The Informed Consent Process for Therapeutic Communication in Clinical Videoconferencing

Abstract

This chapter addresses important issues related to the process and content of informed consent when providing services via clinical videoconferencing (CV). Relevant differences between in-person services and CV services are highlighted for modifying the informed consent form (ICF) and process. ICF modifications are also considered regarding the various settings and contexts within CV services. The chapter also highlights helpful ground rules for communication in CV contexts.

Appendices

Conclusion

The growing demand for mental health care in both rural and urban settings, coupled with the rapid gains in videoconferencing technologies, suggests that treatments via CV will continue to expand as a modality for mental health services. Fortunately, the bulk of the extant literature indicates that treatments by CV are generally as good as in person treatments with regard to symptom improvement, satisfaction , and therapeutic alliance , among other issues [4]. For those of us who are passionate about increasing access to mental health services, the future of CV looks promising. However, the path toward this novel territory should be approached thoughtfully. The informed consent process is central to properly guiding expectations, and it provides the perfect opportunity to provide information about problems that may be unlikely and yet have the potential for confusion or harm. Conducting the informed consent process early, and referring to it throughout treatment, is the optimal way to initiate and maintain good communication in the therapeutic context.

Appendix 7.A: Office-based Clinical Videoconferencing Informed Consent Template

[Note: These templates describe a treatment for PTSD, but any treatment for any disorder may be described.]

• Jane Doe, Ph.D.

• Center for the Treatment of Psychological Disorders

• 100 Sunshine Drive

• San Diego, CA 92013

Informed Consent for Treatment

2.1 Overview of Services

I understand that the purpose of the treatment that Dr. Doe will be providing to me is to help reduce my posttraumatic stress disorder (PTSD) symptoms. Dr. Doe will be using Cognitive Processing Therapy (CPT), a treatment that has been shown to be effective at reducing PTSD symptoms. The purpose of CPT is to help identify negative thoughts that I am having about myself, the world, and others after experiencing the traumatic event. I understand that Dr. Doe and I will be working together on evaluating thoughts related to my traumatic event. I understand that I may experience an increase in anxiety and other symptoms at the beginning of treatment but that Dr. Doe will monitor this with me. I understand that I will be responsible for completing weekly practice assignments that I will have sessions via clinical video (CV) with Dr. Doe. CV includes the use of videoconferencing technology over a computer screen to meet with Dr. Doe. I understand that Dr. Doe will assist me with managing any distress that I may have and will work with me to try to improve my PTSD symptoms. I understand that I am expected to actively engage in the therapy in order to receive the most benefit.

I understand that I will be meeting with Dr. Doe over the next 12 weeks on Mondays at 3 p.m. via CV software. I understand that I will go to the local Center for the Treatment of Psychological Disorders office and use the CV equipment that is in the office, and that Dr. Doe will be at a different site of the Center for Treatment of Psychological Disorders. So, we will be meeting via CV and not in-person. I understand that I can ask the front desk staff or other support person for help using the CV equipment if there are any technological problems.

I understand that I can reach Dr. Doe at her office between the hours of 9 am and 5 pm, Monday through Friday at (555) 555-5555. Also, I understand that I can call Dr. Doe on her cell phone for non-emergencies (e.g., scheduling issues) after these hours and on weekends at (444) 444-4444. I acknowledge that Dr. Doe prefers to communicate over the phone and does not use personal e-mail with clients. Additionally, I understand that I should call 911 in the case of emergency, such as if I am having thoughts of harming myself or others.

2.2 Risks and Benefits

I understand that when engaging in psychological treatment, there may not be benefits to me. However, I may end up experiencing an increase in my mental health and overall well-being. I understand that CPT could help decrease my PTSD symptoms and I could feel better. I understand that I may initially experience greater distress because I am talking about my traumatic event. However, I understand that Dr. Doe will help me work through this distress.

