I recently read an article entitled Google’s Email Security Change does not make Online Counseling Secure. I was interested in the article because I was aware of Google’s recent change to an HTTPS default setting for Gmail. And I agree with the writer of the article that this is not a HIPAA compliant service since the HTTPS simply means that when you login to your Gmail account, you are more secure, particularly if you are logging in from a wifi hot spot. It does not mean however, that emails sent from a Gmail account are encrypted as explained in this WIRED article entitled  Google Turns on Gmail Encryption to Protect Wi-Fi Users.

So I thought I would go to the source- at least the most accurate source I know of- to give us all  the answers.

For years I have used Hushmail email services with clients to ensure my email exchanges are encrypted. The service is easy and affordable. In fact Hushmail offers a free account too. That can be handy if a client only needs an account temporarily while working with a therapist online.  The service is HIPAA compliant and Hushmail is willing to sign a HIPAA Business Associate Agreement (required in the United States). The agreement means that any 3rd parties that may be privy to confidential client information understand their responsibility to keep the information confidential.

I emailed Hushmail support and asked if they could explain more about their service and how encryption works. I asked specifically how Hushmail differs from Gmail. I received this response and I am posting the response here with permission:

Hello DeeAnna,

Thank you for your email and we are delighted to help with this.

Hushmail has been providing web-based secure email services for over a
decade now and uses the well known and well used OpenPGP standard for
encrypting email. We are a hosted service where users create accounts
on our servers and their email/data is stored securely on our servers.

All interactions a Hushmail user has with our servers are, and always
have been done over SSL (HTTPS), which provides a secure tunnel
between the users computer and our servers. If a Hushmail user sends a
message from one Hushmail user to another the email it will be sent
securely over its entire journey over SSL. Gmail is now doing the same
as we are, and we think this is a really good thing. Hushmail however
provides additional security in that users have the ability to easily
individually PGP encrypt their messages before sending them, encrypted
messages are also stored on our servers in an encrypted state. This
means that email has greater protection not only in transit, but also
when it is being stored.

One other area where Hushmail provides additional security is in that
with Hushmail you can send an encrypted message to a non-Hushmail
user, you do this by setting a shared secret as the key to encrypting/
decrypting the message. This is different to gmail in that the message
is individually encrypted (gmail messages are not) but also, once a
message is sent to a recipient outside of your network you may not
have control over whether the email is sent securely over SSL.
Individually encrypting your message resolves this issue.

We have many customers who use our service for counselling via email
and have been doing so for a long time.

If you have any further questions please do not hesitate to contact me.

Kind regards

Ben Cutler
Hush Communications
604 685 7288

I hope you find this explanation as helpful as I did. You can follow @hushmail on twitter. Oh, and Ben says if our readers mention Online Therapy Institute, he will give a discount on hushmail services! Thanks Ben for your time, expertise and a great service!!

Kate writes on the benefits and pitfalls of working and socialising in Cyberspace for the International Employee Assistance Professionals Association (EAPA).

Download the December 09 newsletter here!

Kate

The use of technology in several aspects of service provision – and particularly that of using the Internet to communicate with clients directly for the purpose of therapy – is an established and growing method of delivery. This workshop offers an introduction to online therapy, suitable for all theoretical orientations and levels of service provision, showing how online work can be integrated effectively into existing practice.
Kate Anthony will invite participants to explore their attitudes to working online and look at the differences and similarities to more traditional ways of working. She will take participants through the different types of technology being used in therapy, explain the theoretical model, demonstrate how online therapy works for both email and Internet Relay Chat with experiential exercises, and discuss the ethical implications inherent in working online with particular regard to social networking for professionals. Part of the day will be dedicated to couple counseling online.
Aims of the day:
• to give us confidence in relation to the use of technology
• to raise awareness of the ethics of online work
• to consider the particular issues related to counselling couples online.

Learning outcomes:
By the end of the day participants will:

• be aware of the range of technological interventions available
• understand the online therapeutic relationship
• understand the basics of online etiquette and written communication
• be aware of some of the pitfalls of social networking in the counseling profession
• have considered the ethical considerations of working online
• have had experiential learning of working with online clients
• have considered how couple counselling online could be conducted.

Teaching Format
A combination of presentations, discussion, and experiential smaller group work.

Presenter:
Kate is a Fellow of the British Association of Counselling and Psychotherapy, and developed and co-authored three editions of the Guidelines for Online Counselling and Psychotherapy, including Guidelines for Online Supervision. She is co-editor of Technology in Counselling and Psychotherapy – A Practitioners Guide, The Use of Technology in Mental Health: Applications, Ethics and Practice and co-author of Therapy Online [a practical guide]. She is also Past-President and Fellow of the International Society for Mental Health Online. She trains and consults on using technology in Mental Health as CEO of www.onlinetherapyinstitute.com. Free membership of the Institutes social network is at www.onlinetherapysocialnetwork.com, where over 450 professionals meet to discuss online therapy and use the Institute’s free resources.

