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Wayne Roffer, Psy.D.Pennsylvania Psychological

AssociationJune 17, 2015Harrisburg, PA

Essentials of Telepsychology: Advanced Topics

Disclaimer

Dr. Roffer, while employed by the Department of Veterans Affairs, has not been asked to speak today on their behalf or on behalf of any other federal agency.

The information presented and discussed herein is the opinion of Dr. Roffer and is not to be considered an official policy, statement, or position of the federal government or any associated agencies.

Disclaimer

Dr. Roffer is not an attorney. All information presented is for educational and informational purposes only. You should always consult with a attorney, preferably one specializing in medicine / health care, before implementing any suggestions mentioned today into your practice.

Dr. Roffer has no financial interests / conflicts to disclose.

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Learning Objectives

1) Identify 5 emergency situations and develop an

emergency plan that addresses these crises

2) Describe how HIPAA, HITECH, and Omnibus affects

telepsychology practice

3) Describe the research in the efficacy of smartphone

applications for the treatment of behavioral health

disorders

4) Identify 2 issues related to the reimbursement of

telepsychology sessions

5) Identify at least 2 jurisdictional issues and describe

best practices for addressing inter-state behavioral health

t l h l ti

Case Example 1

A patient you have been seeing for over a year due to cutting and other chronic self-injurious behaviors tells you they are moving to another state. Due to a strong therapeutic relationship, they request to continue working with you. You offer to provide email therapy sessions weekly and video calls once a month.

Case Example 2

In an attempt to expand your practice and become more competitive, you begin to advertise your services to include telemental health. Your state of practice does not mandate reimbursement of 3rd party insurers for this service. To offset the cost of the equipment and other TMH overhead, you begin to charge an additional $35 to those paying out of pocket for this service and file claims to private insurers using standard CPT codes.

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Telepsychology

Walker, J., Roffer, W., & Tennyson, M. (2013, August)

“Telepsychology is defined, for the purpose of theseguidelines, as the provision of psychological services

using telecommunication technologies.”

www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf (September 15 2

email

IM / chat

Video Conferencing

Mobile Devices

Internet

Telephone / FaxTelephone / Fax

Telecommunications

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Benefits

Decreased travel timeIncreased productivity (fewer “no shows”)Increased access to mental health services /

decreased barriers to treatmentFlexibility in schedulingLess stigmaPatients less guardedIncreased frequency of visits = shorter length of

treatment

Dangers

Variation in state guidelinesCompetence of providerStandard of CareRisksAuthentication of patient/providerJurisdictionEmergencies

Guidelines

• APA

• ATA

• APA (psychiatric)

• American Counseling Association

• Federation of State Medical Boards

• American College of Physicians

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APA Telepsychology Guidelines

1.Competence of the Psychologist2.Standards of Care3.Informed Consent4.Confidentiality of Data5.Security of Data6.Disposal of Data and Technologies7.Testing and Assessment8.Interjurisdictional Practice

www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf

Emergency Plans

DangerousnessVoluntary Psychiatric HospitalizationInvoluntary Psychiatric HospitalizationMedicalTechnicalEnvironmental

Clinical Emergencies: Behavioral/Medical

What if patient becomes imminently dangerous? Who do you call?

What if the patient is making statements regarding suicidal or homicidal ideations?

Do you know the patient state’s policies regarding voluntary and involuntary psychiatric hospitalization?

How would you call for an ambulance?

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Clinical Emergencies: Behavioral/Medical

Ensure staff trained on disruptive behavior procedures

May require community emergency responsePractice drillsHave emergency contact numbers readily

availableEnsure communication device available at both

endsConsider other alert mechanisms

Clinical Emergencies: Provider

Technical Emergencies

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Technical Emergencies

Poor audio / video resolutionSoftware crashesPower outage Viruses / malware / trojans / wormsCOMPLETE SYSTEM FAILURE!