I understand that the use of CV for psychological treatment may have some limits of confidentiality . I understand that third parties could access information shared via CV without Dr. Doe or I knowing (e.g., if someone hacks into the computer system or server). However, Dr. Doe and the Center for the Treatment of Psychological Disorders have installed encryption software (i.e., software that allows only the intended recipient to view information) to help protect information that is shared via CV. All software complies with national and state laws (including HIPAA compliance) to protect information shared via CV.

I understand that CV can result in technological difficulties, such as dropped calls , frozen images, pixilated images, lack of sound, or distorted sound. Dr. Doe and I have agreed that if the CV equipment fails during therapy sessions, she will call me on the phone in the therapy room that I am in and we will finish the session over the phone. Dr. Doe and I have also agreed that if the CV equipment fails more than twice, we will meet in person so that I can have the best care possible.

2.3 Confidentiality

I understand that Dr. Doe will keep all of our conversations confidential, but that she must follow mandatory reported laws. I understand that if I reveal any information about child or elder abuse, Dr. Doe will need to report it. I understand that if I reveal any information that I am going to harm myself or others, Dr. Doe will need to report it.

I understand that only Dr. Doe and authorized staff members will have access to my files. Dr. Doe will keep all of my files stored in a locked cabinet in the office so that only she and authorized staff can access them.

2.4 Transmission of Patient Information

I understand that I am not to e-mail any personal information to Dr. Doe or any other staff, but instead I will call Dr. Doe and complete any forms in-person. Dr. Doe will not be audio- or video recording any of my sessions. I agree to tell Dr. Doe if I would like to audio record my therapy sessions. However, I agree to not share these audio recordings online or with the public. Dr. Doe will be documenting weekly clinical progress notes and I understand that I may request to see these. I understand that clinical progress notes will include a summary of my treatment sessions, mental status information, diagnoses, and treatment plans. Dr. Doe may need to fax forms to a different clinical site within the Center for the Treatment of Psychological Disorders, but she will use a cover sheet that states the information is confidential. I understand that both fax machines will be located in locked offices that only staff can access.

2.5 Emergency Plans and Safety

Dr. Doe and I have agreed that in between sessions, if I am in an emergency (e.g., feel like harming myself or others), I will call 911 immediately. If I am engaging in a CV therapy session and I feel particularly distressed, I agree to tell Dr. Doe and notify on-site staff to help me. I also understand that if there is a technological emergency (e.g., CV equipment failing) that Dr. Doe will call me on the office phone where I am located.

2.6 Termination or Changes in Care

I understand that all participation in services is voluntary and that I may decide to end care at any time without penalty (the decision will not affect my ability to access future services). I also understand that once I have completed the 12 weeks of CPT, Dr. Doe may decide to end therapy if my PTSD symptoms have improved. However, if she believes that I need additional sessions, we will continue to meet weekly via CV. I understand that if Dr. Doe believes that more intensive services are needed (e.g., inpatient) that we will stop therapy via CV and will make other arrangements. Dr. Doe will end care if she believes it is in my best interest (e.g., my symptoms are getting worse or the treatment is harmful). Also, I understand that if I skip more than four therapy sessions without notice, Dr. Doe may not provide therapy to me any longer and will give me a referral to another provider.

2.7 Billing and Insurance

Dr. Doe accepts Blue Cross Blue Shield and United Healthcare insurance . I have already confirmed that Dr. Doe is an approved provider within my insurance network and I realize that I am responsible for paying the copay of $ 20 at each therapy session. If Dr. Doe is not an approved provider through my insurance company, I do not have insurance, or I am choosing not to use insurance to cover these services, I agree to pay the full cost for these services out of pocket at each session at $ XXX per session. The staff at the clinic will provide me with a receipt of my payment for my records. Dr. Doe may use a sliding fee scale for individuals who have low-income or extenuating circumstances. If I think that I may be eligible for the sliding fee scale, I should discuss this with Dr. Doe prior to my first therapy appointment. Individuals who earn less than $ XXXX per year (before taxes) or are currently experiencing financial hardship (e.g., chronic illness, medical bills, unemployment) may be eligible.

