My state board recently sent out a great request for feedback. They want to know counselors' thoughts on whether or not telehealth flexibility implemented for COVID-19 should be extended. I have to imagine other states are considering extending rules regarding telehealth flexibility as well. My opinion is a resounding yes to not only extending these provisions, but to making them permanent. The use of technology is growing in our profession, and I believe we will need to understand and utilize technology more often and more effectively. This post has elements that are admittedly technical. I believe it has to explain some of the technology challenges we may face in the near future. While the items discussed here arise from my state’s laws, the same considerations exist in many other states as well.
Initial Face-to-Face Meetings
One item up for possible extension is reducing the need for an initial face-to-face meeting. I cannot count how many clients who worked with me remotely said they would not have been able to do so if they had to make a single two to three hour trip for an initial visit, followed by the same distance back. Since I was working with a niche client base at the time, telehealth allowed these clients to find available services that may have been difficult to find otherwise.
Some female clients have admitted they would not have met with a man they didn’t know (me, or any other man) alone in an enclosed office for the first time, but were happy to videoconference. Some clients do not have access to reliable transportation. Other challenges like lacking stable or permanent housing can make a face-to-face meeting difficult for some of the most marginalized members of society.
To be fair, some states (including mine) consider a videoconference as a face-to-face meeting. At the same time, not all clients have access to a device and high-speed internet. These situations notwithstanding, and given that counseling is a profession built on evidence-based practice, I wonder what evidence exists that initial face-to-face meetings lead to improved outcomes? What, if any, evidence exists that clients have been harmed as a result of counselors conducting telehealth without a face-to-face meeting? One could argue that a licensed counselor, by training, possesses the clinical judgment to make a case-by-case decision as to whether an initial telehealth session is appropriate within the first few minutes of that first session.
Treatment Without Written Consent
Another item up for discussion is extending the ability to conduct treatment without first obtaining written consent. More than 20 years ago, electronic signatures were adopted as equivalent to written signatures. Even at that time, a person could withdraw large sums of money from many financial providers with a username, password, and by typing in their initials. The use of and acceptance of digital signatures has only grown exponentially. It would make sense to me for digital signatures to be treated with the same respect as print signatures. Could a minor not easily download intake paperwork and forge an adult’s signature? How many clients who provide written or digital consent actually read what they are signing? At least with digital consent, it is possible to make sure a client has scrolled through an entire document before signing. We still have verbal informed consent to ensure that clients have stated they have read and understand their rights and limitations and to remind them of key provisions.
Exceeding Health and Human Services Technology Guidelines
The final item being assessed is whether to temporarily remove the requirement that clinicians provide a HIPAA-compliant platform that exceeds current U.S. Department of Health and Human Services guidance. To provide some context and background that will inform my response, my first career was in information technology. I worked a fair amount with security. I was trained to understand many of the tricks criminal hackers use to break into systems in order to prevent that criminal behavior. HIPAA-compliant platforms have rigid and strong security and testing requirements.
While no computer system can be guaranteed to be impenetrable, HIPPA-compliant systems are some of the most secure in the world when used properly (e.g. If a client yells in their house during a telehealth session and their family or neighbors can hear them, no computer system can stop that). My first question is why would exceeding the U.S. Department of Health and Human Services guidance have been put into law in the first place? Has anyone broken into a HIPAA-compliant videoconferencing system during the pandemic to listen in on a counseling session?
Technology isn’t perfect, but much of what we hear about in the news as far as security concerns are related to cyberattacks against large companies to obtain credit card numbers. Are there a large number of criminals with the means and desire to break into an ultra-secure HIPAA-compliant system to hear about someone’s anxiety or depression? If I walk through my building and find it difficult to avoid hearing parts of some mental health professional’s sessions as a result of thin walls, loud clients (and counselors), or overly quiet sound machines. I would argue that a physical counseling waiting room provides significantly less security than a HIPPA-compliant electronic platform such as Doxy. For example, one client could easily run into a neighbor in a waiting room who wonders why they are in a counseling office or chooses to gossip to others.
Understandably, many people do not have in-depth knowledge of technology. We tend to fear what we don’t understand. I wonder if this fear factors into some of our counseling laws? Experience also tells me that security experts (who may have been consulted as part of creating these laws) tend to err on the sign of extreme caution, as they tend to only see the problems and think about preventing the worst for a living.
My take is that technology is far from perfect but can be our friend. I believe if we look at the evidence of technology risks and weigh them against the benefits or compare them to risks that also come from not using technology, we will find there is much less to fear. What do you think? Should the flexibility granted to help us provide telehealth and teletherapy during COVID-19 be extended? Should they be extended permanently? Given how fast technology can change, do laws and ethics related to technology need to be updated much more frequently?
Aaron Engel is a professional counselor in Columbus, OH. He works primarily with couples and individuals wanting help with depression, anxiety, and career concerns. As a private practice owner, Aaron strives to provide excellent care with every aspect of the counseling experience. Learn more about him and the services he provides at https://cardinalpointcounseling.com