Telehealth is an increasingly common and valuable tool to improve access to and quality of mental-health treatment. But as providers add this digital access to their practices, they should be aware of the liability implications.
Establishing a practitioner-patient relationship. The first step when initiating telehealth treatment is to establish a practitioner-patient relationship. Although in-person contact is not essential, having no contact or simply having patients complete questionnaires cannot establish the necessary relationship. Telehealth practitioners must genuinely form patient relationships prior to providing treatment and prescriptions.
Obtaining patients’ informed consent for telehealth encounters is also essential. Telehealth technologies are unique and novel; patients must agree to the use of telehealth in their care and know their rights to stop or refuse treatment. As with any medical care, practitioners should verify the understanding of all parties regarding (1) the provider’s credentials; (2) the nature, capabilities, and limitations of technologies employed; and (3) a mutual agreement that telehealth is appropriate given each patient’s care needs. Some states (e.g., California) require practitioners to obtain patient consent and inform patients of the benefits, risks, and limitations unique to telehealth treatment.
Like consent, appropriate observation and evaluation of patients must occur before the provision of any care or prescription. While evaluations need not necessarily be in person, practitioners should employ sound judgment and discretion to determine the level of contact needed on a patient-by-patient basis. By definition, telehealth does not permit in-person evaluations; telehealth practitioners should determine if circumstances require something more. Where in-person contact is considered necessary, telehealth practitioners can either engage surrogate examiners to be present with patients or recommend in-person appointments to those patients.
Knowing the limitations of care. Practitioners’ responsibilities also include knowing the limitations of the care to be provided. Telehealth allows practitioners to provide any appropriate treatment for patients, including prescriptions. But just as in traditional settings, these practitioners must recognize situations that exceed their expertise or ability, or in which technological limitations frustrate treatment—and should refer these cases elsewhere for appropriate care. Notably, telehealth software prevents in-person examination of a patient’s gestures and body language, and awareness of this potential source of miscommunication is critical to avoiding misdiagnoses and consequent malpractice liability.
Out-of-state licensing. Despite telehealth theoretically making it possible to treat patients anywhere in the country, practitioners should be aware that many states prohibit sustained practice with out-of-state licenses. Furthermore, mental-health professionals incur a practice-specific duty to take reasonable precautions to mitigate or prevent foreseeable injury to others caused by their patients (R3d (Torts) § 315), and telehealth practitioners should be especially aware of these signs, particularly in light of the technological limitations and physical separation from their patients that telehealth involves. It is a best practice, for example, to obtain each patient’s emergency contact information so as to assist endangered patients.
Telehealth simplifies patient interactions, but it does not obviate practitioners’ record-keeping practices. Practitioners must accurately and adequately document patient encounters so that records clearly, concisely, and correctly reflect treatment. Records must be permanent, confidential, and readily available to patients and their treatment providers in accordance with laws and regulations related to maintaining and transmitting such records. HIPAA and HITECH—medical privacy and security laws—require that telehealth software encrypt patient data; Skype, FaceTime and other commercially available communication services fail to meet this requirement. Practitioners must have telehealth-specific video-conferencing providers execute a business associate agreement to maintain patient confidences pursuant to HIPAA.
Telehealth prescriptions entail the same professional accountability as prescriptions penned during an in-person visit. Practitioners must evaluate the indications, appropriateness, and safety considerations for each telehealth prescription in accordance with current standards of practice; for example, practitioners should exercise special caution when prescribing DEA-controlled substances through telehealth. Integration with e-prescription services can help telehealth practitioners ensure accurate and error-free prescribing practices.
Eric A. Norman and Ashley L. Blackburn, attorneys, FAVROS (Seattle, WA)