8 Ethical Considerations for Starting a Telehealth Practice

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Telehealth is the use of digital information and communication technologies, such as computers and mobile devices, to provide, access, and manage health care services remotely. For social workers, telehealth may involve the use of videoconferencing software to provide face-to-face counseling and psychotherapy to clients. It may also incorporate the use of electronic data and client record keeping management tools, the use of wearable technology, and apps. Prior to starting a telehealth practice, social workers should be aware of the following ethical considerations.

1. Get Training and Become Competent

Before pursuing any new practice including using technology in service provision, social workers must ensure that they are competent. According to the NASW Code of Ethics, standard 1.04(a), Competence, “social workers should provide services only within the bounds of their education, training, license, certification, consultation received, supervised experience, or relevant professional experience.” This includes understanding special communication challenges when using technology and having the ability to implement strategies to address these challenges, according to standard 1.04(d).

2. Determine Whether Telehealth Is the Best Service Modality

Deciding to implement telehealth services should be a decision approached through the lens of the best interests of the client. Not all clients may be ideal candidates for remote services. According to the NASW Code of Ethics, social workers should consider the client’s preferences, 1.02, Self-Determination.  If clients do not wish to use services provided through technology, social workers should help them identify alternate methods of service.  Other important considerations include clients’ ability to provide consent; the clients’ intellectual, emotional, and physical ability to use technology to receive services; and the clients’ ability to understand the potential benefits, risks, and limitations of such services,1.03(f)(g), Informed Consent. Social workers should also “…assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.”, 1.05(d), Cultural Awareness and Social Diversity.

3. Ensure You Are Licensed and Adequately Insured to Provide Telehealth Services

Before beginning a telehealth practice, social workers must consult with the social work licensing board in the state they are physically practicing in, and with the state licensure board where the client is physically located when receiving services, according to standard 1.04(e), Competence. Social workers are responsible for ensuring they have the appropriate licensure in place to practice telehealth within their state and across state lines. Note that many states offer exceptions due to public health emergencies and when clients are receiving services on a temporary basis, for example when on travel. The Association of Social Work Boards (ASWB) is a resource for exploring licensing requirements across the country.

Securing professional liability insurance that covers your telehealth practice is an important consideration. NASW Assurance Trust offers assistance to social workers with determining the coverage options available for the provision of telehealth services.

4. Select a Secure and HIPAA-Compliant Platform

When selecting a platform for telehealth service delivery, social workers should consider the ethical guidance in standard 1.07(m), Privacy and Confidentiality, which addresses safeguards that should be taken to protect confidentiality when communicating electronically, specifically the use of encryption, firewalls, and passwords. Generally video conferencing platforms used for telehealth care should be HIPAA compliant. Although NASW does not presently endorse any particular platform, you can learn more about selecting an appropriate platform available on the NASW Telehealth web page.

5. Pay Attention to Payment for Services and Billing Requirements

According to the NASW Code of Ethics, standards 1.13, Payment for Services, and 3.05, Billing, social workers should determine a “fair and reasonable” fee structure and ensure that “billing practices are accurate, and reflect the nature and extent of services provided, including who provided the services in the practice setting.” Additional considerations for payment and billing for telehealth services include determining in advance any telehealth guidelines that must be met for third party payers such as insurance panels, Medicare, and Medicaid. Moreover, again standard 1.07(m), Privacy and Confidentiality, advises social workers to take “reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties.” This guidance requires determining whether there are limits to confidentiality when selecting electronic payment platforms and obtaining the proper consent to use them.

6. Implement Technology Standards, Policy, and Procedures

Social workers who offer telehealth services should develop a telehealth policy and discuss it with clients, according to standard 1.03(e), Informed Consent. Telehealth policy and procedures should include the following:

Obtaining informed consent to provide telehealth services per standard 1.03(a), Informed Consent.

Setting clear and appropriate boundaries when using technology, per standard 1.06(e), Conflicts of Interests, which guides social workers to “avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes.”

Disclosing procedures for addressing breach of confidentiality or unauthorized access to client information consistent with applicable laws and professional standards, per standard 1.07(n), Privacy and Confidentiality.

In addition to the NASW Code of Ethics, there are many telehealth resources that should be considered when developing technology policy and procedures for your telehealth practice. Technology Standards for Social Work Practice provides additional guidance that can be incorporated in technology policy and procedures.

7. Develop an Emergency Backup Plan

The Code advises social workers to “make reasonable efforts” to ensure continuity of services in the event that services are interrupted, per standard 1.15, Interruption of Services. As such, social workers should discuss contingency plans with clients in the event of disruptions in electronic communications including power outages or loss of Internet signal when providing services remotely. This may include having landline phones available to connect with clients in the event of loss of Internet connectivity, and identifying and securing proper consents for an emergency contact in the event of the social worker’s or client’s unexplained absence.

8. Seek Consultation as Needed

Social workers are required to practice ethically when using technology. This entails staying abreast of and adhering to licensing, legal, and other pertinent regulations and guidelines. At times, this may require seeking advice and consultation from an IT professional, an attorney, or another professional colleague with relevant expertise and competence.

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