayincludecallingthepatientviatelephoneandattemptingtotroubleshoottheissuetogether.Theplanmayalsoincludeprovidingthepatientwithaccesstoothermentalhealthcare.Ifthetechnicalissuecannotberesolved,theprofessionalmayelecttocompletethesessionviaavoice-basedtelecommunicationsystem.Screen-in-screenoptions,alsoknownaspicture-in-a-pictureor"PIP"mayalsobeusedwhenfeasibleandarewidelyavailableinprofessionalgradedesktopvideoconferencingsoftwarepackages.Professionalsandpatientsmayopttousecamerasthatallowforpan,tilt,andzoomformaximalflexibilityinviewingtheremoteroom.C.ConnectivityTelementalhealthcareservicesprovidedthroughpersonalcomputersormobiledevicesthatuseinternet-basedvideoconferencingsoftwareprogramsshouldprovidesuchservicesatabandwidthof384Kbpsorhigherineachofthedownlinkanduplinkdirections.Suchservicesshouldprovideaminimumof640X360resolutionat30framespersecond.Becausedifferenttechnologiesprovidedifferentvideoqualityresultsatthesamebandwidth,eachendpointshallusebandwidthsufficienttoachieveatleasttheminimumqualityshownaboveduringnormaloperation.Wherepractical,providersmayrecommendpreferredvideoconferencingsoftwareand/orvideoandaudiohardwaretothepatient,aswellasprovidinganyrelevantsoftwareand/orhardwareconfigurationconsiderations.Theproviderand/orpatientmayuselinktesttools(e.g.,bandwidthtest)topre-testtheconnectionbeforestartingtheirsessiontoensurethelinkhassufficientqualitytosupportthesession.Wherepossible,eachpartyshouldusethemostreliableconnectionmethodtoaccesstheInternet.Wherewiredconnectionsareavailable(e.g.,Ethernet),theyshouldbeused.Thevideoconferencesoftwareshouldbeabletoadapttochangingbandwidthenvironmentswithoutlosingtheconnection.D.PrivacyThevideoconferencesoftwareshouldbecapableofblockingtheprovider’scallerIDattherequestoftheprovider.

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Alleffortsshallbetakentomakeaudioandvideotransmissionsecurebyusingpoint-to-pointencryptionthatmeetsrecognizedstandards.Currently,FIPS140-2,knownastheFederalInformationProcessingStandard,istheUSGovernmentsecuritystandardusedtoaccreditencryptionstandardsofsoftwareandlistsencryptionsuchasAES(AdvancedEncryptionStandard)asprovidingacceptablelevelsofsecurity.Providersshouldfamiliarizethemselveswiththetechnologiesavailableregardingcomputerandmobiledevicesecurity,andshouldhelpeducatethepatient.Whenthepatientand/orprovideruseamobiledevice,specialattentionshouldbeplacedontherelativeprivacyofinformationbeingcommunicatedoversuchtechnology.Providersshouldensureaccesstoanypatientcontactinformationstoredonmobiledevicesisadequatelyrestricted.Mobiledevicesshallrequireapassphraseorequivalentsecurityfeaturebeforethedevicecanbeaccessed.Ifmulti-factorauthenticationisavailable,itshouldbeused.Mobiledevicesshouldbeconfiguredtoutilizeaninactivitytimeoutfunctionthatrequiresapassphraseorre-authenticationtoaccessthedeviceafterthetimeoutthresholdhasbeenexceeded.Thistimeoutshouldnotexceed15minutes.Mobiledevicesshouldbekeptinthepossessionoftheproviderwhentravelingorinanuncontrolledenvironment.Unauthorizedpersonsshallnotbeallowedaccesstosensitiveinformationstoredonthedevice,orusethedevicetoaccesssensitiveapplicationsornetworkresources.Providersshouldhavethecapabilitytoremotelydisableorwipetheirmobiledeviceintheeventitislostorstolen.Videoconferencesoftwareshallnotallowmultipleconcurrentsessionstobeopenedbyasingleuser.Shouldasecondsessionattempttobeopened,thesystemshalleitherlogoffthefirstsessionorblockthesecondsessionfrombeingopened.Sessionlogsstoredin3rdpartylocations(i.e.,notonpatients’orproviders’accessdevice)shallbesecure.Accesstothesesessionlogsshallonlybegrantedtoauthorizedusers.Protectedhealthinformationandotherconfidentialdatashallonlybebackeduptoorstoredonsecuredatastoragelocations.CloudservicesunabletoachievecomplianceshallnotbeusedforPHIorconfidentialdata.Professionalsmaymonitorwhetheranyofthevideoconferencetransmissiondataisintentionallyorinadvertentlystoredonthepatientorprofessional’scomputerharddrive.Ifso,theharddriveoftheprovidershouldusewholediskencryptiontotheFIPSstandardtoensuresecurityandprivacy.Pre-bootauthenticationshouldalsobeused.Professionalsshould