Operational Emergencies

Practice drills to determine risksEmergency numbersBackup equipmentAlternate telecommunication waysBackup care plan (avoid

negligence/abandonment)

Operational Emergencies

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Emergency Plans

Informed consentPolicies and ProceduresTelehealth Emergency Plan (TEP) “contract”

Emergency Plans

Department of Veterans Affairs Telehealth Service Agreement (TSA)

Private Practice Incorporate plan into informed consent Consider separate Telehealth Emergency Plan

(TEP)

Emergency Plans: TEP

Patient NameAddressPhone numbersOther individuals in the homeFriends / family nearbyLocal emergency contact #

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Emergency Plans: Summary

PLANBACKUP

DOCUMENTTRAIN

HIPAA, HITECH, and Omnibus Final Rule

HIPAA: Introduction

Enacted 19963 Rules Transmission Privacy Security

Applies to “covered entities” onlyBusiness Associate Agreements

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HITECH ACT 2011

• Expanded enforcement of violations and penalties

• Established breach notification rules for unsecured PHI

• Electronic record access• Expands business associates and business

associate agreements• Regulations

• Audit trails

HIPAA Breach Notifications

TheftUnauthorized Access

/ DisclosureLossHacking / ITImproper DisposalUnknownOther

www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

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Omnibus Final Rule

Released January 1, 2013

New rules / modifications effective March 26, 2013

Compliance required by September 23, 2013

Omnibus Final Rule

Consumers can request their electronic medical (in electronic format)

Privacy for out-of-pocket payees (including Medicare)

Marketing rules and sale of PHIIncreased penalties for negligenceAmendment to breach notification ruleRequired update to Notice of Privacy PracticeUpdate to Business Associate Agreements

HIPAA: Business Associate Agreements

Persons or companies who provide services on your behalf

Handle PHIOmnibus Rile provided greater responsibility to

BAsConduit exception

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HIPAA: Encryption

“Protected health information (PHI) is rendered unusable, unreadable, or indecipherable to

unauthorized individuals…”

HIPAA: Encryption

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/brguidance.html

HIPAA: Secure Disposal

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/brguidance.html

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HIPAA: Encryption

Asymmetric Encryption

http://msdn.microsoft.com/en-us/library/ff647097.aspx

HIPAA: Encryption

Symmetric Encryption

http://msdn.microsoft.com/en-us/library/ff647097.aspx

HIPAA: Encryption - FIPS 140-2

Required by U.S. government for all information classified as “sensitive but unclassified” (SBU) or higher

Includes Protected Health Information (PHI) when being transmitted (data in motion)

Standard by which secret keys are generated and managed (stored)

Cryptographic modules certified FIPS 140-2 through Cryptographic Algorithm Validation Program (CAVP)

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https://support.skype.com/en/faq/FA31/does-skype-use-encryption?q=hipaa

https://www.microsoft.com/privacystatement/en-us/skype/default.aspx

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HIPAA: Video Solutions

Adobe ConnectCounsol.comeCounselingGoToMeeting iCouch Interactive Care iTelBehavior Imaging Solutions thera-LINKCisco Telepresence

MDLiveMyTherapyNetSecure TelehealthSecureVideo.comSmart House CallsVia3VSeeVirtualTherapyConnectWeCounsel***Facetime***

HIPAA: Facetime

Previous validations for Mac OSX and iOSCurrent iOS validation only up to iOS 7.0 Cert #2020 Cert #2021

All platforms authorized to run iOS 7 covered by current validations

All Apple applications and services compliant (except BT)

No user intervention required

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HIPAA: Audit Trails

Record of: who accessed what was accessed what operations or actions performed

Selecting telepsychology platform are audit trails created? who maintains them? who has access to them?

6 6 %

6 2 %

Smartphone Applications

http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/

Smartphone Apps

1.5 Million Android Apps (May 2015)

1.4 Million iOS Apps (May 2015)

http://www.statista.com/statistics/276623/number-of-apps-available-in-leading-app-stores/

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Smartphone Apps

Smoking cessation, stress, sleep, anger management, PTSD, chronic pain, etc

Smartphone Apps: Efficacy

Donker, T., Petrie, K., Proudfoot J., Clarke J., Birch, MR., & Christensen, H. (2013) majority of apps lack scientific evidence of

their efficacyJuarascio, AS., Manasse, SM., Goldstein, SP.,

Forman, EM., & Butry, ML. (2014) ED intervention apps lacked EBPs

Smartphone Apps: Efficacy

Bush, NE., Dobscha, SK., Crumpton, R., Denneson, LM., Hoffman, JE., Crain, A., Cromer, R., and Kinn, JT. (2014) Virtual Hope Box

Kuhn, Greene, Hoffman, et al., 2014 PTSD Coach acceptable and perceived as

helpful for PTSD symptomsMinor, Kuhn, Hoffman, et al., (under review) Pilot RCT with trauma survivors in community PTSD coach feasable, acceptable

