Ethical decision-making regarding Telehealth should include the following considerations: Proper and valid identification of the client. Obtaining of reliable, basic client's information, such as full name, address, age, gender, phone, fax, emergency contacts, etc. Obtaining reliable biographical information, which also includes clinical and medical history, past therapy, suicidality, etc. Validation of any information obtained via tele-means. Providing clients with a meaningful and valid Informed Consent detailing the limitations of telehealth, in general, and confidentiality and privacy, in particular. Informing clients of potential limitations of telehealth when it comes to crisis interventions and dealing with dangerous situations. Therapists practicing within their limits of clinical and technological competence. Having a crisis intervention plan in place, including ways to reach local emergency services and make referrals to local psychotherapists, psychiatrists and psychiatric hospitals in the client's vicinity. Capacity to make a valid assessment and diagnosis, when relevant. Providing thorough screening when considering which clients may not be suited to this kind of medium for clinical, intelligence, technical or other reasons. Having a clear agreement in regard to what is being charged, how is it being charged, the rates and method of payment. Rendering medical or psychiatric advice by giving a diagnosis or proposing a course of treatment online or by other telehealth means prior to establishing professional psychotherapeutic relationships. Following relevant and applicable state laws, therapists' licensing board rules and therapists' state and national professional association guidelines and code of ethics.  Giving special, serious consideration to issues of practicing across state lines. Taking into account, if appropriate and relevant, laws in client's state and in therapist's state. Practicing within the standard of care. Documentation. Technical considerations, such as access codes, access logs, virus protection, fire wall and backup. HIPAA Compliance Telehealth is one of the fastest growing fields in medicine. Therapists must regularly update themselves on the latest research on telehealth and changes in laws, regulations and codes of ethics. Code of Ethics on Telehealth Generally, telehealth practices are subject to exactly the same federal and state regulations, codes of ethics, and professional guidelines that define the fiduciary relationship in face-to-face and office-based therapy. It falls within the same standard of care. Following are Ethics codes of different professional associations that have attended to the telehealth concerns differently. Following are: American Psychological Association (APA) Code of Ethics of 2002 (http://www.apa.org/ethics/code2002.html) simply states that basically, therapy that uses telephone or Internet must abide by the same ethical guidelines as in person therapy. This Ethics Code applies only to psychologists' activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code. (Introductory and applicability, 2nd Para.) American Counseling Association Code of Ethics (ACA, 2005) devotes a separate section (A. 12) to “Technology Application” where it is spells out guidelines regarding limitations, access, informed consent, use of the Web and more, regarding telehealth and related issues. American Mental Health Counselors Association (AMHCA, 2000) Code of Ethics (http://www.amhca.org/code) Principle 14:   Internet On-Line Counseling: Mental health counselors engaged in delivery of services that involves the telephone, teleconferencing and the Internet in which these areas are generally recognized, standards for preparatory training do not yet exist. Mental health counselors take responsible steps to ensure the competence of their work and protect patients, clients, students, research participants and others from harm. A) Confidentiality Mental health counselors ensure that clients are provided sufficient information to adequately address and explain the limitations of computer technology in the counseling process in general and the difficulties of ensuring complete client confidentiality of information transmitted through electronic communications over the Internet through on-line counseling. Professional counselors inform clients of the limitations of confidentiality and identify foreseeable situations in which confidentiality must be breached in light of the law in both the state in which the client is located and the state in which the professional counselor is licensed. Mental health counselors shall become aware of the means for reporting and protecting suicidal clients in their locale. Mental health counselors shall become aware of the means for reporting homicidal clients in the client's jurisdiction. B) Mental Health Counselor Identification Mental health counselors provide a readily visible notice advising clients of the identities of all professional counselor(s) who will have access to the information transmitted by the client. Mental health counselors provide background information on all professional communications, including education, licensing and certification, and practice information. C) Client Identification Professional counselors identify clients, verify identities of clients, and