Telehealth services have expanded extensively in the last few years. This can partly be attributed to the COVID-19 pandemic, the increasing number of Medicare item numbers dedicated to telehealth and the increasing utilisation of technology in society. This guide provides additional information for psychologists to consider when providing telehealth services.
Definitions
Telehealth utilises technology as an alternative to traditional, in-person, face-to-face service delivery. This can include text-based interactions, telephone-based services, or audio and visual (video) based services. Not all telehealth delivery methods are supported by all funding schemes or appropriate for all clients, so this needs to be clarified prior to service delivery.
Just because you can doesn’t mean you should… when is telehealth not appropriate?
With Australian health professionals and clients broadly embracing telehealth services, it is important to discuss when and where telehealth services might not be appropriate. These aspects may not require that face-to-face services be provided, but many necessitate accommodations to the usual processes or require consideration of the availability of appropriate resources to support the safe and effective use of telehealth, including:
- Where access to secure and reliable platforms is not available, or the client is unwilling to use these platforms.
- Where internet access is unreliable.
- Where disability, language spoken, or other factors are a barrier to accessing telehealth services.
- Where the client displays significant risks to self or others.
- Where there is a significant risk to the client if overheard by others during their counselling session, i.e., when there is family violence occurring.
- Where there is no opportunity for the client to have enough privacy to participate actively and safely in the session.
- Where the environment the client is in is too loud or distracting, resulting in the client becoming easily distracted and unable to complete therapy.
- Where the client does not consent to telehealth services or has a personal requirement for face-to-face services.
- Where services are provided to children who may not have the capacity to interact via telehealth services (i.e., selective mutism, very young age, disability, other impairment).
- Where there are limited social supports to ensure the safety of the client between sessions.
Ways to account for these challenges if face-to-face services are not appropriate or unable to be provided:
- Assess (and regularly re-assess) whether telehealth is safe and clinically appropriate for the patient or client, particularly noting the limitations of telehealth, and whether a direct physical examination is necessary.
- Changes can be made to the informed consent process, outlining the risks present in providing services via telehealth if secure platforms are not available or the client is unable to use these platforms.
- Where video technology is not available, have other ways available to assess the wellbeing of the client, as much can be missed during voice-only calls.
- Processes need to be in place to deal with interruptions to service provision, particularly when significant risks are present.
- Seeing clients with an extremely high level of distress and risk to themselves or others may not be appropriately cared for by practitioners in private practice. Therefore, it is important to assess whether the client is appropriately triaged to private practice or whether they need to be diverted to public/community mental health services where assertive outreach services can be provided to manage high levels of risk.
- Where services cannot be provided to children in person, telehealth services might be delivered to their caregiver, supporting appropriate care to the child (note – please check how this will impact funding schemes such as Medicare, private health or NDIS as appropriate).
Risk Management
Risk management processes need to be implemented with clients who present with significant risk and whom you have decided to see via telehealth. These should be created in partnership with clients and their support network and include details of next of kin/other supports who can be contacted in an emergent situation. They should also include:
- A risk management plan.
- Details of local services that can provide crisis support in the clients' local area.
- Detail what will happen if the client will not adequately answer questions about risk.
- Detail what will happen if technology failure occurs.
- Ensuring that you check where the client is physically located at the start of each session so that you can ensure help is available if needed during the session.
- Consider whether other local services can provide assistance or support to increase the safety of telehealth services. For example, some services provided by NDIS can offer more social supports for those that have inadequate support at home to maintain safety during telehealth services or allow access to treatment sessions provided via telehealth that they would have difficulty accessing otherwise due to disability or impairment.
Ethical Considerations
As per the Code of Ethics, psychologists need to consider the reasonably foreseeable outcomes of their actions and abide by Ahpra guidance around facilitating access to psychological treatment (Australian Health Practitioner Regulation Agency - Facilitating access to care in a COVID-19 environment: Guidance for health practitioners (ahpra.gov.au)).
Some clients may have no option but to access services via telehealth. Consultation with a senior practitioner is advised whenever making decisions with an ethical component, particularly around the safe management of client care where significant risks are present.
Assessment of suitability should be undertaken regularly rather than considered a once-off decision at the start of treatment. Clearly document your decision-making, should this require review, or you need to justify your position later.
At times you will need to terminate services with clients if improvements are not being made, the client is unsuitable for telehealth services, or you need to transfer them to other treatment services with more assertive care provision. It is important to engage in supervision with a senior colleague or supervisor if this occurs to ensure that you manage this situation in line with the Code of Ethics. It is important to also arrange for on-referral of clients who are not suitable for telehealth to ensure continuity of care.