2.8 Other Information

I agree to give Dr. Doe 24 h notice if I need to cancel or reschedule an appointment. Dr. Doe agrees to waive the fee for the first missed appointment without notice. However, if I miss a second appointment without notice, I will be responsible for the $ XXX hourly fee. I agree to pay this fee if I do not provide 24 h notice to Dr. Doe before cancelling. I can contact the office at (555) 555-5555 if I need to cancel or reschedule.

2.9 Voluntary

I am aware that my participation in therapy with Dr. Doe is completely voluntary. I understand that I can end services at any time without penalty and that Dr. Doe will work with me to provide another referral, if desired.

2.10 Client Consent to Services

[If the person consenting is the person receiving services]: I, (insert patient name), have read this entire document and have had the opportunity to ask any questions. I acknowledge all content in this document. I understand the limits of confidentiality when using CV and when required to report by law. I agree to pay my $ 20 copay at each therapy session, at the time of services. I agree that I may end therapy at any time and may refuse to participate in any portions of the therapy.

[If the person consenting is a PROXY]: I have signed this consent agreement on behalf of a person who may be temporarily or permanently incompetent, unable to sign, or a minor, I represent that I have the authority to sign this consent agreement on behalf of this person. This use of the first person in this consent agreement shall include me, and the person for whom I am representing.

I have read and understand the information provided above regarding treatment, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the participation in this treatment.

Appendix 7.B: In-Home Clinical Videoconferencing Informed Consent Template

[Note: This is a modified version of the in-office template. This version includes specific language that is unique to in-home CV.]

• Jane Doe, PhD

• Center for the Treatment of Psychological Disorders

• 100 Sunshine Drive

• San Diego, CA 92013

Informed Consent for Treatment

3.1 Overview of Services

I understand that the purpose of the treatment that Dr. Doe will be providing to me is to help reduce my posttraumatic stress disorder (PTSD) symptoms. Dr. Doe will be using cognitive processing therapy (CPT), a treatment that has been shown to be effective at reducing PTSD symptoms. The purpose of CPT is to help identify negative thoughts that I am having about myself, the world, and others after experiencing the traumatic event. I understand that Dr. Doe and I will be working together on evaluating thoughts related to my traumatic event. I understand that I may experience an increase in anxiety and other symptoms at the beginning of treatment but that Dr. Doe will work through these symptoms with me. I understand that I will be responsible for completing weekly practice assignments that I will discuss via clinical video (CV) with Dr. Doe. I understand that Dr. Doe will assist me with managing any distress that I may have and will work with me to try to improve my PTSD symptoms. I understand that I am expected to actively engage in the therapy in order to receive the most benefit.

I understand that I will be meeting with Dr. Doe over the next 12 weeks on Mondays at 3 pm via CV software. CV includes the use of videoconferencing technology over a computer screen to meet with Dr. Doe. I understand that I will be responsible for providing the CV equipment (e.g., webcam, microphone and speakers) , installing the CV equipment onto my home computer prior to my first therapy session. If for some reason the CV technology does not work or I have problems, I will call the clinic staff for help over the phone. However, I understand that the staff is unable to provide me help in person. I acknowledge that I may encounter technological difficulties when trying to install the software when using CV throughout therapy and I agree to work with Dr. Doe to fix any problems that arise (e.g., dropped calls, frozen images) . I understand that Dr. Doe will be at the Center for Treatment of Psychological Disorders, so we will be meeting via CV and not in-person.

I have agreed to treat therapy via CV the same way that I would treat in-person therapy. This agreement includes but is not limited to: appropriate dress (e.g., as if I were being seen in a public clinic), 24 h cancellation notice, active engagement in therapy (e.g., not checking emails or surfing the web during session), etc. I have agreed that I will place any pets that I have in a separate room prior to the start of each session so that I am not distracted during therapy. I confirm that I will be in a private room during therapy and that I have asked for my family and friends to not enter the room while I am in session. I agree to work with Dr. Doe in ensuring that my privacy is protected both via CV and in my home because of the sensitive topics that we may discuss during therapy sessions.

