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“Emerging Digital Health Technologiesand Continuing Care”
Arthur S. Trotzky, Ph.D. DCCOnline Group Therapy, LLC.
www.onlinegrouptherapy.com
Israel Ant-Drug Authority
Treatment and Rehabilitation
▪ Treatment programs within the community, offered in 150 communities(including treatment for alcoholics).
▪ 20 Regional day care facilities, 4 of them designated for youth.▪ 6 Detoxification units, 1 for alcohol.▪ Therapeutic communities: 8 for long term intervention, one accepts
mothers with children and one for women only, one for youth and onefor dual diagnosis patients. A special short program for alcoholics is alsooffered in one of the TCs.
▪ Ambulatory treatment for youth and adults. Special units for alcoholics.▪ Special treatment programs for prisoners.▪ Hostels: 2 hostels for adolescent girls, 2 hostels for adolescent boys, 1 hostel▪ for alcoholics.▪ Rehabilitation programs in 10 municipalities: technological preparation
courses and academic scholarships for clean addicts, employment▪ Workshop for methadone patients.▪ Youth treatment network.▪ Internet support group for recovering addicts
TERMINOLOGY
~ Telecounseling
~ Online Counseling
~ Online Therapy, Internet Therapy
~ Telepsychology
~ Telemental Health
~ Etherapy, Ehealth
~ Behavioral Telehealth
~ Telemedicine
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BENEFITS OF WORKING ONLINE
~ Increased client satisfaction
~ Less travel time
~ Savings in child, elderly and travel costs
~ Acess to remote underserved populations
~ Greater access to specialists
~ No loss in productivity or income
~ Aftercare support
Maheu. Pulier, Wilhelm & Brown-Connolly (2004). The mental health professionals and the new
technologies. Erlbaum, New York
Recent Research
Backhouse and associates.(May 2012) in a meta-analysis:~ 821 articles were reviewed, 65 selected
~ results show that vdeoconference psychotherapy is used in a
variety of therapeutic approaches, with diverse populations, is
associated with user satisfaction and is shown to have comparable
clinical outcomes when compared to face to face psychotherapy.
Videoconferencing psychotherapy: A systematic review.
Backhouse, Agha, Maglione, Repp. Ross, Zuest, Rice-Thorpe, Lohr, Thorp.
Psychological Services. Vol 9(2), May 2012, 111-131
EFFECTIVENESS RESEARCH
“Is Telepsychiatry Equivalent to Face-to-Face Psychiatry?
Results From a Randomized Controlled Equivalence Trial”495 patients randomly assigned to live video or in-person care
Equal rates of recovery
Online care cost 10% less
Psychiatric consultation and short-term follow-up can be as effective when
delivered by telepsychiatry as when provided face to face.
Psychiatric Services, VOL. 58, No. 6, June 1, 2007
EFFECTIVENESS RESEARCH
“Assessing the effectiveness of an Internet-based
videoconferencing platform for delivering intensified substance
abuse counseling.”
study of 37 drug addicts randomized to live video group or in-
person care
~ Equal rates of recovery
~ Patients preferred online care
J. Subst Abuse Treat. 2009 Apr;36(3):331-8.
EFFECTIVENESS RESEARCH
“Outcomes of 98,609 U.S. Department of Veterans Affairs
patients enrolled in telemental health services, 2006-2010.
study of 98,609 veterans who chose live video care”
25% fewer hospitalizations
25% shorter hospitalizations
This four-year study, the first large-scale assessment of telemental health services, found that
after initiation of such services, patients' hospitalization utilization decreased by an average of
approximately 25%.
Psychiatr Serv. 2012 Apr;63(4):383-5
Rooksby, M., Elouafkaoui, P., Humphris, G., Clarkson, J., & Freeman, R. (2015). Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: Systematic review and meta-analysis. Journal of anxiety disorders, 29, 83-92.
Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: systematic review and meta-analysis.
