Content uploaded by Kenneth Drude
Author content
All content in this area was uploaded by Kenneth Drude on Sep 30, 2014
Content may be subject to copyright.
Policy
ATA Practice Guidelines for Video-Based Online Mental Health Services
Carolyn Turvey, PhD,
1
Mirean Coleman, LICSW, CT,
2
Oran Dennison, BS,
3
Kenneth Drude, PhD,
4
Mark Goldenson,
5
Phil Hirsch, PhD,
6
Robert Jueneman, BS,
7
Greg M. Kramer, JD, PhD,
8
David D. Luxton, PhD,
8
Marlene M. Maheu, PhD,
9
Tania S. Malik, JD,
10
Matt C. Mishkind, PhD,
8
Terry Rabinowitz, MD, DDS,
11,12
Lisa J. Roberts, PhD,
13
Thomas Sheeran, PhD, ME,
14,15
Jay H. Shore, MD, MPH,
16
Peter Shore, PsyD,
17
Frank van Heeswyk, PhD,
18
Brian Wregglesworth,
3
Peter Yellowlees, MBBS, MD,
19
Murray L. Zucker, MD,
20
Elizabeth A. Krupinski, PhD,
21
and Jordana Bernard, MBA
22
1
Department of Psychiatry, University of Iowa, Iowa City, Iowa.
2
National Association of Social Workers, Washington, D.C.
3
Alaska Native Tribal Health Consortium, Anchorage, Alaska.
4
Ohio Board of Psychology, Dayton, Ohio.
5
Breakthrough, Palo Alto, California.
6
HealthLinkNow, Sacramento, California.
7
Spyrus, Inc., Santa Fe, New Mexico.
8
National Center for Telehealth and Technology/T2, Joint Base Lewis-McChord, Tacoma, Washington.
9
TeleMental Health Institute, Inc., San Diego, California.
10
COPE Today, Raleigh, North Carolina.
11
Departments of Psychiatry and Family Medicine, University of Vermont College of Medicine, Burlington, Vermont.
12
Division of Consultation Psychiatry and Psychosomatic Medicine, Fletcher Allen Health Care, Burlington, Vermont.
13
Clinical Innovations, Sales and Business Development, Viterion TeleHealthcare, Bellevue, Washington.
14
Rhode Island Hospit al, The Warren Alpert Medical School of Brown University and Institute of Geriatric Psychiatry,
Providence, Rhode Island.
15
Weill Cornell Medical College, White Plains, New York.
16
Department of Psychiatry, School of Medicine, Community and Behavioral Health, Colorado School of Public Health Centers
for Am erican Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Denver, Colorado.
17
Oregon Health & Science University, Portland, Oregon.
18
Ontario Telehealth Network, Toronto, Canada.
19
University of California Davis, Health Informatics Graduate Program, University of California Davis, Sacramento, California.
20
Optum, San Francisco, California.
21
Department of Medical Imaging, University of Arizona, Tucson, Arizona.
22
American Telemedicine Association, Washington, D.C.
Table of Contents
PREAMBLE..........................................................................................................................................................................................................................723
SCOPE.................................................................................................................................................................................................................................. 724
INTRODUCTION.................................................................................................................................................................................................................. 724
Internet-Based Telemental Health Models of Care Today ...................................................................................................................................... 724
CLINICAL GUIDELINES.....................................................................................................................................................................................................724
A. Professional and Patient Identity and Location ................................................................................................................................................. 724
1. Provider and Patient Identity Verification.....................................................................................................................................................724
2. Provider and Patient Location Documentation ............................................................................................................................................. 725
3. Contact Information Verification for Professional and Patient ..................................................................................................................725
4. Verification of Expectations Regarding Contact Between Sessions ...........................................................................................................725
B. Patient Appropriateness for Videoconferencing-Based Telemental Health ...................................................................................................725
1. Appropriateness of Videoconferencing in Settings Where Professional Staff Are Not Immediately Available...................................725
C. Informed Consent...................................................................................................................................................................................................726
722 TELEMEDICINE and e-HEALTH SEPTEMBER 2013 DOI: 10.1089/tmj.2013.9989
D. Physical Environment ........................................................................................................................................................................................... 726
E. Communication and Collaboration with the Patient’s Treatment Team.........................................................................................................726
F. Emergency Management ....................................................................................................................................................................................... 726
1. Education and Training ................................................................................................................................................................................... 726
2. Jurisdictional Mental Health Involuntary Hospitalization Laws................................................................................................................726
3. Patient Safety When Providing Services in a Setting with Immediately Available Professionals........................................................727
4. Patient Safety When Providing Services in a Setting Without Immediately Available Professional Staff ......................................... 727
5. Patient Support Person and Uncooperative Patients ...................................................................................................................................727
6. Transportation...................................................................................................................................................................................................727
7. Local Emergency Personnel ............................................................................................................................................................................727
G. Medical Issues.........................................................................................................................................................................................................727
H. Referral Resources..................................................................................................................................................................................................727
I. Community and Cultural Competency................................................................................................................................................................ 727
TECHNICAL GUIDELINES .................................................................................................................................................................................................727
A. Videoconferencing Applications ......................................................................................................................................................................... 728
B. Device Characteristics............................................................................................................................................................................................ 728
C. Connectivity............................................................................................................................................................................................................728
D. Privacy.....................................................................................................................................................................................................................728
ADMINISTRATIVE GUIDELINES ..................................................................................................................................................................................... 729
A. Qualification and Training of Professionals....................................................................................................................................................... 729
B. Documentation and Record Keeping ................................................................................................................................................................... 729
C. Payment and Billing .............................................................................................................................................................................................. 729
REFERENCES...................................................................................................................................................................................................................... 729
PREAMBLE
The American Telemedicine Association (ATA), with members from
throughout the United States and throughout the world, is the principal
organization bringing together telemedicine practitioners, healthcare in-
stitutions, vendors, and others involved in providing remote healthcare
using telecommunications. ATA is a nonprofit organization that seeks to
bring together diverse groups from traditional medicine, academia,
technology and telecommunications companies, e-health, allied profes-
sional and nursing associations, medical societies, government, and others
to overcome barriers to the advancement of telemedicine through the
professional, ethical, and equitable improvement in healthcare delivery.