I understand that I can reach Dr. Doe at her office between the hours of 9 am. and 5 pm., Monday through Friday at (555) 555-5555. Also, I understand that I can call Dr. Doe on her cell phone for non-emergencies (e.g., scheduling issues) after these hours and on weekends at (444) 444-4444. I acknowledge that Dr. Doe prefers to communicate over the phone and does not use personal e-mail with clients. Additionally, I understand that I should call 911 in the case of emergency, such as if I am having thoughts of harming myself or others.

3.2 Risks and Benefits

I understand that when engaging in psychological treatment, there may not be benefits to me. However, I may end up experiencing an increase in my mental health and overall well-being. I understand that CPT could help decrease my PTSD symptoms and I could feel better. I understand that I may initially experience greater distress because I am talking about my traumatic event. However, I understand that Dr. Doe will help me work through this distress.

I understand that the use of CV for psychological treatment may have some limits of confidentiality. Also, I acknowledge that third parties could access information shared via CV without Dr. Doe or I knowing (e.g., if someone hacks into the computer system or server). However, Dr. Doe, Center for the Treatment of Psychological Disorders and I have all installed encryption (i.e., software that allows only the intended recipient to view information) to help protect information that is shared via CV. All software complies with national and state laws (including HIPAA compliance) to protect information shared via CV.

I understand that CV can result in technological difficulties, such as dropped calls , frozen images, pixilated images, lack of sound, or distorted sound. Dr. Doe and I have agreed that if the CV equipment fails during therapy sessions and cannot be fixed in less than 5 min, she will call me on my cell phone and we will finish the session over the phone. Dr. Doe and I have also agreed that if the CV equipment fails more than twice, we will meet in person so that I can have the best care possible. I understand that I am responsible for fixing any problems that my internet, computer, or CV equipment is having and that staff will not be able to assist me in person.

3.3 Confidentiality

I understand that Dr. Doe will keep all of our conversations confidential, but that she must follow mandatory reported laws . I understand that if I reveal any information about child or elder abuse, Dr. Doe will need to report it. I understand that if I reveal any information that I am going to harm myself or others, Dr. Doe will need to report it.

I understand that only Dr. Doe and authorized staff members will have access to my files. Dr. Doe will keep all of my files stored in a locked cabinet in the office so that only she and authorized staff can access them. I am aware that I can request to see Dr. Doe’s clinical progress notes about me at any time.

3.4 Transmission of Patient Information

I understand that I am not to e-mail any personal information to Dr. Doe or any other staff, but instead I will fill out electronic versions of any questionnaires that Dr. Doe may have for me. I understand that these electronic files are located and saved on a secure portal that only the staff at the Center for the Treatment of Psychological Disorders can access. I recognize that Dr. Doe will not be audio- or video recording any of my sessions. I agree to tell Dr. Doe if I would like to audio or video record my therapy sessions. However, I agree to not share these audio or video recordings online or with the public. Dr. Doe will be documenting weekly clinical progress notes and I understand that I may ask to see these at any time. I understand that clinical progress notes will include a summary of my treatment sessions, mental status information, diagnoses, and treatment plans.

3.5 Emergency Plans and Safety

Dr. Doe and I have agreed that if I am in an emergency (e.g., feel like harming myself or others) in-between sessions that I will call 911 . I recognize that because I am in my own home and not in a mental health clinic, Dr. Doe and staff will not be able to readily assist me in-person if I become particularly distressed during a session. Therefore, I understand that if I am engaging in a CV therapy session and I feel particularly distressed, I will tell Dr. Doe so that she can contact local emergency personnel, if needed. I have given Dr. Doe my most recent address so that she can identify the local emergency staff and I understand that she will have this information readily available at all times during sessions. I agree to tell Dr. Doe if my address should change so that she can update the information and identify different emergency resources, if needed. I understand that if there is a technological emergency (e.g., CV equipment failing) that Dr. Doe will call me my cell phone where I am located.