The findings together suggested that CBT programs involving computerisedelements were well received by children and their families, and its efficacy was almost as favorable as clinic-based CBT
Analysis supports online delivery for wider access of this evidence-based therapy
Telemedicine-Based Collaborative Care for Posttraumatic Stress Disorder
Fortney, John C., Jeffrey M. Pyne, Timothy A. Kimbrell, Teresa J. Hudson, Dean E. Robinson, Ronald Schneider, WilliamM. Moore, Paul J. Custer, Kathleen M. Grubbs, and Paula P. Schnurr. (2015). “Telemedicine-based collaborative carefor posttraumatic stress disorder: a randomized clinical trial.” JAMA psychiatry 72, no. 1, 58-67
Telemedicine Outreach for PTSD (TOP) intervention to improve PTSD outcomes for veterans treated at VHA community-based outpatient clinics
*133 patients received the TOP intervention while 132 received usual care
“Telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes,"
http://telehealth.org/bibliography/
Perceptions of Video-Based Appointments from the Patient's Home: A Patient Survey
Gardner Matthew R., Jenkins Sarah M., O'Neil Daniel A., Wood Douglas L., Spurrier Barbara R., and Pruthi Sandhya. Mayo Clinic, Rochester, Minnesota, Telemedicine and e-Health. April 2015,
Patient survey data indicate that most patients are likely tobe accepting of telehealth care to the home using video calland that most have the required technology. Nevertheless,there are still significant hurdles to effectively implementthis adaptation of telehealth care as part of mainstreampractice.
The Effectiveness of Telemental Health: A 2013 Review
Donald M. Hilty, MD, Daphne C. Ferrer, MD, Michelle Burke Parish, MA, Barb Johnston, MSN, Edward J. Callahan, PhD, and Peter M. Yellowlees, MD
Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care
Some have noted that with some populations (i.e., children and adolescents), telepsychiatry may be better than in-person services because of the novelty of the interaction, direction of the technology, the psychological and physical distance, and the authenticity of the family interaction
Morland LA, Greene CJ, Rosen C, Mauldin PD, Frueh BCContemp Clin Trials. 2009 Nov; 30(6):513-22.
Children and Adolescents
Patient Perceptions of Telemental Health: Systematic Review of Direct Comparisons to In-Person Psychotherapeutic Treatments
“Comparable treatment satisfaction as well as similar ratings of therapeutic alliance.”
A comprehensive search of the PsychINFO and MEDLINE databases for articles published in the last 10 years (2004–2014) on TMH treatments that included in-person comparison groups, yielding 552 initial results with 14 studies meeting our full inclusion criteria.
Jenkins-Guarnieri Michael A., Pruitt Larry D., Luxton David D., and Johnson Kristine. Telemedicine and e-Health. July 2015, 21(8): 652-660. doi:10.1089/tmj.2014.0165.
Current research suggests that telepsychology offers effective means of delivering CBT, consultation, and continuing education services for disorders such as adult anxiety, depression, insomnia, pediatric recurrent pain and anxiety, oppositional defiant disorder, and attention deficit/hyperactivity disorder (Dyck & Hardy, 2013).
Fitt and Rees (2012), indicated that “videoconferencing can be a highly effective and acceptable means of delivering psychotherapy” (p. 227). All participants in this study stated that videoconferencing helped them to stay focused between sessions (e. g., seeing therapist's face on the screen served as a memory aid between sessions) and they felt less intimidated than in face-to-face sessions.
Additional Findings
The therapeutic alliance appears comparable in online versus face-to-face services (Dyck & Hardy, 2013).
The social stigma regarding attending therapy can be lessened for many individuals with the use of online treatment.Online therapy has proven to be a viable option that allows access to multicultural counselors and gives clients more therapeutic options.