Please contact Alice Still or Diana Reilly for more information.
Alice.still@relationships-scotland.org.uk
Diana.reilly@relationships-scotland.org.uk
Date:
Tuesday 9th March 2010
Time:
9.45am for 10.00am – 4.00pm
Venue:
Relationships Scotland
18 York Place, Edinburgh
Cost for Members of RS Network:
£75 to include training materials, sandwich lunch and refreshments.
Cost for Non-Members:
£115 as above.
Participants:
For relationship counsellors, sex therapists, and managers of services.

I will be traveling to the Phoenix area soon to facilitate another Distance Credentialed Counselor training.  The dates for this training are Feb 25 and Feb 26. I will be teaching the course at Rio Salado College in Tempe and would love to see you there!

The following week I will be in Lafayette, Louisiana.

Spring months take me to Florida, North Carolina, New Jersey, Illinois and Georgia.

SAMPLING OF THE 20 COMPETENCIES COVERED:

• Determine Counselor Suitability to Distance Counseling
• Determine Client Suitability to Distance Counseling
• Learn Security and Confidentiality Strategies
• Create Individual Treatment Plans
• Discuss Ethical and Legal Issues
• Develop an Action Plan to Implement Distance Counseling in Various Work Settings
• Learn about Online Culture
• Handle Crises with Distance Counseling Clients

For full workshop details go to ReadyMinds at http://www.readyminds.com/training/dcc_event.asp.

You can also download a flyer. DCC Arizona

My full training schedule is available at http://www.deeannamerznagel.com/id5.html.

Hope to see you on my travels!

DeeAnna

Early in 2004, the American Medical Association published a new CPT code 0074T that allowed physicians in the USA reimbursement for online consults. The new code was released January 1st, 2004.

*  Code 0074T: Online evaluation & management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient’s request, established patient.

In 2008, the CPT code 0074T was replaced. The code relating to online counseling was previously in the CPT manual under category III (emerging technologies).  As of 2008, it has been replaced by the new code numbers and is now under category I.

CPT Code 98969 is used to describe online services provided by non physician. CPT code 98966 is used to bill for phone consultation services.

Here are the billing guidelines about these two codes.  These two codes do not specify mental health-related services so the best advice is to check with the insurance carrier and advise your clients to do the same. For now it is best to assume that online counseling is not covered unless you can verify otherwise.

CPT 98969 On-Line Medical Evaluation by a Non-Physician

Online assessment and management service provided by a qualified non-physician health care professional to an established patient, guardian, or health care provider not originating from a related E/M service within the previous 7 days, using the Internet or similar electronic communications network.

Guidelines

•  Reportable services involve a personal and timely response to the patient’s inquiry, and must include permanent storage (electronic or hard copy)
• The online encounter is reported only once for the same problem/issue during a seven-day period, and includes the sum of all communication related to the online encounter (eg telephone calls, prescriptions, lab orders).
• If the online encounter relates to and occurs within 7 days of another E/M service performed and reported by the same provider for the same problem, it is not separately reportable.
• If the online encounter relates to a procedure performed by the same physician and occurs during the global post-operative period, it is not separately reportable.
• Online services should not be reported for care plan oversight or anticoagulation management when the same communication is reported using codes 99339-99340, 99374-99380, or 99363-99364.
• Online services which result in a face-to-face visit for the same problem may be reported in addition to the face-to-face visit.

Example: A patient emails her physician to request information about cancer screening after learning that there is a history of breast, colon, and prostate cancer in close family members. The physician responds and explains the implications of the family history, reviews risk factors, and offers an opinion as to what types of screening may be appropriate. The physician may also direct the patient to informational websites or attach handouts that are routinely provided to patients.

Example: The mother of a 16 year old patient with cystic acne, controlled with topical medications, emails the physician because of a recent flare-up. She is concerned about scarring and desires information about other appropriate treatment options, and the impact of diet and stress on the condition. The physician responds to her concerns, offers a short course of antibiotic therapy, provides long-term treatment options, and instructions for a follow-up visit.