ATA has embarked on an effort to establish practice guidelines and
technical standards for telemedicine to help advance the science and
to assure the uniform quality of service to patients. These guidelines,
based on clinical and empirical experience, are developed by working
groups that include experts from the field and other strategic stake-
holders and designed to serve as both an operational reference and an
educational tool to aid in providing appropriate care for patients. The
guidelines and standards generated by ATA undergo a thorough
consensus and rigorous review, with final approval by the ATA Board of
Directors. Existing products are reviewed and updated periodically.
The practice of medicine is an integration of both the science and art
of preventing, diagnosing, and treating diseases. Accordingly, it should
be recognized that compliance with these guidelines will not guarantee
accurate diagnoses or successful outcomes with respect to the treat-
ment of individual patients, and ATA disclaims any responsibility for such
outcomes. These guidelines are provided for informational and educa-
tional purposes only and do not set a legal standard of medical or other
healthcare. They are intended to assist practitioners in providing effec-
tive and safe medical care that is founded on current information,
available resources, and patient needs. The practice guidelines and
technical standards recognize that safe and effective practices require
specific training, skills, and techniques, as described in each document,
and are not a substitute for the independent medical judgment, training,
and skill of treating or consulting practitioners.
If circumstances warrant, a practitioner may responsibly pursue a course
of action different from the guidelines when, in the reasonable judgment of
the practitioner, such action is indicated by the condition of the patient,
restrictions or limits on available resources, or advances in information or
technology subsequent to publication of the guidelines. Nonetheless, a
practitioner who uses an approach that is significantly different from these
guidelines is strongly advised to provide documentation, in the patient
record, that is adequate to explain the approach pursued.
Likewise, the technical and administrative guidelines in this docu-
ment do not purport to establish binding legal standards for carrying
out telemedicine interactions. Rather, they are the result of the ac-
cumulated knowledge and expertise of the ATA working groups and
intended to improve the technical quality and reliability of tele-
medicine encounters. The technical aspects of and administrative
procedures for specific telemedicine arrangements may vary de-
pending on the individual circumstances, including location of the
parties, resources, and nature of the interaction.
This practice guidelines document focuses on telemental health
services delivered in real time using Internet-based videoconferencing
technologies through personal computers and mobile devices. These
guidelines serve as a companion document to ATA’s Practice Guidelines
for Videoconferencing-Based Telemental Health, a document adopted in
2009 that focuses on real-time videoconferencing-based telemental
health services delivered using technologies other than the Internet.
VIDEO-BASED ONLINE MENTAL HEALTH SERVICES
ª MARY ANN LIEBERT, INC. VOL. 19 NO. 9 SEPTEMBER 2013 TELEMEDICINE and e-HEALTH 723
SCOPE
The scope of these guidelines covers the provision of mental health
services provided by a licensed healthcare professional when using
real-time videoconferencing services transmitted via the Internet.
Other certified professionals may take guidance from these guide-
lines, but the current version targets the practice of behavioral health
by licensed healthcare professionals. The guidelines pertain to tele-
mental health conducted between two parties and do not address
concerns related to multipoint videoconferencing. These guidelines
include telemental health services when the initiating, receiving, or
both sites are using a personal computer with a Webcam or a mobile
communications device (e.g., ‘‘smartphone,’’ laptop, or tablet) with
two-way camera capability. These guidelines do not address com-
munications between professionals and clients or patients via text-
ing, e-mail, chatting, social network sites, online ‘‘coaching,’’ or other
non-mental health services.
This document contains requirements, recommendations, or ac-
tions that are identified by text containing the key words ‘‘shall,’’
‘‘should,’’ or ‘‘may.’’ ‘‘Shall’’ indicates a required action whenever
feasible and practical under local conditions. ‘‘Should’’ indicates an
optimal recommended action that is particularly suitable, without
mentioning or excluding others. ‘‘May’’ indicates additional points
that may be considered to further optimize the telemental healthcare
process.