3.6 Termination or Changes in Care

I understand that all participation in services is voluntary and that I may decide to end care at any time without penalty (or the decision affecting future services). I also understand that once I have completed the 12 weeks of CPT, Dr. Doe may decide to end therapy if my PTSD symptoms have improved. However, if she believes that I need additional sessions, we will continue to meet weekly via CV. I understand that if Dr. Doe believes that more intensive services are needed (e.g., inpatient) that we will stop therapy via CV and will make other arrangements. Dr. Doe will end care if she believes it is in my best interest (e.g., my symptoms are getting worse or the treatment is harmful). Also, I understand that if I skip more than four therapy sessions without notice, Dr. Doe may not provide therapy to me any longer and will give me a referral to another provider.

3.7 Billing and Insurance

Dr. Doe accepts Blue Cross Blue Shield and United Healthcare insurance . I have already confirmed that Dr. Doe is an approved provider within my insurance network and I realize that I am responsible for paying the copay of $ 20 at each therapy session. If Dr. Doe is not an approved provider through my insurance company, I do not have insurance, or I am choosing not to use insurance to cover these services, I agree to pay the full cost for these services out of pocket at each session at $ XXX per session. I will pay at the end of each therapy session via the secure online portal (the same one that is used to fill out questionnaires). If for some reason I cannot process the transaction online, I agree to send a check via postal mail to the office. I recognize that the online portal will provide me with a printable receipt of payment for my records. I recognize that Dr. Doe may use a sliding fee scale for individuals who have low-income or extenuating circumstances. If I think that I may be eligible for the sliding fee scale, I should discuss this with Dr. Doe prior to my first therapy appointment. Individuals who earn less than $ XXXX per year (before taxes) or are currently experiencing financial hardship (e.g., chronic illness, medical bills, temporary unemployment) may be eligible for the sliding fee scale.

3.8 Other Information

I agree to give Dr. Doe 24 h notice if I need to cancel or reschedule an appointment. Dr. Doe agrees to waive the fee for the first missed appointment without notice. However, if I miss a second appointment without notice, I will be responsible for the $ XXX hourly fee. I agree to pay this fee if I do not provide 24 h notice to Dr. Doe before cancelling. I can contact the office at (555) 555-5555 if I need to cancel or reschedule. If I miss more than four appointments without notice, Dr. Doe may discontinue therapy with me.

3.9 Voluntary

I am aware that my participation in therapy with Dr. Doe is completely voluntary. I understand that I can end services at any time without penalty and that Dr. Doe will work with me to provide another referral, if desired.

3.10 Client Consent to Services

[If the person consenting is the person receiving services]: I, (insert patient name), have read this entire document and have had the opportunity to ask any questions. I acknowledge all content in this document. I understand the limits of confidentiality when using CV and when required to report by law. I recognize that I am responsible for installing the CV software onto my computer and fixing any problems that come up. I agree to pay my $ 20 copay at the end of each therapy session via the online portal and will mail a check if needed. I acknowledge that I may end therapy at any time and may refuse to participate in any portions of the therapy.

[If the person consenting is a PROXY]: I have signed this consent agreement on behalf of a person who may be temporarily or permanently incompetent, unable to sign, or a minor, I represent that I have the authority to sign this consent agreement on behalf of this person. This use of the first person in this consent agreement shall include me, and the person for whom I am representing.

I have read and understand the information provided above regarding treatment for PTSD, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the participation in this study.

Appendix 7.C: Issues to Address During Initial Contact with Patients Regarding Clinical Videoconferencing Services (Prior to the Informed Consent Process)

The informed consent process will include a more in-depth review of issues related to clinic videoconferencing but potential patients should be primed regarding the relevant issues relating to CV during the initial contact. The person initiating contact with the patient should:

• A. Describe CV.