Telephone Services–Non-Physician

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment;

•  98966 5-10 minutes of medical discussion
• 98967 11-20 minutes of medical discussion
• 98968 21-30 minutes of medical discussion

Coding Guidelines

• These codes may be reported only for established patients.
• The patient or patient’s parent/guardian must initiate the contact. These codes may not be used for calls initiated by a provider.
• Codes 99441-99443 are used only for services personally performed by a physician.
• Calls resulting in a face-to-face encounter for the same problem within 24 hours (or soonest available urgent appointment) are not reportable. Instead, consider the call part of the pre-service work for the billable E/M service.
• If the call relates to and occurs within 7 days of another E/M service performed and reported by the same provider for the same problem, the call is not reportable. This also means that a telephone call related to a previous call within 7 days is not reportable, since these codes are themselves an E/M service.
• Do not report a call that is related to and takes place within the postoperative period of a procedure performed by the same physician. These calls are considered to be part of the global surgical package.
• Telephone calls should not be reported for care plan oversight or anticoagulation management when the same communication is reported using codes 99339-99340, 99374-99380, or 99363-99364.

References:

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=498   

http://www.acpinternist.org/archives/2008/01/billing.htm

http://www.memo-snap.com/memo-snap/cpt.htm

http://www.memo-snap.com/memo-snap/online.htm

http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20080229cptcodes.html

http://my.counseling.org/2009/10/29/is-phone-counseling-and-online-counseling-covered-by-insurance/

http://www.google.com/#hl=en&source=hp&q=CPT+Code

.

OTI has been remiss in offering regular blog posts these past couple of months but with good cause and great outcomes!

So what’s in store for 2010? Our authored book, Therapy Online: A Practical Guide was just released and we have another edited book, The Use of Technology in Mental Health: Applications, Ethics and Practice due out this summer. This book has 30 chapters with a total of 47 contributing authors from across the globe.

As promised, we are offering online training about online therapy. We have launched the first 6 workshops with more to come. Each workshop is the equivalent of 5 clock hours of instruction. The workshops are online and self-paced.  The cost per workshop is $119.00/70.00 £.

• Introduction to Cyberspace: A Primer for Helping Professionals
• Relationships in Cyberspace: An Introduction for Helping Professionals
• The Online Therapeutic Relationship: Theoretical Considerations
• Ethical Considerations of Online Therapy
• Working Therapeutically Using Asynchronous Email
• Working Therapeutically Using Synchronous Chat

The workshop details can be accessed at our training portal. We have partnered with DigitalChalk to bring you a user-friendly yet state-of-the-art experience. Continuing Education credits for U.S. psychologists, social workers and counselors will be available very soon.

www.onlinetherapyinstitute.digitalchalk.com.

Just create an account and peruse our catalog! Your account will remain active should you decide to return to take a course.

We are giving our website a facelift so resources are easier to navigate.

We will soon offer an Online Therapy Institute ~verified~ seal that will provide a way for online helping professionals to indicate to the public that their site meets standards of best practice.

We will be facilitating groups and workshops as well as co-sponsoring conferences online and at our Second Life location.

We are collaborating with others to add to our Ethical Framework resources.

We have created:

• Ethical Framework for the Use of Technology in Mental Health
• Ethical Framework for the Use of Technology for Career and School Guidance

Coming Soon:

• Ethical Framework for the Use of Technology in Professional Coaching
• Ethical Framework for the Use of Technology in Crisis, Disaster and Critical Incident Interventions
  

We are offering a directory listing to everyone who joins our social network at www.onlinetherapysocialnetwork.com and your listing will be posted at www.onlinetherapydirectory.net.

For OTI members who practice online, a website listing in the OTI Web Directory (online counseling category) will be added provided the following standards are met:

1. Offer encrypted services for email, chat and web conferencing.
2. List level of education, schools attended and dates graduated.
3. List certifications and licenses if applicable with verification web links.
4. List crisis information or a link on the website’s home page.
5. List therapist’s alternate contact information in addition to email.

Mostly, we will continue to encourage dialogue among our members and friends at Online Therapy Institute so that we can all learn and grow together!

Kate and DeeAnna

Authored by DeeAnna Nagel, Stephen Goss and Kate Anthony, a new chapter called “The Use of Technology in Supervision” has just been published under the section heading “Emerging and Specialist Issues” in “The Clinical Practice of Supervision”, edited by Pelling, Barletta and Armstrong, published by Australian Academic Press (2009).

You can buy the book here: http://www.australianacademicpress.com.au/Publications/Books/4-921513312.html

In the chapter, we discuss

Technology Assisted Supervision
Enhancing the Use of Video and Audio through Analytical and Research Software
Extending Direct Observation
Delivery via phone, email, listserv, chat, videoconferencing and virtual worlds
Review of the Current Standards for issues such as contracting, informed consent, legalities, confidentiality and encryption, the use (and abuse) of verbatim material
Issues of transference and countertransference
The Suitability of the Supervisor regarding technical competency, training and education

The chapter concludes with questions and activities and has an OTI hand-picked selection of resources and references.