INTRODUCTION
Telemental health is one of the most active telemedicine appli-
cations rendered in the United States. Telemental health is an in-
tentionally broad term referring to the provision of mental health and
substance abuse services from a distance. Mental health is particu-
larly suited to the use of advanced communication technologies and
the Internet for delivery of care. By using advanced communication
technologies, mental health professionals are able to widen their
reach to patients in a cost-effective manner, ameliorating the mal-
distribution of specialty care.
Establishing guidelines for telemental health improves clinical
outcomes and promotes informed and reasonable patient expecta-
tions. ATA has developed core standards for telemedicine operations
that provide overarching guidance for clinical, technical, and admin-
istrative standards (www.americantelemed.org/practice/standards/
ata-standards-guidelines/core-standa rds-for-telemedicin e-operations).
1
This document provides further guidance on the clinical, technical,
and administrative as well as ethical issues as related to electronic
communication between professionals and patients using advances
in Internet-based videoconferencing technologies and the resulting
treatment models. These guidelines also serve as a companion doc-
ument to ATA’s Practice Guidelines for Videoconferencing-Based
Telemental Health, a document that focuses on real-time, video-
conferencing-based telemental health services delivered using
methods other than the Internet
2,3
and applies to the groups and
services described therein.
Other professional organizations in the United States and abroad
have published guidelines for the provision of mental healthcare
utilizing the desktop and mobile Internet-based communication
technologies.
4–7
When guidelines, position statements, or standards
from any professional organization or society exist, mental health
professionals should also review these documents and, as appropri-
ate, incorporate them into practice.
INTERNET-BASED TELEME NTAL HEALTH MODELS
OF CARE TODAY
Today, mental health professionals are using inexpensive tech-
nologies available through the proliferation of personal computers,
the Internet, mobile devices, and videoconferencing software to
provide mental health services. For example, many mental health
professionals are using widely available, commercial software
downloaded from the Internet to provide care directly to a patient’s
home or other noninstitutional setting. Internet-based Web sites can
serve as a conduit or portal for mental health professionals and pa-
tients seeking treatment online. Mental health professionals can sign
up with one or more Web-based companies and provide a profes-
sional profile that can be viewed online by prospective patients.
Patients find such sites by searching online or through word of
mouth. In both of these models of care, telemental health services are
delivered directly to the patient. Thus, methods to ensure patient
safety and privacy as well as identity verification of both profes-
sionals and patients can be implemented.
In other scenarios, mental health services are outsourced to
companies that contract with hospitals or other institutions in need of
such resources. In turn, some companies also contract with outside
professionals to provide telemental healthcare using technology
maintained and provided by the company.
This is a rapidly growing and evolving field, and the risks and
benefits of telemental health services delivered using videoconfer-
encing technologies are not widely discussed or addressed in formal
training of mental health practitioners. Therefore, thoughtful eluci-
dation of the key issues and the potential solutions are needed to
better inform those who want to practice responsibly.
CLINICAL GUIDELINES
A. PROFESSIO NAL AND PATIENT IDENTITY
AND LOCATION
At the beginning of a video-based mental health treatment (i.e.,
not at every subsequent encounter unless circumstances warrant
reverification) with a patient, the following essential information
shall be verified:
1. Provider and patient identity verification. The name and cre-
dentials of the professional and the name of the patient shall be veri-
fied. For services with the patient at a remote healthcare institution, the
verification of both professional and patient may occur at the host
clinic. When providing professional services to a patient in a setting
without an immediately available mental health professional, the tele-
health provider shall provide the patient (or legal representative) with
his or her qualifications, licensure information, and, when applicable,
registration number and where the patient can verify this information.
TURVEY ET AL.
724 TELEMEDICINE and e-HEALTH SEPTEMBER 2013
Patients shall provide their full name. Professionals may ask patients to
verify their identity more formally by showing a government-issued
photo ID on the video screen or by using a smart card.
2. Provider and patient location documentation. The location(s)
where the patient will be receiving services by videoconferencing
shall be confirmed and documented by the provider. In addition, the
location of the provider may need to be documented, especially in
cases where such documentation is needed for the appropriate pay-
ment of services. However, it is not necessary for the mental health
provider to reveal his or her specific location to the patient, especially
if the provider is located at home at the time of the service.
Verification of provider and patient location is critical for four key
reasons:
a. The professional shall comply with the relevant licensing laws
in the jurisdiction where the provider is physically located
when providing the care and where the patient is located when
receiving care. Note that in the United States the jurisdictional
licensure requirement is usually tied to where the patient is
physically located when he or she is receiving the care, not
where the patient lives.
8
b. The emergency management protocol is entirely dependent
upon where the patient receives services. Once again, where
the patient resides is only relevant if that is also where he or
she is receiving care.
c. Mandatory reporting and related ethical requirements such as
duty to notify are tied to the jurisdiction where the patient is
receiving services.
d. In some cases, provider payment amounts are tied to where the
provider and patient are located.