  It should be clear that patients will communicate in real-time with the therapist via videoconferencing.

• B. Describe where CV will be conducted.

  • 1. Provider-side settings often include clinic office or home.

  • 2. Patient-side settings often include clinic office, home, work, or other community setting.

• C. Describe how CV might be integrated into care.

  • 1. For example:

    • a. Staged care beginning with in-person services and transitioning to CV, 100 % CV services.

    • b. CV as an occasional or planned supplement to face-to-face care.

• D. Provide risks and benefits of CV.

  • 1. Commonly identified benefits include:

    • c. Patient convenience, cost-savings, privacy, and flexibility of scheduling.

  • 2. Commonly identified risks include:

    • a. Potential threats to data privacy, potential disruptions in the signal and communication, and getting use to a new way of interacting.

  • 3. For home-based CV risks also include:

    • a. Lack of available on-site emergency personnel, and a potential to collude with existing patient avoidance or isolation.

• E. Describe the eligibility requirements and assess suitability for CV services.

  • 1. Potential considerations include:

    • b. Significant cognitive deficits (dementia, developmental deficits).

    • c. High-risk behaviors (imminently suicidal/homicidal, i.e., more than ideation).

    • d. History of intoxication during treatment sessions.

    • e. Acute psychosis or mania.

    • f. History of delusions regarding thought broadcasting via technology.

    • g. Sensory deficits that would preclude ability to initiate or communicate via CV.

Appendix 7.D: Checklist: Content to Include in Informed Consent Forms for Clinical Videoconferencing

[Note: The items below should be written in language that is easily understood and consistent with legal requirements and accepted professional standards.]

• A. Define what CV consists of and how it differs from in-person care

• B. Provide the structure of services

• C. Provider and patient expectations

  • 1. Role of provider and patient in services

  • 2. Boundaries

  • 3. State when and how provider will respond to routine electronic messages

  • 4. In-between session contact

• D. Acknowledge potential risks and benefits of care provided through CV

  • 1. Explain potential technological problems (e.g., unpredictable disruption of services)

  • 2. Identify alternative means of re-establishing communication in the event services are disrupted (e.g., another form of electronic communication; telephone)

  • 3. Note whether CV programs and services are fully HIPAA-compliant

• E. Inform the client about confidentiality and limits to confidentiality

  • 1. Advise client about mandatory reporting laws

  • 2. Clarify who else may have access to communications between provider and client

  • 3. Detail safeguards used to protect against risk related to CV

    • a. Methods utilized to ensure that only intended recipients (e.g., provider) have access to client information (e.g., encryption, portals)

• F. Communicate how data will be transmitted and stored

  • 1. Indicate whether or not sessions will be recorded

  • 2. Describe how client information will be documented (e.g., clinical notes)

  • 3. Convey how provider stores electronic communications exchanged with the client

• G. Instruct the client regarding emergency contact information

  • 1. Present emergency plans

  • 2. Establish alternative means of communication under emergency circumstances

• H. Discuss possible changes in care

  • 1. Outline conditions of care delivered through CV

  • 2. List alternative services in the event CV is no longer an appropriate delivery of care

  • 3. Notify the client that they have the right to end treatment without penalty of care

• I. Billing and Insurance

  • 1. Overview how all billing and insurance will be handled

• J. Voluntary

  • 1. Inform patient that all care is voluntary and that the patient has the right to end care without penalty

• K. Define what CV consists of and how it differs from in-person care

• L. Provide the structure of services

• M. Provider and patient expectations

  • 1. Role of provider and patient in services

  • 2. Boundaries

  • 3. State when and how provider will respond to routine electronic messages

  • 4. In-between session contact

• N. Acknowledge potential risks and benefits of care provided through CV

  • 1. Explain potential technological problems (e.g., disruption of services)

  • 2. Identify alternative means of re-establishing communication in the event services are disrupted (e.g., another form of electronic communication; telephone)