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educatepatientsaboutthepotentialforinadvertentlystoreddataandpatientinformationandprovideguidanceonhowbesttoprotectprivacy.Professionalsandpatientsshalldiscussanyintentiontorecordservicesandhowthisinformationistobestoredandhowprivacywillbeprotected.Recordingsshouldbeencryptedformaximumsecurity.Accesstotherecordingsshallonlybegrantedtoauthorizedusersandshouldbestreamedtoprotectfromaccidentalorunauthorizedfilesharingand/ortransfer.Theprofessionalmayalsowanttodiscusshisorherpolicywithregardstothepatientsharingportionsofthisinformationwiththegeneralpublic.Writtenagreementspertainingtothisissuecanprotectboththepatientandtheprofessional.Ifservicesarerecorded,therecordingsshallbestoredinasecuredlocation.Accesstotherecordingsshallonlybegrantedtoauthorizedusers.

c.AdministrativeGuidelinesA.QualificationsandTrainingofProfessionalsInadditiontoclinical,legal,andethicaltrainingrequiredforlicensureforin-personservices,professionalsshallmakeuseofthewidelyavailableresourcesprovidingeducationofproperconductofvideoconferencingtobothprofessionallysupervisedsettingsandthosewithoutreadilyavailableclinicalstaff.Mentalhealthprofessionalsshallalsodeterminewhethertherearesite-specificcredentialingrequirementswherethepatientislocated.Professionalsshallconductcareconsistentwiththejurisdictionallicensinglawsandrulesfortheirprofessioninboththejurisdictioninwhichtheyarepracticingaswellasthejurisdictionwherethepatientisreceivingcare.Licensedmentalhealthprofessionalsshouldcontacttheirlicensingboardtoreviewtheirpracticebeforestartinganyprovisionoftelementalhealthservices.Theprofessionalshouldalsocontactthelicensingboardrelevanttothepatient’slocationduringtreatment,todeterminewhetherornottheservicesprovidedfallundertheirjurisdictionandwhat,ifany,restrictionsexist.B.DocumentationandRecordKeepingProfessionalsshallmaintainanelectronicrecordforeachpatientforwhomtheyprovideremoteservices.Sucharecordshouldincludeanassessment,clientidentificationinformation,contactinformation,history,treatmentplan,informedconsent,andinformationaboutfeesandbilling.

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Atreatmentplanbaseduponanassessmentofthepatient’sneedsshouldbedevelopedanddocumented.Theplanshouldmeettheprofessional’sdisciplinestandardsandguidelinesandincludeadescriptionofwhatservicesaretobeprovidedandthegoalsforservices.Servicesshouldbeaccuratelydocumentedasremoteservicesandincludedates,durationandtypeofservice(s)provided.Documentationshallcomplywithapplicablejurisdictionalandfederallawsandregulations.Policiesforrecordretentionanddisposalshouldbeinplace.Allcommunicationswiththepatient(e.g.,written,audiovisual,orverbal)shallbedocumentedinthepatient’suniquerecordandallsuchrecordsshallbestoredincompliancewithrelevantgovernmentregulations,suchasHIPAAandHI-TECHwithintheUS.(15)Requestsforaccesstosuchrecordsshallrequirewrittenauthorizationfromthepatientwithaclearindicationofwhattypesofdataandwhichinformationistobereleased.Ifprofessionalsarestoringtheaudiovisualdatafromthesessions,thesecannotbereleasedunlessthepatientauthorizationindicatesspecificallythatthisistobereleased.Upondirectionandwrittenapprovalbythepatient,thepatient’srecordshallbemadeavailabletoanotherproviderthatiscaringforthepatient.Allbillingandadministrativedatarelatedtothepatientshallbesecuredtoprotectconfidentiality.Specifically,allrecordsareconfidential;HIPAAregulationsregardingpsychotherapynotesareadheredto;andonlyrelevantinformationisreleasedforreimbursementpurposesasoutlinedbyHIPAAintheUS.C.PaymentandBillingPriortothecommencementofinitialservices,thepatientshallbemadeawareofanyandallfinancialchargesthatmayarisefromtheservicestobeprovided.Arrangementforpaymentshouldbecompletedpriortothecommencementofservices.