When patients are receiving telemental health services at an accre-
dited health center, the emergency management and reporting proto-
cols shall be coordinated with the remote health center in accordance
with applicable jurisdictional law and licensing requirements.
In instances where the mental health professional is providing ser-
vices to patients in settings without clinical staff immediately available
and/or to patients who change locations over the course of treatment,
they should discuss the importance of consistency in where the patient
chooses to receive care as it is tied to emergency management. Although
patients who change locations may likely remain in the same state, they
may change cities, which will impact emergency management protocols
related to police intervention and location of local emergency rooms
willing to evaluate potentially lethal psychiatric issues.
3. Contact information verification for professional and pa-
tient. The contact information for both provider and patient shall be
verified. This shall include gathering telephone and mail contact
information for both the provider and the patient and may also in-
clude contact information through electronic sources such as e-mail.
4. Verification of expectations regarding contact between ses-
sions. Reasonable expectations about contact between sessions shall
be discussed and verified with the patient. At the start of the treat-
ment, the patient and provider should discuss whether or not the
provider will be available for phone or electronic contact between
sessions and the conditions under which such contact is appropriate.
The provider should provide a specific time frame for expected re-
sponse between session contacts. This should also include a discus-
sion of emergency management between sessions.
B. PATIENT APPROPRIATENESS FOR
VIDEOCONFERENCING-BASED TELEMENTAL HEALTH
To date, no studies have identified any patient subgroup that does
not benefit from, or is harmed by, mental healthcare provided
through remote videoconferencing. Recent large randomized con-
trolled trials have demonstrated effectiveness of telemental health,
with many smaller trials also supporting this conclusion.
9–11
Re-
garding specific subgroups, such as patients with psychotic or phobic
disorders, one review by Sharp et al.
12
found no evidence for infe-
riority of videoconferencing telemental health for patients with
psychosis. Dongier et al.
13
compared in-person versus videoconfer-
encing interviews in psychotic patients and concluded that even
those with delusions pertaining to the TV responded appropriately to
videoconferencing and did not incorporate their experience into their
delusional system. Bouchard et al.
14
found videoconferencing
treatment effective for agoraphobia and panic disorder.
1. Appropriateness of videoconferencing in settings where pro-
fessional staff are not immediately available. Mental health pro-
fessionals should consider the patients’ expectations and level of
comfort with home-based care to determine the appropriateness of
using videoconferencing in this setting.
15
Provision of telemental
health services in professionally unsupervised settings requires
that the patient take a more active and cooperative role in the
treatment process than in in-person settings.
15,16
Determining
whether a patient can handle such demands may be more de-
pendent on the patient’s organizational and cognitive capacities
than on diagnosis.
When the patient is located outside an institutional location, the
patient (guardian or caretaker) is responsible for setting up the vid-
eoconferencing system at his or her site, maintaining the appropriate
computer settings, and establishing a private space. In addition, even
with establishment of a community-based emergency management
protocol, such as that described in the Emergency Management
section of this document, patient cooperation is critical for effective
safety management in settings where a professional is not immedi-
ately available.
Determining patient appropriateness for videoconferencing-based
telemental health services should, in addition to considering the pa-
tient’s ability to potentially benefit from them, rely on the profes-
sional’s assessment of the patient’s ability to arrange an appropriate
setting for receiving videoconferencing services and the patient’s
continued cooperativeness regarding managing safety issues. Pro-
fessionals should also consider such things as patient’s cogni-
tive capacity, history regarding cooperativeness with treatment
VIDEO-BASED ONLINE MENTAL HEALTH SERVICES
ª MARY ANN LIEBERT, INC. VOL. 19 NO. 9 SEPTEMBER 2013 TELEMEDICINE and e-HEALTH 725
professionals, current and past difficulties with substance abuse, and
history of violence or self-injurious behavior.
Professionals shall consider geographic distance to the nearest
emergency medical facility, efficacy of patient’s support system,
current medical status, and patient’s general level of competence
around technology when determining patient appropriateness for
videoconferencing.
Professionals should evaluate the potential for risk factors or
problems at the start of providing videoconferencing services in
settings where a professional is not immediately available. In addi-
tion, evaluation of appropriateness of videoconferencing care should
continue throughout the treatment, including monitoring of symp-
toms and patient cooperativeness in assuming the responsibilities
inherent in remote care. The consent process shall include discussion
of conditions of participation around session management so that if a
professional decides a patient can no longer be managed through
distance technology, the patient is aware that services may be dis-
continued if no longer appropriate.
C. INFORMED CONSENT
A thorough informed consent at the start of services shall be
performed. The consent should be conducted with the patient in real
time. Local, regional, and national laws regarding verbal or written
consent shall be followed. If written consent is required, then elec-
tronic signatures, assuming these are allowed in the relevant juris-
diction, may be used. The provider shall document the provision of
consent in the medical record.
The consent should include all information contained in the consent
process for in-person care, including discussion of the structure and
timing of services, record keeping, scheduling, privacy, potential risks,
confidentiality, mandatory reporting, and billing. In addition, the in-
formed consent process should include information specific to the
nature of videoconferencing as described below. The information shall
be provided in language that can be easily understood by the patient.
