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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.
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 is available at http://www.nbcc.org/webethics2.
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) Code of Ethics (http://www.camft.org/CamftBenefits/whatiscamft_ethnic1.html) attends (to telehealth concerns in several places:
1. RESPONSIBILITY TO PATIENTS: Marriage and family therapists advance the welfare of families and individuals, respect the rights of those persons seeking their assistance, and make reasonable efforts to ensure that their services are used appropriately. 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.
1.15: When therapy is provided by Internet or other electronic media, marriage and family therapists ensure that patients are intellectually, emotionally, and physically capable of engaging in therapy by such means.
2.3: Marriage and family therapists are aware of the possible adverse effects of technological changes with respect to the dissemination of patient information, and take reasonable care when disclosing such information. Marriage and family therapists are also aware of the limitations regarding confidential transmission by Internet or electronic media and take extra care when transmitting or receiving such information via these mediums.
3.6: Marriage and family therapists actively strive to understand the diverse cultural backgrounds of their clients by gaining knowledge, personal awareness, and developing sensitivity and skills pertinent to working with a diverse client population. Marriage and family therapists who provide therapy over the Internet or by other electronic media take extra measures to identify and understand the diversity, ethnicity, and cultural sensitivity of such patients.
3.12: Marriage and family therapists initiate services by Internet or other electronic media to patients located only in jurisdictions where the therapist may lawfully provide such services.
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