Appendix

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2. GradyB,MyersKM,NelsonEL,BelzN,BennettL,CarnahanL,etal.Evidence-basedpracticefortelementalhealth.TelemedJEHealth.2011;17(2):131-48.

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3. YellowleesP,ShoreJ,RobertsL.Practiceguidelinesforvideoconferencing-basedtelementalhealth-October2009.TelemedJEHealth.2010;16(10):1074-89.

4. APAStatementonServicesbyTelephone,Teleconferencing,andInternet:AstatementbytheEthicsCommitteeoftheAmericanPsychologicalAssociation1997December30,2004:Availablefrom:http://www.apa.org/ethics/education/telephone-statement.aspx.

5. AustralianPsychologicalSociety.Guidelinesforprovidingpsychologicalservicesandproductsusingtheinternetandtelecommunicationstechnologies.2011:Availablefrom:http://aaswsocialmedia.wikispaces.com/file/view/EG-Internet.pdf

6. StandardsforTechnologyandSocialWorkPractice.NationalAssociationofSocialWorkersandASWBStandardsforTechnologyandSocialWorkPractice,2005.http://www.socialworkers.org/practice/standards/naswtechnologystandards.pdf

7. OhioPsychologicalAssociation.TelepsychologyGuidelines,2010:Availablefrom:http://www.ohpsych.org/psychologists/files/2011/06/OPATelepsychologyGuidelines41710.pdf.

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10. O'ReillyR,BishopJ,MaddoxK,HutchinsonL,FismanM,TakharJ.Istelepsychiatryequivalenttoface-to-facepsychiatry?Resultsfromarandomizedcontrolledequivalencetrial.PsychiatrServ.2007;58(6):836-43.

11. RuskinPE,Silver-AylaianM,KlingMA,ReedSA,BradhamDD,HebelJR,etal.Treatmentoutcomesindepression:comparisonofremotetreatmentthroughtelepsychiatrytoin-persontreatment.TheAmericanjournalofpsychiatry.2004;161(8):1471-6.

12. SharpIR,KobakKA,OsmanDA.Theuseofvideoconferencingwithpatientswithpsychosis:areviewoftheliterature.Annalsofgeneralpsychiatry.2011;10(1):14.

13. DongierM,TempierR,Lalinec-MichaudM,MeunierD.Telepsychiatry:psychiatricconsultationthroughtwo-waytelevision.Acontrolledstudy.CanJPsychiatry.1986;31(1):32-4.

14. BouchardS,PaquinB,PayeurR,AllardM,RivardV,FournierT,etal.Deliveringcognitive-behaviortherapyforpanicdisorderwithagoraphobiainvideoconference.TelemedJEHealth.2004;10(1):13-25.

15. LuxtonDD,O'BrienK,McCannRA,MishkindMC.Home-basedtelementalhealthcaresafetyplanning:whatyouneedtoknow.TelemedJEHealth.2012;18(8):629-33.

16. LuxtonDD,SirotinAP,MishkindMC.Safetyoftelementalhealthcaredeliveredtoclinicallyunsupervisedsettings:asystematicreview.TelemedJEHealth.2010;16(6):705-11.

17. ShoreP.Home-BasedTelementalHealth(HBTMH)StandardOperatingProceduresManual.2011.