This is particularly important when discussing technical issues like
encryption or the potential for technical failure.
Key topics that shall be reviewed include: confidentiality and the
limits to confidentiality in electronic communication; an agreed-
upon emergency plan, particularly for patients in settings without
clinical staff immediately available; the process by which patient
information will be documented and stored; the potential for tech-
nical failure; procedures for coordination of care with other profes-
sionals; a protocol for contact between sessions; and conditions
under which telemental health services may be terminated and a
referral made to in-person care.
D. PHYSICAL ENVIRONMENT
Both the professional and the patient’s room/environment should
aim to provide comparable professional specifications of a standard
services room. Efforts shall be made to ensure privacy so clinical
discussion cannot be overheard by others outside of the room where
the service is provided. If other people are in either the patient or the
professional’s room, both the professional and the patient shall be
made aware of the other people and agree to their presence. Seating
and lighting should be tailored to allow maximum comfort to the
participants. Both the professional and the patient should maximize
clarity and visibility of the person at the other end of the video
services. For example, patients receiving care in nontraditional set-
tings should be informed of the importance of reducing light from
windows or light emanating from behind them. Both provider and
patient cameras should be on a secure, stable platform to avoid
wobbling and shaking during the videoconferencing session. To the
extent possible, the patient and provider cameras should be placed at
the same elevation as the eyes with the face clearly visible to the other
person.
E. COMMUNICATION AND COLLABORATION
WITH THE PATIENT’S TREATMENT TEAM
Professionals shall acknowledge that optimal clinical manage-
ment of patients depends on coordination of care between a multi-
disciplinary treatment team. This shall be discussed with all patients.
However, patients may have specific privacy concerns about release
of information about mental health treatment, even to other health
professionals providing services to them, and these concerns shall be
respected.
For patients who agree to coordination of care, telemental health
professionals should arrange for appropriate and regular private
communication with other professionals involved in care for the
patient. Moreover, professionals conducting telemental health to
patients in settings without clinical staff immediately available are
encouraged to develop collaborative relationships with local com-
munity professionals, such as a patient’s local primary care provider,
as these professionals may be invaluable in case of emergencies.
F. EMERGENCY MANAGEMENT
Providing mental healthcare to patients using videoconferencing
involves particular considerations regarding patient safety. There are
also additional considerations when providing care to patients in
settings without staff immediately available.
17
Below are issues that
should be considered in both types of practice, followed by separate
sections for emergency management for supervised and unsuper-
vised settings.
1. Education and training. Professionals should review their
discipline’s definitions of ‘‘competence’’ prior to initiating telemental
health patient care to assure that they maintain both technical and
clinical competence for the delivery of care in this manner. Profes-
sionals shall have completed basic education and training in suicide
prevention. The depth of training and the definition of ‘‘basic’’ are
solely at the professional’s discretion.
2. Jurisdictional mental health involuntary hospitalization laws.
Each jurisdiction has its own involuntary hospitalization and duty-
to-notify laws outlining criteria and detainment conditions. Profes-
sionals shall know and abide by the laws in the jurisdiction where the
patient is receiving services.
TURVEY ET AL.
726 TELEMEDICINE and e-HEALTH SEPTEMBER 2013
3. Patient safety when providing services in a setting with im-
mediately available professionals. When a professional sees a patient
via personal computer and/or mobile device outside of the patient’s
home (e.g., local clinic, community-based outpatient clinic, school
site, library) or other facility where dedicated staff may be present, it
may be important that the professional become familiar with the
facility’s emergency procedures. In some cases, the facility will not
have procedures in place. In such cases, the professional should co-
ordinate with the distant site clinic to establish basic procedures. The
basic procedures may include: (1) identifying local emergency re-
sources and phone numbers; (2) becoming familiar with the location
of the nearest hospital emergency room capable of managing psy-
chiatric emergencies; and (3) having patient’s family/support contact
information. The professional may also learn the chosen emergency
response system’s average response time (30 min versus 5 h) and the
contact information for other local professional associations, such as
city, county, state, provincial, or other regional professional associ-
ation(s), in case a local referral is needed to follow up with a local
professional.
4. Patient safety when providing services in a setting without
immediately available professional staff. For treatment occurring
where the patient is in a setting without clinical staff, the professional
may request the contact information of a family or community
member who could be called upon for support in the case of an
emergency. This person will be called ‘‘the Patient Support Person,’’
an individual selected by the patient. In the case of an emergency, the
professional may contact the Patient Support Person to request as-
sistance in evaluating the nature of the emergency and/or initiating
9-1-1 from the patient’s home telephone.
17
5. Patient Support Person and uncooperative patients. It is pos-
sible that a patient will not cooperate in his or her own emergency
management, which underlies the practice of involuntary hospitali-
zation in mental healthcare. Professionals should be prepared for this
as well as the possibility that Patient Support Persons also may not
cooperate if the patients themselves are adamant that they do not
want to seek emergency care. Therefore, any emergency plan shall
include local emergency personnel and knowledge of available re-
sources in case of involuntary hospitalization.