Online Therapy: Where We Are and Where We Need To Go Priscilla Zoma, M.A., Melanie Ho, M.A., Dustin K. Shepler, Ph.D., & Jessica Dluzynski, M.A. Michigan School of Professional Psychology ,2014
Additional Findings
Clients will benefit from online therapy with the ability to contact their therapist at any distance, at any time, at their convenience, and from their home. In this way, the traditional office-bound, prescheduled, face-to-face, therapist-client appointment has become irrelevant (Barak et al., 2009)
Telehealth services are significantly lower in cost than in- person services.
Many clients trying to seek psychological services are unable to travel great distances or afford the costs incurred with travel (Backhaus, et al., 2012).
Online counseling affords various distinct advantages, such as convenience and the ability to overcome existing psychological and physical barriers that individuals can face in assessing counseling services (Richards, 2012).
Online Therapy: Where We Are and Where We Need To Go Priscilla Zoma, M.A., Melanie Ho, M.A., Dustin K. Shepler, Ph.D., & Jessica Dluzynski, M.A. Michigan School of Professional Psychology, 2014
Additional Findings
Molfenter, Boyle, Holloway and ZwickAddiction Science and Clinical Practice10(1):14 · May 2015
Telemedicine Modalities: Telephone-based care, web-based screening, web-based treatment, videoconferencing, smartphone mobile applications (apps), and virtual world
“Trends in Telemedicine Use in Addiction Treatment”
Telemedicine offers great potential for enhancing treatment and recovery for people with substance use disorders (SUDs). Telemedicine also offers clinicians ways to increase contact with SUD patients during and after treatment
Molfenter, Boyle, Holloway and ZwickAddiction Science and Clinical Practice10(1):14 · May 2015
“Trends in Telemedicine Use in Addiction Treatment”
Purchasers expressed the most interest in implementing videoconferencing and smartphone mobile devices
The greatest barriers identified were: costs associated with implementation,lack of reimbursement for telemedicine services, providers’ unfamiliarity withtechnology, lack of implementation models, and confidentiality regulations
http://telehealth.org/bibliography/
http://telehealth.org/bibliography/
https://www.telementalhealthcomparisons.com
Using Technology-Based Therapeutic Tools in Behavioral Health Serviceshttp://store.samhsa.gov/shin/content//SMA15-4924/SMA15-4924_PT3.pdf
Unexpected Problems
50 State Requirements for Telehealth:
http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf.
Laws Regarding Online Practice
American Psychological Association
Practice –Legal & Regulatory Affairs
October 2013
50-State Survey of Telemental/Telebehavioral Health (2016)
Epstein Becker Green’s 50-State Legal Survey of Telemental Health is an extensive compilation of research regarding the laws, regulations, and regulatory policies impacting the practice of Telemental Health in all 50 states and the District of Columbia. The Survey is organized using an easy to use question-and-answer format and has 12 distinct areas of focus:
1. General Telemedicine/Telehealth2. Psychiatrists3. Psychologists4. Social Workers5. Counselors6. Marriage/Family Therapists7. Advanced Practice Registered Nurses (“APRNs”)8. Privacy/Confidentiality9. Minors10. Follow-Up Care11. Coverage & Reimbursement12. Controlled Substances
Conforming to HIPAA in a Digital Age
The Health Insurance Portability and Accountability Act
(HIPAA) of 1996, which stipulates that ALL methods
available should be used to ensure a patient's privacy is
maintained, affects nearly every organization that collects,
stores, or transacts protected health information
Protected Health Information (PHI)
• For HIPAA, only those folks who qualify as “covered entities” are legally required to comply with the law. For health care providers, this is how the law defines a “covered entity”:
• A health care provider that conducts certain transactions in electronic form
Some claim that these transactions are thingslike sending emails or using Skype to speakwith clients. .“Covered transactions” relates to billing insurance and making
inquiries with insurance such as statements of benefits.
Specifically, they are the transactions defined in HIPAA’s
lesser-known Transaction Rule.
If your practice has never billed insurance, itis probably not a HIPAA covered entity.