  • 3. Note whether CV programs and services are fully HIPAA-compliant

• O. Inform the client about confidentiality and limits to confidentiality

  • 1. Advise client about mandatory reporting laws

  • 2. Clarify who else may have access to communications between provider and client

  • 3. Detail safeguards used to protect against risk related to CV

    • a. Methods utilized to ensure that only intended recipients (e.g., provider) have access to client information (e.g., encryption, portals)

• P. Communicate how data will be transmitted and stored

  • 1. Indicate whether or not sessions will be recorded

  • 2. Describe how client information will be documented (e.g., clinical notes)

  • 3. Convey how provider stores electronic communications exchanged with the client

• Q. Instruct the client regarding emergency contact information

  • 1. Present emergency plans

  • 2. Establish alternative means of communication under emergency circumstances

• R. Discuss possible changes in care

  • 1. Outline conditions of care delivered through CV

  • 2. List alternative services in the event CV is no longer an appropriate delivery of care

  • 3. Notify the client that they have the right to end treatment without penalty of care

• S. Billing and Insurance

  • 1. Overview how all billing and insurance will be handled

• T. Voluntary

  • 1. Inform patient that all care is voluntary and that the patient has the right to end care without penalty

Appendix 7.E: Telemedicine Informed Consent Laws

Many US states do not have statutes and regulations specific to CV. However, several states do have statutes and regulations for telemedicine provision, including those involving informed consent. In states without specific CV statues and regulations, providers offering these services can ensure that their practices are HIPAA-compliant and may consult APA ethical guidelines for further guidance. For providers who practice in states with legal statutes guiding telemedicine provision, they should be aware of relevant statues and adhere to them when providing care through videoconferencing. With regard to informed consent , it is important to be aware of any requirements for this process. For example, whether written, verbal, or both forms of consent are required prior to beginning services delivered via CV. Furthermore, determining if electronic signatures are permitted to provide informed consent is also a consideration.

The resources provided here offer a brief overview of CV laws by state; however, due to the evolving nature of CV and related laws, this resource should not be used as a definitive source. Providers should independently verify information, contact their respective state licensing board, and/or contact legal counsel to access the most up-to-date statutes and regulations. For more information about telemedicine laws please visit:

APA—State laws for telemedicine and teleconferencing

http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf

Accessed: 29 Oct. 2013

Appendix 7.F: Clinical Note Template for Documenting Initiation of CV Services

[Note: The following is an example of a clinical progress note written by a Veteran’s Affairs (VA) provider. The note documents services that were provided via office-to-office CV.]

7.1 Clinical Video (CV) from Therapist’s Office to Community Based Outpatient Clinic (CBOC):

Appointment was conducted via CV. Veteran was located at [FILL IN LOCATION], where in-person clinicians were available to join the appointment in case of emergency. The provider was located at [FILL IN LOCATION].

At the outset of this appointment, Veteran was provided with the following information:

• 1. The nature of CV health and its benefits and risks

• 2. Confidentiality and its limits

• 3. The emergency plan, which has been established and agreed upon with the CBOC

• 4. Time-limited, evidence based therapy options available via CV

• 5. Alternative, non CV, therapy options

• 6. The importance of consistent therapy attendance and homework completion

The Veteran provided verbal consent to the above items.

Appendix 7.G: Lessons Learned

The purpose of this section is to provide useful examples of “lessons learned” from the authors’ use of CV in research trials and clinical care.

8.1 Computer Equipment Knowledge and Resources

Patients who are interested in CV treatment are often concerned about obtaining the equipment necessary for in-home CV . More specifically, patients tend to express concern regarding their ability to obtain a computer and their level of computer knowledge. Therefore, providers should be aware that for home-based CV, some patients may not be able to engage in treatment due to a lack of resources (e.g., webcam, computer, fast internet). For example, a patient dropped out of one research study because the study could not provide CV equipment. If the patient is unable to provide the necessary resources for in-home CV, then the provider and patient should come up with an alternative plan for treatment.