6. Transportation. As videoconferencing-based telemental health
has developed, in part, to increase access to patients in geographi-
cally remote areas, it is expected that there may be barriers to
transportation to local mental health services. In light of this, the
professional shall know any limitations the patient has in terms of
self-transporting and/or access to transportation. Strategies to
overcome these limitations in light of an emergency shall be devel-
oped prior to starting treatment for patients in settings without staff
immediately available.
In the event of a behavioral and/or medical emergency, the pa-
tient’s Patient Support Person should discuss with emergency per-
sonnel whether he or she should transport the patient.
7. Local emergency personnel. In providing care to patients in
settings without professional staff immediately available, determin-
ing distance between local emergency personnel in the patient’s
community and the patient’s location can shape the professional’s
decision process in determining appropriate actions.
Professionals shall acquire telephone numbers for local resources
in the patient’s community. At the beginning of each session, the
professional shall have the patient’s local emergency personnel
telephone contact information readily available. Prior to each ses-
sion, the provider shall also determine the patient’s location and
whether there have been any changes to the patient’s personal sup-
port system or the emergency management protocol.
G. MEDICAL ISSUES
In case of medication side effects, elevation in symptoms, and/or
issues related to medication noncompliance, the professional should
be familiar with the patient’s prescription and medication dispen-
sation options.
Likewise, when prescribing, the clinician should be aware of the
availability of specific medications in the geographic location of the
patient, and that should inform prescribing choices. Patients re-
ceiving treatment through telemental health services should have an
active relationship with a prescribing professional in their physical
vicinity.
If services are provided in a setting where a professional is not
immediately available, the patient may be at risk if there is an
acute change in his or her medical condition. The professional
should be familiar with whom the patient is receiving medical
services.
H. REFERRAL RESO URCES
The professional shall be familiar with local in-person mental
health resources should the professional exercise clinical judgment to
make a referral for additional mental health or other appropriate
services.
I. COMMUNITY AND CULTURAL COMPETENCY
Professionals shall be culturally competent to deliver services to
the populations that they serve. Examples of factors to consider in-
clude awareness of the client’s language, ethnicity, race, age, gender,
sexual orientation, geographical location, and socioeconomic and
cultural backgrounds. Mental health professionals may use online
resources to learn of the community where the patient resides, in-
cluding any recent significant events and cultural mores of that
community.
TECHNICAL GUIDELINES
Videoconferencing can be characterized by key features: the
videoconferencing application, device characteristics including their
mobility, network or connectivity features, and how privacy and
security are maintained. The more recent use of desktop and mobile
devices requires consideration of each of these.
VIDEO-BASED ONLINE MENTAL HEALTH SERVICES
ª MARY ANN LIEBERT, INC. VOL. 19 NO. 9 SEPTEMBER 2013 TELEMEDICINE and e-HEALTH 727
A. VIDEOCONFERENCING APPLICATIONS
All efforts shall be taken to use videoconferencing applications
that have been vetted and have the appropriate verification, confi-
dentiality, 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 capa-
bility to create a video chat ‘‘room’’ that allows others to enter at will.
This type of functionality should be disabled.
B. DEVICE CHARACTERISTICS
When using a personal computer, both the professional device for
video transmission and the patient’s site should, when feasible, use
professional-grade or high-quality cameras and audio equipment
now widely available for personal computers. Personal computers
shall have up-to-date antivirus software and a personal firewall in-
stalled. Providers should ensure their personal computer or mobile
device has the latest security patches and updates applied to the
operating system and third-party applications that may be utilized
for this purpose.
Provider organizations should utilize mobile device management
software to provide consistent oversight of applications, device and
data configuration, and security of the mobile devices used within the
organization.
In the event of a technology breakdown, causing a disruption of
the session, the professional shall have a backup plan in place. The
plan shall be communicated to the patient prior to commencement of
treatment and may also be included in the general emergency
management protocol. The professional may review the technology
backup plan on a routine basis.
The plan may include calling the patient via telephone and at-
tempting to troubleshoot the issue together. The plan may also
include providing the patient with access to other mental health-
care. If the technical issue cannot be resolved, the professional may
elect to complete the session via a voice-based telecommunication
system.
Screen-in-screen options, also known as picture-in-a-picture or
‘‘PIP,’’ may also be used when feasible and are widely available in
professional-grade desktop videoconferencing software packages.
Professionals and patients may opt to use cameras that allow for pan,
tilt, and zoom for maximal flexibility in viewing the remote room.
C. CONNECTIVITY
Telemental healthcare services provided through personal com-
puters or mobile devices that use Internet-based videoconferenc-
ing software programs should provide such services at a bandwidth of
384 kilobits per second (Kbps) or higher in each of the downlink and
uplink directions. Such services should provide a minimum of
640 · 360 resolution at 30 frames per second. Because different tech-
nologies provide different video quality results at the same bandwidth,
each end point shall use bandwidth sufficient to achieve at least the
minimum quality shown above during normal operation.
Where practical, providers may recommend preferred videocon-
ferencing software and/or video and audio hardware to the patient, as
well as providing any relevant software and/or hardware configu-
ration considerations.