obtain alternative methods of contacting clients in emergency situations. D) Client Waiver Mental health counselors require clients to execute client waiver agreements stating that the client acknowledges the limitations inherent in ensuring client confidentiality of information transmitted through on-line counseling and acknowledge the limitations that are inherent in a counseling process that is not provided face-to-face. Limited training in the area of on-line counseling must be explained and the client's informed consent must be secured. E) Electronic Transfer of Client Information Mental health counselors electronically transfer client confidential information to authorized third-party recipients only when both the professional counselor and the authorized recipient have "secure" transfer and acceptance communication capabilities; the recipient is able to effectively protect the confidentiality of the client's confidential information to be transferred; and the informed written consent of the client, acknowledging the limits of confidentiality, has been obtained. F) Establishing the On-Line Counseling Relationship 1. Appropriateness of On-line Counseling Mental health counselors develop an appropriate in-take procedure for potential clients to determine whether on-line counseling is appropriate for the needs of the client. Mental health counselors warn potential clients that on-line counseling services may not be appropriate in certain situations and, to the extent possible, inform the client of specific limitations, potential risks, and/or potential benefits relevant to the client's anticipated use of on-line counseling services. Mental health counselors ensure that clients are intellectually, emotionally, and physically capable of using on-line counseling services, and of understanding the potential risks and/or limitations of such services. 2. Counseling Plans Mental health counselors develop individual on-line counseling plans that are consistent with both the client's individual circumstances and the limitations of on-line counseling. Mental health counselors who determine that on-line counseling is inappropriate for the client should avoid entering into or immediately terminate the on-line counseling relationship and encourage the client to continue the counseling relationship through a traditional alternative method of counseling. 3. Boundaries of Competence Mental health counselors provide on-line counseling services only in practice areas within their expertise. Mental health counselors do not provide services to clients in states where doing so would violate local licensure laws or regulations. G) Legal Considerations Mental health counselors confirm that the provision of on-line services are not prohibited by or otherwise violate any applicable state or local statutes, rules, regulations or ordinances, codes of professional membership organizations and certifying boards, and/or codes of state licensing boards. National Board for Certified Counselors (NBCC) Code of Ethics (amended 2005) (http://www.nbcc.org/extras/pdfs/ethics/nbcc-codeofethics.pdf) states in section B.12: Counselors using electronic means in which counselor and client are not I immediate proximity must present clients with local sources of care before establishing a continued short or long-term relationship. Counselors who communicate with clients via Internet are governed by NBCC standards for Web Counseling. NBCC Practice of Internet Counseling (at http://www.nbcc.org/webethics2.)  states: Standards for the Ethical Practice of Internet Counseling These standards govern the practice of Internet counseling and are intended for use by counselors, clients, the public, counselor educators, and organizations that examine and deliver Internet counseling. These standards are intended to address practices that are unique to Internet counseling and Internet counselors and do not duplicate principles found in traditional codes of ethics. These Internet counseling standards of practice are based upon the principles of ethical practice embodied in the NBCC Code of Ethics. Therefore, these standards should be used in conjunction with the most recent version of the NBCC ethical code. Related content in the NBCC Code are indicated in parentheses after each standard. Recognizing that significant new technology emerges continuously, these standards should be reviewed frequently. It is also recognized that Internet counseling ethics cases should be reviewed in light of delivery systems existing at the moment rather than at the time the standards were adopted. In addition to following the NBCC® Code of Ethics pertaining to the practice of professional counseling, Internet counselors shall observe the following standards of practice: Internet Counseling Relationship In situations where it is difficult to verify the identity of the Internet client, steps are taken to address impostor concerns, such as by using code words or numbers.  Internet counselors determine if a client is a minor and therefore in need of parental/guardian consent. When parent/guardian consent is required to provide Internet counseling to minors, the identity of the consenting person is verified.  