8.2 Technological Issues

It is important for therapists to properly orient themselves to CV equipment (monitor, camera, and remote) and to have technical and administrative support at each site to help facilitate the process for both providers and patients. Monitoring the call quality and dropped calls can be useful in case the bandwidth needs to be adjusted at each site. When all else fails, re-booting the equipment often solves problems. Technological issues are one of the main risks of CV .

8.3 Privacy

Prior to engaging in in-home CV services, the provider will discuss with the patient the importance of a quiet, private place to set up for sessions as well as what type of internet connection is necessary. For example, one patient agreed to find a quiet, private place for in-home CV sessions but when he connected with provider he was in his car. The car was parked, but the patient was using free Wi-Fi from a nearby restaurant. This session was discontinued and the provider discussed with the patient the limitations of public internet connections and the lack of privacy. Another patient connected to CV from a booth in a restaurant and told the provider, “I have on a headset and no one can see the screen, so I am ok with it.” Needless to say, the provider discontinued the session and re-visited the informed consent and importance of privacy.

8.4 In-Home CV

During the third session with a patient, the patient logged into CV to connect with the provider and was wearing only a bathrobe and had disheveled hair. The provider requested the patient disconnect and dress appropriately prior to engaging in session. When patients call in from the comfort of their home, they may be more casually dressed. It is important for the provider to set expectations about appropriate dress prior to engaging in session. Additionally, when conducting a session with a patient using in-home CV , unexpected visitors may show up or enter the room that the patient is in. Similarly, clinicians have started videoconferencing sessions only to discover later that young children who need supervision are in the room and that no other form of childcare is available, or that family members are nearby and are unwilling or unable to leave. The provider and patient should discuss a plan about how to handle possible interruptions, privacy, and the presence of other family members prior to beginning services. It may be helpful to tell clients that they should be alone in a room for the duration of the service unless special circumstances warrant another person in the room (e.g., couples therapy, exposure treatments that involve other people).

Sometimes interruptions are unavoidable even when they are discussed. During one session, as we noted earlier in this chapter, a patient’s dog ran into the room and jumped on the computer keyboard, disconnecting the session. The situation was resolved when the patient reconnected to the provider and plans were made to have the dog in another room during session. Another provider had a different experience with a pet. During an early Exposure and Response Prevention treatment session delivered via in-home CV, a patient diagnosed with obsessive-compulsive disorder was engaging in a challenging exposure. During the course of the exposure, it became clear that the patient was distracted by something in the room. When the clinician asked the patient what she was looking at, the patient turned her screen to show her dog standing at her feet. The patient reported that she had been petting the dog through all previous exposures because it was more comforting and eased the anxiety caused by the exposure. As the clinician had a limited view of the room, she was unable to see that the client was engaging in this new compulsion. It is important for providers to educate patients about how the presence of animals in the room can impact the services. As noted in Backhaus et al. (2012), the limited scope of the camera with CV (usually the head and shoulders of each person) can also block views of wheelchairs or fidgeting.

It is important to have a conversation about expectations for the patient during in-home CV sessions. For example, one patient was editing unrelated documents on the computer during a session, a different patient was texting during the session, and another would prepare his lunch at the beginning of the session. Similar situations and other unexpected events are bound to happen and add to the clinical richness of the situation. In an effort to minimize some of these events, the informed consent process and in depth discussion of appropriate treatment boundaries are necessary prior to the start of services.

The ease of in-home CV also has drawbacks. Patients sometimes display a reduced commitment to treatment or are more apt to cancel a session last minute, as there is often less planning needed to attend a CV session (in comparison to having to visit a local clinic or office). It may be helpful to include a clause in the consent that encourages clients to regard each session as though it were an in-person office visit (e.g., requiring 24 h notice for cancellations) and to emphasize the importance of treating these sessions as though they were occurring in an external environment. Given these experiences, it may be helpful to add a short section in the informed consent that provides guidelines for an appropriate therapeutic environment during sessions (as we have described in our templates, above).