A worthy addition to any online therapy library, and wwe hope you enjoy it!

Kate

Some of you who are thinking about delivering therapy online are wondering what might be the best way to get started.  Some practitioners opt to deliver services straight from their own websites tapping into platforms such as Skype and Hushmail. Skype offers encrypted voice, web and chat services. Hushmail offers encrypted email and chat. Skype and Hushmail are but two examples of available services. Now many companies are offering encrypted communication platforms. Currently I use Skype and Hushmail because these services are free and user friendly for clients.

Others may opt to join an “E-Clinic” which is an easy way to describe a platform or portal that allows providers of services and potential clients to conduct therapy. There are some nuances across the E-Clinic menus but in a nutshell, it is a one-stop shop for the client and therapist. I have previously joined E-Clinics in the past and I am still listed on a few.  It might be interesting to note that I have been listed for several (a decade in some cases) years on some e-clinic sites and I rarely if ever receive an inquiry from a potential client. I’ll get back to that in a minute.  E-Clinics are convenient and easy. Some E-Clinics offer appointment setting, billing capability, credit card processing and an extensive listing. Conceivably, one could create a listing on such a site and use the listing as a website. Some E-Clinics offer customized or “branded” services so that you can integrate the platform into a custom website of your own.  And most E-Clinics conduct some variation of credentialing so that license and certification numbers as well as malpractice insurance information is verified.

So it sounds hassle-free. So, why not? Well, there are a few reasons why not.  One is cost. Some of these sites charge monthly fees. That’s great but if you also have a website of your own then you might be paying twice, so to speak. Remember I said previously that I rarely if ever receive client inquiries from these sites so just because they have a glossy “store front” and offer a suite of products to the therapist, it does not mean that the site is marketed well. If you want to know, do an internet search using keywords like online therapy, online counseling, online counselling, or etherapy. What comes up? Is the E-Clinic listed on the first page of results? That is but one way to find out how “popular” the service is.  The other way is to check press or media tabs on the websites. Has anyone interviewed the company? Is there any information about advertising campaigns, past, present or future?  Remember, you can create a listing anywhere on the World Wide Web. That does not mean people can find you. In the case of E-Clinics, make sure your money is working for you.

Another concern is security. Is the site encrypted? Is the information held on the company’s server? I often joke that we need to be careful about setting up our services using encrypted platforms that are hosted on Joe’s server located in Joe’s garage somewhere in an urban neighborhood across the country or the world. But seriously, the security and encryption of the site should meet very high standards. Does the E-Clinic serve via contract, any major government or insurance entities? That is one reasonable and simple way to know if the E-Clinic has “clout” so to speak. But even so, do your own security tests. Take the E-Clinic for a spin. Use their web, messaging or chat services with a colleague. When you are logged on, send the URL (which should begin with https://) via your regular email or chat (yahoo or gmail for instance). Can the person on the other end open the the URL? If so, the site is not secure. Why is this important? If you do this same test with sites like Amazon, Ebay or your bank once you have logged in, the other person will not be able to see your information and will most likely be sent to a login page for that site. The same process should occur for E-Clinic sites.

If you think you have found an E-Clinic you want to use, be sure to check out their Terms of Use, Privacy Policy and other Terms and Conditions.  You should be concerned with what you are agreeing to as the provider of services and what the consumer agrees to as the recipient of services. Does it match your legal and ethical responsibilities? Do you have the ability to upload your own informed consent documents to your clients? And if you take client referrals from these sites using their platform, what intake information do you receive? Does the site conduct any screening? Is the site set up to provide crisis intervention? If the site clearly states that online therapy is not for people in crisis, then consider whether you want to make yourself available immediately. Many of the E-Clinic sites offer instant sessions as a way to lure consumers into using the site. Some would say these E-Clinics are offering a viable service to people who are in immediate need. So I ask, is the immediate need a crisis or just needing to have a personal issue addressed right away, representing the immediacy of our culture? Be careful not to compromise standards of care. For instance, if you make yourself available immediately, what client information do you have on hand during this initial contact? Is the client allowed to remain anonymous? If so, what happens if the client is genuinely in crisis?  I recommend that if you are going to utilize the option of immediate availability that you use this option as an initial consultation- and treat that time much like you would if a client called on the phone inquiring about services.  Why? Well, consider your ethical responsibility to properly screen your client and to know the identity of your client. If you are providing crisis intervention then the site should clearly state that services are for people in crisis with the proper terms and conditions in place.  Counseling and psychotherapy services that occur within a contracted relationship are very different than crisis intervention services.