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Smartphone Apps: Evaluation

Empirical support for theoryEmpirical support for appUtilityUser ratingsPeer reviewBlogsEase of useConfidentiality / Security

Smartphone Apps

PTSD CoachMindfulness CoachConcussion CoachLifeArmorParenting2GoTactical BreatherBreathe2Relax

Smartphone Apps: EBPs

ACT CoachPE CoachCPT CoachCBT-IStay Quit

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Smartphone Apps: Provider Support

PFA MobileProvider Resilience

Smartphone Apps: Coming Soon…

PTSD Family CoachCBT-I (self-administered)Trauma Recovery Coach

Smartphone Apps: Digital Prescription

Assess clinical competencePresent rationaleDemonstrate in sessionDownload in sessionReview usage regularly

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Smartphone Apps: Additional Issues

Security Don’t download / exchange digital clinical data Encourage use of passwords / screen lock / etc

HIPAA Not applicable if no transmission of data

Privacy GPS? Data collected?

Inter-Jurisdictional Issues

If a licensed health care provider electronically interacts with a patient in another state, the provider must be licensed or registered (but verify State-specific regulations) in each state in which he or she electronically practices.

http://www.telehealthresourcecenter.org/toolbox-module/licensure-and-scope-practice

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Inter-Jurisdictional Issues

Licensing boards’ interestlies in protecting their ownconsumers

Any licensing board mayclaim jurisdiction

Consider your state andpatient’s state

Safest approach to only provide services where you are licensed

Inter-Jurisdictional Issues: Best Practice

1. Provide services only where you are licensed 2. Require patient affirm their location every

session

Inter-Jurisdictional Exceptions

Guest licensureTemporary practiceInter-jurisdictional Practice Certificate (ASPBB)e-passport / inter-state compact Psychology Interjurisdictional Compact

(PSYPACT)

http://c.ymcdn.com/sites/asppb.site-ym.com/resource/resmgr/Docs/Psychology_Interjurisdiction.pdf

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Reimbursement

LicensingCredentialing Medicare 3rd party insurers

Billing / ICD10 online vs in-person

Reimbursement: Credentialing

Variation across insurersTelemental health not automaticNo guarantee of cross-state credentialing especially true for telemental health

Telepsychology credentialing specific equipment, policies, etc? where are you providing services?

WHAT IS REQUIRED BEFORE YOU BEGIN?

Reimbursement: Definitions

Eligible siteEligible patientLocation originating site / local site (patient) distant / remote site (provider)

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Reimbursement: Medicare

Limited to rural and Health Provider Shortage Areas (HPSA)

Limited to Medicare beneficiariesInteractive A/V onlyMultiple licensesMay need pre-authorizationPaid based on provider location***

Reimbursement: Medicare

Requires use of speciality modifier codes GT GQ

Originating site fee Government support to use technology HCPCS Q3014

Reimbursement on par with in-person

Reimbursement: Medicare

Some reimbursable servicesPsychiatric interviewPsychotherapyInd/Grp health & behavior assessmentSmoking cessationAnnual alcohol misuse screeningAnnual depression screeningPsychoanalysisPsychological testing by computer

CMS 2015 Medicare Physician Fee Schedule Final Rule October 1 2014

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Reimbursement: Medicaid

Most states offer some reimbursement for telehealth services (but not necessarily telemental health)

Are psychologists listed as qualifying providers in state’s Medicaid telemedicine list? Pennsylvania: Psychologists included for tele

psychiatry services only but it’s a pain…

http://www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx

Reimbursement: 3rd Party Insurers

BCBSUnited HealthcareCignaHumanaAetna

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Reimbursement: Private

No guarantee of 3rd party reimbursement unless mandated by state law

Requirements for billing may vary from state to state

Reimbursement: ICD-10

October 1 2015September 1 2015Be prepared to not get paidCheck ICD website for which codes are covered ICD Tabular Index

(ie www.cdc.gov/nchs/icd/icd10cm.htm DSM5 is a mistake

Effect of “other” or “unspecified”?

Reimbursement: Miscellaneous

Charges for service interruptionsOverage charges data plansOther costs (emailing, texting, etc)Value Based Modifier Program

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Resources

APA Telepsychology GuidelinesAmerican Telemedicine AssociationTelemental Health InstituteOnline Therapy InstituteThe Zur InstitutePerson-Centered TechCenter for Connected Health PolicyNational Center for Telehealth & TechnologyTelehealth Resource Centers

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