The creation of policies and procedures about this is important to ensure there is consistency and that this is dealt with in the best possible way.
Informed consent
If you cannot provide a service to the same standard as an in-person consultation due to the limits of technology, then you must advise the client of this.
You need to inform clients about the limitations of telehealth services and the risks of using these platforms and apps with regard to their privacy and confidentiality. Clients should be provided with information about the policies and procedures that are involved in the provision of telehealth.
Examples are – privacy policies, complaints processes, record-keeping processes, risk assessment and management and data security processes.
AAPi has consent forms available for member use to ensure you are meeting the requirements of informed consent. Find these forms here.
You may also need to inform clients of the laws that related to your state or territory and their state or territory related to when you are required to breach their confidentiality and make a mandatory report.
It is important that the client is aware of what will occur if a service is disrupted due to technical failure or interception by another party. Part of the intake process should be setting expectations for communication between sessions and what other services are available to them.
Culturally safe and sensitive practice
Some cultures may have difficulty engaging with therapy via telehealth services. There may also be a need for interpreting services to be used during sessions that bring more complexity to the services provided and the ethical considerations. There are some free interpreting services available for allied health providers. Refer to the Australian Government Translating and Interpreting Services website. Some clients also have access to interpreting services through JobAccess or the NDIS.
It is important to be curious about a client's social, cultural or linguistic needs prior to the provision of telehealth services. It is important that services are modified to ensure the needs of the client are met through modifications to the telehealth process. It is important to be aware of and sensitive to the stressors experienced by clients of different cultural backgrounds. If you are not familiar with the needs of the cultural group your client belongs to, ensure you seek information and supervision around this to ensure that services are delivered appropriately and holistically.
Personal boundaries
It can be challenging when providing services via telehealth to ensure that personal boundaries are not relaxed. It is also important to consider the management of communication between sessions with clients seen via telehealth. The provision of telehealth can sometimes result in the boundaries of therapy being more fluid and difficult to manage.
If clients engage in telehealth within their homes, this may mean that you have exposure to other members of their families and their private spaces. They may feel more relaxed with regard to their clothing choices, and having therapy from unusual places like their bed or their car. They will also have visual knowledge of your spaces as well, and it is important to be mindful of this and ensure that they only have access to information about you and your spaces that is appropriate and professional.
The use of headphones and virtual background to ensure clients do not have information about your personal spaces if you are working from home is important, as are considerations of how you protect their privacy if there are other people in your workspace that may overhear conversations.
The same needs to be considered for the client. You will need to ensure that they are in a space that allows for privacy and confidentiality and that they are safe from interference from others.
Confidentiality and Safety Considerations
Clients need to know how to access emergency care out of session and that this may not be appropriate or possible for the clinician to provide (this is a great way to ensure practitioner burnout if there is no "off switch" from client care). Ensure that this is part of the onboarding process with clients so they are clear about where they can access support (i.e., provide details for Lifeline, suicide callback, MHCall, etc.) and when it is appropriate to communicate with their psychologist. Ensure that you do not attempt to provide a service that puts patient or client health or safety at risk.
Confirm with your clients at the start of each session that they have adequate privacy to have confidential conversations and check what risks might be present in their environment that may make telehealth services unsafe.
Risk assessment should be a regular part of telehealth service provision. As you may not be receiving information easily when clients are face-to-face, it is important to directly ask the client questions to assess their mental state.
Risk management plans need to be developed very early in the first session with this in mind so that should the client be at risk, steps can be put into place to ensure their safety. Ensuring you have details for their next of kin, GP, and other care providers is an important step. If the client will not provide these details, then thoroughly consider whether telehealth is appropriate given the risks present. Supervision with a senior colleague is highly recommended when navigating situations involving risk to a client. Other steps could be asking the client for their location at the start of the session in case you become aware of significant risk during the session. Developing a risk management plan in partnership with the client, outlining services that can be utilised between sessions and steps they can take, is also advised.
Ahpra provides these procedural steps to take when conducting telehealth-
At the beginning of a telehealth consultation:
- Identify yourself and confirm the identity of your patient or client.
- Provide an explanation to your patient or client of what to expect from a telehealth consultation.
- Ensure information is provided to your patient or client in a way they understand, and that informed consent is obtained, in particular, in relation to fees, proposed treatment, sharing of information with others in their care team and if you are recording the consultation.
- Ensure you protect your patient or client’s privacy and their rights to confidentially, particularly if you are working from home.
During a telehealth consultation:
- Ensure you effectively communicate with your patient or client to establish their current condition and past health and medication history.
- Use qualified language or cultural interpreters where needed.
- Use strategies and evidence-informed practices to reflect the standard of care expected in a face-to-face consultation, as far as possible.