The provider and/or patient may use link test tools (e.g., bandwidth
test) to pretest the connection before starting their session to ensure
the link has sufficient quality to support the session.
Where possible, each party should use the most reliable connection
method to access the Internet. Where wired connections are available
(e.g., Ethernet), they should be used.
The videoconference software should be able to adapt to changing
bandwidth environments without losing the connection.
D. PRIVACY
The videoconference software should be capable of blocking the
provider’s caller ID at the request of the provider.
All efforts shall be taken to make audio and video transmission
secure by using point-to-point encryption that meets recognized
standards. Currently, FIPS 140-2, known as the Federal Information
Processing Standard, is the U.S. Government security standard used
to accredit encryption standards of software and lists encryption such
as AES (Advanced Encryption Standard) as providing acceptable
levels of security. Providers should familiarize themselves with the
technologies available regarding computer and mobile device secu-
rity and should help educate the patient.
When the patient and/or provider use a mobile device, special
attention should be placed on the relative privacy of information
being communicated over such technology.
Providers should ensure access to any patient contact information
stored on mobile devices is adequately restricted.
Mobile devices shall require a passphrase or equivalent security
feature before the device can be accessed. If multifactor authenti-
cation is available, it should be used.
Mobile devices should be configured to utilize an inactivity
timeout function that requires a passphrase or re-authentication to
access the device after the timeout threshold has been exceeded. This
timeout should not exceed 15 min.
Mobile devices should be kept in the possession of the provider
when traveling or in an uncontrolled environment. Unauthorized
persons shall not be allowed access to sensitive information stored on
the device or use the device to access sensitive applications or net-
work resources.
Providers should have the capability to remotely disable or wipe
their mobile device in the event it is lost or stolen.
Videoconference software shall not allow multiple concurrent
sessions to be opened by a single user. Should a second session at-
tempt to be opened, the system shall either log off the first session or
block the second session from being opened.
Session logs stored in third-party locations (i.e., not on patients’ or
providers’ access device) shall be secure. Access to these session logs
shall only be granted to authorized users.
TURVEY ET AL.
728 TELEMEDICINE and e-HEALTH SEPTEMBER 2013
Protected health information (PHI) and other confidential data
shall only be backed up to or stored on secure data storage locations.
Cloud services unable to achieve compliance shall not be used for PHI
or confidential data.
Professionals may monitor whether any of the videoconference
transmission data is intentionally or inadvertently stored on the
patient’s or professional’s computer’s hard drive. If so, the hard drive
of the provider should use whole disk encryption to the FIPS standard
to ensure security and privacy. Preboot authentication should also be
used. Professionals should educate patients about the potential for
inadvertently stored data and patient information and provide
guidance on how best to protect privacy.
Professionals and patients shall discuss any intention to record
services and how this information is to be stored and how privacy will
be protected. Recordings should be encrypted for maximum security.
Access to the recordings shall only be granted to authorized users and
should be streamed to protect from accidental or unauthorized file
sharing and/or transfer. The professional may also want to discuss his
or her policy with regard to the patient-sharing portions of this in-
formation with the general public. Written agreements pertaining to
this issue can protect both the patient and the professional.
If services are recorded, the recordings shall be stored in a secured
location. Access to the recordings shall only be granted to authorized
users.
ADMINISTRATIVE GUIDELINES
A. QUALIFICATION AND TRAINING OF PROFESSIONALS
In addition to clinical, legal, and ethical training required for li-
censure for in-person services, professionals shall make use of the
widely available resources providing education of proper conduct of
videoconferencing to both professionally supervised settings and
those without readily available clinical staff. Mental health profes-
sionals shall also determine whether there are site-specific cre-
dentialing requirements where the patient is located.
Professionals shall conduct care consistent with the jurisdictional
licensing laws and rules for their profession in both the jurisdiction in
which they are practicing and that where the patient is receiving care.
Licensed mental health professionals should contact their licens-
ing board to review their practice before starting any provision of
telemental health services. The professional should also contact the
licensing board relevant to the patient’s location during treatment, to
determine whether or not the services provided fall under their ju-
risdiction and what, if any, restrictions exist.
B. DOCUMEN TATION AND RECORD KEEPING
Professionals shall maintain an electronic record for each patient
for whom they provide remote services. Such a record should include
an assessment, client identification information, contact informa-
tion, history, treatment plan, informed consent, and information
about fees and billing.
A treatment plan based upon an assessment of the patient’s needs
should be developed and documented. The plan should meet
the professional’s discipline standards and guidelines and include a
description of what services are to be provided and the goals for
services.
Services should be accurately documented as remote services and
include dates, duration, and type of service(s) provided.
Documentation shall comply with applicable jurisdictional and
federal laws and regulations. Policies for record retention and dis-
posal should be in place.
All communications with the patient (e.g., written, audiovisual, or
verbal) shall be documented in the patient’s unique record, and all
such records shall be stored in compliance with relevant government
regulations, such as the Health Insurance Portability and Account-
ability Act (HIPAA) and HI-TECH within the United States.