As part of the counseling orientation process, the Internet counselor explains to clients the procedures for contacting the Internet counselor when he or she is off-line and, in the case of asynchronous counseling, how often e-mail messages will be checked by the Internet counselor.  As part of the counseling orientation process, the Internet counselor explains to clients the possibility of technology failure and discusses alternative modes of communication, if that failure occurs.  As part of the counseling orientation process, the Internet counselor explains to clients how to cope with potential misunderstandings when visual cues do not exist.  As a part of the counseling orientation process, the Internet counselor collaborates with the Internet client to identify an appropriately trained professional who can provide local assistance, including crisis intervention, if needed. The Internet counselor and Internet client should also collaborate to determine the local crisis hotline telephone number and the local emergency telephone number. The Internet counselor has an obligation, when appropriate, to make clients aware of free public access points to the Internet within the community for accessing Internet counseling or Web-based assessment, information, and instructional resources.  Within the limits of readily available technology, Internet counselors have an obligation to make their Web site a barrier-free environment to clients with disabilities.  Internet counselors are aware that some clients may communicate in different languages, live in different time zones, and have unique cultural perspectives. Internet counselors are also aware that local conditions and events may impact the client. Confidentiality in Internet Counseling  The Internet counselor informs Internet clients of encryption methods being used to help insure the security of client/counselor/supervisor communications.  Encryption methods should be used whenever possible. If encryption is not made available to clients, clients must be informed of the potential hazards of unsecured communication on the Internet. Hazards may include unauthorized monitoring of transmissions and/or records of Internet counseling sessions.  The Internet counselor informs Internet clients if, how, and how long session data are being preserved.  Session data may include Internet counselor/Internet client e-mail, test results, audio/video session recordings, session notes, and counselor/supervisor communications. The likelihood of electronic sessions being preserved is greater because of the ease and decreased costs involved in recording. Thus, its potential use in supervision, research, and legal proceedings increases.  Internet counselors follow appropriate procedures regarding the release of information for sharing Internet client information with other electronic sources.  Because of the relative ease with which e-mail messages can be forwarded to formal and casual referral sources, Internet counselors must work to insure the confidentiality of the Internet counseling relationship.  Legal Considerations, Licensure, and Certification  Internet counselors review pertinent legal and ethical codes for guidance on the practice of Internet counseling and supervision.  Local, state, provincial, and national statutes as well as codes of professional membership organizations, professional certifying bodies, and state or provincial licensing boards need to be reviewed. Also, as varying state rules and opinions exist on questions pertaining to whether Internet counseling takes place in the Internet counselor's location or the Internet client's location, it is important to review codes in the counselor's home jurisdiction as well as the client's. Internet counselors also consider carefully local customs regarding age of consent and child abuse reporting, and liability insurance policies need to be reviewed to determine if the practice of Internet counseling is a covered activity.  The Internet counselor's Web site provides links to websites of all appropriate certification bodies and licensure boards to facilitate consumer protection. National Association of Social Workers (NASW) Code of Ethics of 1999 (http://www.socialworkers.org/pubs/code/code.asp) mentions briefly under Informed Consent: Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (NASW, 1999, Section 1.03, Para. E). California Association of Marriage and Family Therapists (CAMFT) 2008 Code of Ethics (http://www.camft.org/scriptcontent/index.cfm?displaypage=../CamftBenefits/EthicalStandards1.html): 1.4.1 ELECTRONIC THERAPY: When patients are not physically present (e.g., therapy by telephone or Internet) during the provision of therapy, marriage and family therapists take extra precautions to meet their responsibilities to patients. Prior to utilizing electronic therapy, marriage and family therapists consider the appropriateness and suitability of this therapeutic modality to the patient’s needs. When therapy occurs by electronic means, marriage and family therapists inform patients of the potential risks, consequences, and benefits, including but not limited to, issues of confidentiality, clinical limitations, transmission difficulties, and ability to respond to emergencies. Marriage and family therapists ensure that such therapy complies with the informed consent requirements of the California Telemedicine Act.

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