HIPAA: Electronic Data Interchange (EDI) Rule
Transmissions via Electronic Media
Conduit Rule
The Department of Health and Human Services (HHS)
Business Associate Agreement (BAA)“Business Associates” are all those persons or entities who, on behalf of the provider:
• Perform or assist in the performance of any function or activity that involves the use or disclosure of PHI, including claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, billing, benefit management, practice management, re-pricing or any other function or activity regulated by the Administrative Simplifications Provisions of HIPAA; and
• Provide legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services that involve PHI.
BAA
Ransomware
Air-gapped computers
Fansmitter
Hackers use fax machines to infiltrate networkCheck Point researchers explain how hackers can use an organization's
fax machine to hack its computers.
plugging a printer into a phone line opens computers to hackers.
~ suffering from psychiatric disorders needing immediate
attention
~ significantly depressed
~ a danger to themselves or others
~ struggling with serious substance abuse issues
~ presenting psychotic or actively suicidal concerns
~ struggling with psychological disorders characterized by
distortion of reality
~ highly reactive and potentially dangerous
~ struggling with certain personality disorders such as those
with borderline personality disorder, paranoia or dissociative
disorders
CLIENT APPROPRIATENESS
• All of these professional organizations’ ethics codes, at the very least, explicitly require that we take steps to maintain the confidentiality of client data, including in electronic media: ACA, APA, NASW, AAMFT, and NBCC.
Law - Ethical Standards
Ethical Standards
• It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. AAMFT Code of Ethics, 2015, 6.3
• Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium. ACA Code of Ethics, 2014, B.3.e
• Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible. NASW Code of Ethics, 1.07 (m)
• This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions.Ethical Principles of Psychologists and Code of Conduct (“APA Code of Ethics”),
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Social Media Presence
There is an emerging professional standard for therapists with an online presence to distribute a social media policy that relates your guidelines regarding use of social media and relationships to clients in social media
http://www.drbeckybeaton.com/shopping-center.htmlhttp://drkkolmes.com/social-media-policy/
Professionals need to know and be
To Google, or not to Google: that is the question?
Is it ethical for Psychotherapists to Search their Clients on the Web?
▪ Is it ethical to conduct an online search on a client without the client's knowledge? ▪ Is it ethical to search online for a client without the client's (informed) consent? ▪ If therapists Google their clients with neither the clients' consent nor knowledge, must
they inform their clients after they have Googled them? ▪ If therapists find clinically significant information on their clients via online searches, do
they have to tell clients what they have discovered? ▪ Is it ethical to Google clients in order to save lives, but not just to find more general
information about them? ▪ How may the information gained from online searches by therapists of their clients
affect the work of therapy itself and the therapeutic relationships? ▪ How do therapists document online searches of their clients? ▪ Are the online search results part of the clinical or psychotherapy records? • Are the online searches by therapists legally discoverable?
The 2014 ACA Code of Ethics requires Counselors to "respect the privacy" of clients' social media unless given permission otherwise.
Zur Institute
▪ If client’s can search me then I can search them.
▪ Informed consent and discuss with client prior to searches.
▪ Voyeuristic and intrusive to the therapeutic framework
Points Of View
Summary of Ethical Issues
~ Practitioner Competency
~ Confidentiality
~ Dual Relationships
~ Proper Client Screening
~ Benefits and Hazards
~ Crisis Intervention
~ Jurisdiction
www.onlinegrouptherapy.com
www.drtrotzky.com
Cookies
An HTTP cookie (also called web cookie, Internet cookie, browser cookieor simply cookie) is a small piece of data sent from a website and stored in the user's web browser while the user is browsing.
• Session cookie• Persistent cookie• Secure cookie HTTPS• HttpOnly cookie• SameSite cookie• Third-party cookie• Supercookie .com, .uk.co• Zombie cookie
Q: Do I need to set my browser to accept cookies in order to use your website?You can browse our website without having cookies enabled. However, if you need to log in to an existing account, you will need to adjust your browser's privacy settings to accept cookies. We primarily use cookies to provide you with secure access to your account.