15
Requests for access to such records shall require written authori-
zation from the patient with a clear indication of what types of data
and which information is to be released. If professionals are storing
the audiovisual data from the sessions, these cannot be released
unless the patient authorization indicates specifically that this is to be
released. Upon direction and written approval by the patient, the
patient’s record shall be made available to another provider that is
caring for the patient.
All billing and administrative data related to the patient shall be
secured to protect confidentiality: specifically, all records are con-
fidential; HIPAA regulations regarding psychotherapy notes are
adhered to; and only relevant information is released for reim-
bursement purposes as outlined by HIPAA in the United States.
C. PAYMENT AND BILLING
Prior to the commencement of initial services, the patient shall be
made aware of any and all financial charges that may arise from the
services to be provided. Arrangement for payment should be com-
pleted prior to the commencement of services.
REFERENCES
1. Core standards for telemedicine operations. Washington, DC: American
Telemedicine Association, 2007. Available at www.americantelemed.org/
practice/standards/ata-standards-guidelines/core-standards-for-telemedicine-
operations (last accessed July 22, 2013).
2. Grady B, Myers KM, Nelson EL, Belz N, Bennett L, Carnahan L, Decker VB, Holden
D, Perry G, Rosenthal L, Rowe N, Spaulding R, Turvey CL, White R, Voyles D.
Evidence-based practice for telemental health. Telemed J E Health 2011;
17:131–148.
3. Yellowlees P, Shore J, Roberts L. Practice guidelines for videoconferencing-
based telemental health—October 2009. Telemed J E Health 2010;16:1074–
1089.
4. APA-ASPPB-APAIT Guidelines for the Practice of Telepsychology (adoption
pending): Personal communication, Debora Baker, JD, July 22, 2013; Director of
Legal and Regulatory Policy, American Psychological Association.
5. Australian Psychological Society. Guidelines for providing psychological services
and products using the internet and telecommunications technologies. 2011.
Available at http://aaswsocialmedia.wikispaces.com/file/view/EG-Internet.pdf
(last accessed July 22, 2013).
6. Standards for technology and social work practice. National Association of
Social Workers and ASWB Standards for Technology and Social Work Practice.
2005. Available at www.socialworkers.org/practice/standards/
naswtechnologystandards.pdf (last accessed July 22, 2013).
VIDEO-BASED ONLINE MENTAL HEALTH SERVICES
ª MARY ANN LIEBERT, INC. VOL. 19 NO. 9 SEPTEMBER 2013 TELEMEDICINE and e-HEALTH 729
7. Ohio Psychological Association. Telepsychology guidelines. 2010. Available at
www.ohpsych.org/psychologists/files/2011/06/
OPATelepsychologyGuidelines41710.pdf (last accessed July 22, 2013).
8. Hyler SE, Gangure DP. Legal and ethical challenges in telepsychiatry. J Psychiatr
Pract 2004;10:272–276.
9. Day SX, Schneider PL. Psychotherapy using distance technology: A comparison of
face-to-face, video, and audio treatment. J Couns Psychol 2002;49:499–503.
10. O’Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is
telepsychiatry equivalent to face-to-face psychiatry? Results from a
randomized controlled equivalence trial. Psychiatr Serv 2007;58:836–843.
11. Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Bradham DD, Hebel JR, et al.
Treatment outcomes in depression: Comparison of remote treatment through
telepsychiatry to in-person treatment. Am J Psychiatry 2004;161:1471–1476.
12. Sharp IR, Kobak KA, Osman DA. The use of videoconferencing with patients with
psychosis: A review of the literature. Ann Gen Psychiatry 2011;10:14.
13. Dongier M, Tempier R, Lalinec-Michaud M, Meunier D. Telepsychiatry:
Psychiatric consultation through two-way television. A controlled study. Can J
Psychiatry 1986;31:32–34.
14. Bouchard S, Paquin B, Payeur R, Allard M, Rivard V, Fournier T, Renaud P,
Lapierre J. Delivering cognitive-behavior therapy for panic disorder with
agoraphobia in videoconference. Telemed J E Health 2004;10:13–25.
15. Luxton DD, O’Brien K, McCann RA, Mishkind MC. Home-based telemental
healthcare safety planning: What you need to know. Telemed J E Health
2012;18:629–633.
16. Luxton DD, Sirotin AP, Mishkind MC. Safety of telemental healthcare delivered
to clinically unsupervised settings: A systematic review. Telemed J E Health
2010;16:705–711.
17. Shore P. Home-based telemental health (HBTMH) standard operating
procedures manual. United States Department of Veterans Affairs, 2011.
Address correspondence to:
Carolyn Turvey, PhD
Department of Psychiatry
The Roy J. and Lucille A. Carver College of Medicine
University of Iowa
500 Newton Road, 2-204 MEB
Iowa City, IA 52242-1000
E-mail: carolyn-turvey@uiowa.edu
Received: June 20, 2013
Accepted: June 24, 2013
TURVEY ET AL.
730 TELEMEDICINE and e-HEALTH SEPTEMBER 2013