Remember that E-Clinics cater to many disciplines so be sure that you can follow your legal and ethical codes and that you remain within your scope of practice.  If you live in a geographic area that does not regulate your profession and you have no real code of ethics to fall back on for reference, then consider using best practice standards set forth by the Online Therapy Institute’s Ethical Frameworks for Mental Health Practitioners and Career and School Guidance.

Hoping this has been a helpful post~ perhaps this will generate a healthy discussion of the topic.

DeeAnna

Ethical Implications Online: Working and Socializing in Cyberspace

NEW LOW PRICE! $155.00 for the full-day session!

REGISTRATION FORM

Presented by: DeeAnna Nagel, LPC, DCC
Dallas, Texas EAPA Pre-Conference Training
Co-Founder of the Online Therapy Institute

The Employee Assistance Professionals Association (EAPA) invites you to
Register For This Full-Day Ethics Course
Ethical Implications Online: Working and Socializing in Cyberspace
Tuesday, October 20 8:00 AM – 5:00 PM; 7.5 PDH/CE contact hours

This full-day workshop will discuss best practice with regard to communicating online with potential and existing clients, business associates, friends and other therapists. With the advent of Web 2.0 and Social Media, counselors and psychotherapists now must understand the boundaries of working and socializing in cyberspace. Topics to be covered include communicating confidentially with existing clients, how to handle the email inquiry from a potential client, the basics of ethical online counseling and the slippery slope of marketing your practice on the internet via social networking sites such as Facebook, LinkedIn and Twitter.

Learn more about EAPA’s 2009 Annual World EAP conference or download the conference preview book.
PDH/CE credit hours provided by:
Employee Assistance Certification Commission (EACC)
National Association of Social Workers (NASW)
National Board for Certified Counselors (NBCC)
California Board of Behavioral Sciences
National Association of Alcohol and Drug Abuse Counselors (NAADAC)

Ethical Implications Online: Working and Socializing in Cyberspace
Presented by: DeeAnna Nagel, LPC, DCC
Dallas, Texas EAPA Pre-Conference Training
Co-Founder of the Online Therapy Institute

The Employee Assistance Professionals Association (EAPA) invites you to
Register For This Full-Day Ethics Course
Ethical Implications Online: Working and Socializing in Cyberspace
Tuesday, October 20 8:00 AM – 5:00 PM; 7.5 PDH/CE contact hours

This full-day workshop will discuss best practice with regard to communicating online with potential and existing clients, business associates, friends and other therapists. With the advent of Web 2.0 and Social Media, counselors and psychotherapists now must understand the boundaries of working and socializing in cyberspace. Topics to be covered include communicating confidentially with existing clients, how to handle the email inquiry from a potential client, the basics of ethical online counseling and the slippery slope of marketing your practice on the internet via social networking sites such as Facebook, LinkedIn and Twitter.

Special OTI Discounted Price: $295
(You Save $60!)

Add This Full-Day Business-Building Course
For Just $100 More!

Essential Sales Skills for the Non-Sales Professional
Wednesday, October 21 8:00 AM – 5:00 PM; 7.5 PDH/CE contact hours

Presented by: Shelley Plemons MS, LCDC
President/CEO, Strategic Sales Solutions

The economy is poor and the behavioral health marketplace is increasingly competitive. As a mental health professional, you may be faced with the challenge of maintaining your current work-load while becoming more involved in sales efforts. You want to increase your client base and land business, but sales is not your first profession, and feels daunting. What do you do?

First, don’t panic! Second, participate in this unique full-day training session! This is the only sales training program for non-sales professionals, written and presented by a fellow clinician, and targeted to building the sales capacity of mental health and employee assistance professionals and their programs. Shelley will introduce you to the principles and skills of consultative selling. It’s a logical, non-manipulative approach that focuses on being responsive to the needs of your prospective client and matching them to your products or services. Enhance your confidence by using your personality and skills in consultation, relationship building, and communication to build business!

Total OTI Discounted Price for Both Courses: $395
(You Save $315!)

Offer Expires September 30, 2009!

Don’t Wait ‘Til It’s Too Late!
Use This Special Form to Register Today!

Learn more about EAPA’s 2009 Annual World EAP conference or download the conference preview book.
PDH/CE credit hours provided by:
Employee Assistance Certification Commission (EACC)
National Association of Social Workers (NASW)
National Board for Certified Counselors (NBCC)
California Board of Behavioral Sciences
National Association of Alcohol and Drug Abuse Counselors (NAADAC)