What is SSL?
SSL (Secure Socket Layer) is the standard security technology forestablishing an encrypted link between a web server and a browser. Thissecure link ensures that all data transferred remains private. It’s alsocalled TLS (Transport Layer Security). Millions of websites use SSLencryption everyday to secure connections and keep their customer’sdata safe from monitoring and tampering.SSL is visible to users in several ways in the website address bar:A lock icon in the browser barThe website address starting with https://Example:
Connect365 Program Benefits
§Consistent support for one full year
§No additional cost
§HIPAA compliant
§Personal Sierra Tucson Recovery Coach
§Interactive platform for mobile device/computer
§Convenient, secure messaging between participant, Recovery Coach, and
support team (if desired)
§Designated participant-identified support team
§Prevention assistance
§Personal accountability
§Support meeting log
§Weekly progress reports
§Reporting tools for EAPs, legal affiliates, and licensing boards
Sign up and add people to your Circle of SupportFundamentally, this is your accountability networkBe very courageous when selecting these peopleChoose people who care about you … it is critical to the success of the systemThese are the people that will receive text messages or emails on a daily or weekly basis on your progressThey will know your check-in rate and will verify your urine alcohol and drug testsThese are the people to whom you are accountable
Touchstone Circle of Support
“We can extend our staff’s ability to support and monitor our residents ongoing recovery. The application allows us to create an accountability network outside the walls of the residences. These circles of support share in their daily victories, such as overcoming the impulses to renew previous addiction-related behaviors, and they give encouragement that reinforces our residents’ recovery journey.”
Beth Fisher Sanders Founder and Executive Director, Hope Homes Recovery Services
Touchstone Circle of Support
Circle of Support sends feedback to the Member via
love, hugs and kudos emojis, triggering psychological
desire/need to accumulate them and be rewarded, similar
effect to the like button on Facebook
Touchstone Circle of Support
BHC
The Joint Commission:TRAC9 monitors individual’s treatment progress using
standardized assessments.TRAC9 collects, scores, and displays results
automatically.TRAC9 provides the means to evaluate outcomes of
care for your clients.Standard CTS.03.01.09
CARF Accreditation:(Commission on Accreditation of Rehabilitation Facilities)
All instruments used in TRAC9 are reliable, valid, comprehensive, and accurate.
Provides a wide variety of data on substance use disorder populations served.
Both pathology and resilience factors are assessed.2018 Behavioral Health Standards – Section M.2, M.4-5
BHC
Real-time monitoring of the client’s progress
Instant alerts to the treatment team if symptoms increase
Clinical Director monitors quality of care for all clients
Monitoring of clients satisfaction with treatment
Monitoring of symptoms and protective factors that promote recovery
12 Monthly follow-ups after client discharges from treatment
Real-time monitoring for each of our locations
Computer analysis that allows for identification of high risk patients
BSC
Measures Resilience & Pathology Data
Through self-reported assessments, clinicians are alerted of discrepancies that indicate a risk of treatment failure. With new insights into how clients are changing over the course of a recovery program, facilities can optimize their treatment programs, leading to measurable, positive outcomes.
Digital Life in 2025 - Pew Internet & American Life Project
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Thank You
AAMFT - American Association of Marriage and Family Therapists
-Code of Ethics
ACA - American Counseling Association
-Code of Ethics
AMA - American Medical Association
-Resolution 317 in favor of quality telemedicine policies
APA - American Psychological Association
-Guidelines for Ethical Practice of Telepsychology
ATA - American Telemedicine Association
-Guidelines for Video Telemental Health
NBCC - National Board for Certified Counselors
-Policy Regarding the Provision of Distance Services
PROFESSIONAL ORGANIZATIONS