- Ensure you maintain clear and accurate health records of the consultation.
Ensure continuity of care:
- Make appropriate arrangements to follow the progress of your patient or client and, with the consent of the patient or client, inform other relevant health practitioner(s) of the treatment provided, including any medications prescribed.
- Where appropriate, keep other practitioners informed of the patient or client’s condition and the treatment you have provided when you are sharing the care of the patient.
- Where direct physical examination is required to continue providing good care, support your patient or client to attend a face-to-face consultation.
Data Security
Free versions of applications (i.e. non-commercial versions) may not meet applicable laws for security and privacy. Practitioners must ensure that their chosen telecommunications solution meets their clinical requirements, their client’s needs and satisfies privacy laws.
Because you are transmitting personal information about clients when you engage in telehealth (the session could be intercepted/hacked), it is important to ensure you are meeting your legal obligations under the privacy and health records legislation of your state or territory. The best source of information is the Office of the Information Commissioner. This resource also outlines what steps you can take to protect the data you hold about clients.
If, for any reason, your records are accessed by someone unintended, you may need to make a notifiable data breach notification. More information about this can be found here. If you are unsure about the steps to take, please contact your indemnity insurer or AAPi.
There are some measures you can take to ensure you are protecting client data adequately. Ensuring you have security software installed and up to date on any devices you are using to provide telehealth services or communicate with clients, encrypting personal data on devices so that there is less risk of unauthorised access and using two-factor authentication are other measures that can be put in place to ensure the security of client data.
It is also important to maintain backups in a dedicated and secure location for all client data and ensure you keep contemporary records of telehealth services the client uses.
There are other circumstances you can avoid to reduce the risk to client data. One important one is to avoid using free wifi in public settings as this increases the risk of others accessing private client data due to the security settings used by these wifi providers.
Another is using paid versions of telehealth applications rather than the free versions, as security is often increased in the paid versions. If you are uncertain, please contact an IT advisor with experience in healthcare settings to audit your practices and put measures in place to protect client data.
It is also important to use separate devices or separate logins for business and personal use. This will ensure that others do not accidentally access client data or that personal information is accidentally shared with clients.
What about clients in different states or overseas?
Telehealth and technology-based consultations are increasingly used to improve access to health services, especially in rural and remote areas. If you are providing services to someone in a different state or territory to yourself, you need to adhere to the laws of your own state as well as those that relate to the state where they are located.
The same would apply if your client is overseas. Some countries require that psychologists are registered in that country in order to provide telehealth services in that country. You will need to check what the requirements are with each country you wish to provide services to, as well as check with your indemnity insurer to determine if you are covered for providing services in that country.
Your obligations under privacy laws are important to consider as well. Any country that you are providing services in needs to have equivalent laws or measures put into place to ensure data security.
Health practitioners currently based overseas who want to continue providing services to their patients in Australia are able to use technology to do so. Clients will not be able to access Medicare rebates or some other funding sources to cover their sessions if both parties (client and psychologist) are not physically located in Australia. It is important to advise clients of this in the informed consent process.
Ahpra – what do they require
If you are registered with the Psychology Board and are based overseas, Ahpra and the National Boards consider that you can still provide telehealth services to patients based in Australia. The Psychology Board has the same expectations of psychologists, regardless of whether they are providing a patient consult/patient service by telehealth or face-to-face. You need to abide by the Code of Ethics, as well as the Psychology Boards Regulatory Standards, when you provide telehealth services including:
- Act in accordance with the standards set out in your profession’s Code of conduct or equivalent, including expectations about confidentiality and privacy, informed consent, good care, communication, health records and culturally safe practice. Further information is provided below.
- Ensure you have appropriate professional indemnity insurance (PII) arrangements in place for all aspects of your practice, including telehealth consultations. Your PII provider can advise you about your PII coverage.
- You are aware of and comply with:
- state and territory legislative requirements including (but not limited to) authorities that regulate heath records;
- privacy legislation and/or any other relevant privacy requirements;
- any other relevant legislation and/or regulatory requirements.
Further resources regarding Telehealth:
AAPi has a range of on-demand webinars available here.
AAPi Telehealth resources can be found here.
AAPi Medicare Quick Reference Guide.
AHPA-Telehealth-Guide_Allied-Health-Professionals-May-2020.
Australian Health Practitioner Regulation Agency - Telehealth guidance for practitioners.
ACRRM How to do a high quality remote consultation.
Cyber security - Australian Digital Health Agency.
Australasian Telehealth Society.
Digital Health CRC.
SIRA Resources.
WorkSafe VIC Telehealth Item Codes.
Download this guide as a PDF.