Telehealth Issues: Be Vigilant About Ethics Breaches

One of the bright lights in the otherwise dark world of the COVID-19 pandemic has been the expansion of telehealth services (audio only or video) in medical and psychiatric care. APA and the AMA have declared that telehealth is a critical part of the future of health care and have advocated for the expansion of telehealth policy, research, and resources to ensure physician practice sustainability and fair payment.

In a survey of APA members conducted two months after the federal declaration of the public health emergency (PHE) related to COVID-19 in 2020, 62% of respondents were not providing telehealth services before the PHE, but by the time of the survey, 86% of respondents were seeing the majority of their patients via telehealth. This incredible turnaround is a testament to the commitment, flexibility, and determination of psychiatrists to ensure continuity of care in uncertain and dangerous times. A pleasant surprise were the findings that the rate of no-shows for appointments had decreased and patient satisfaction had increased. Who would have thought! Video visits were more readily covered by Centers for Medicare & Medicaid Services and third-party payers, but audio-only visits were permitted for patients who did not have access to video or when the patient’s condition was such that audio-only visits were appropriate. A majority of survey respondents stated, however, that between 1% and 25% of their patients could not access care regardless of platform (audio or video) due to technical issues such as the lack of broadband access, inability to afford video technology, hearing difficulties, cognitive impairment, unreliable or weak signal strength, or inability to operate the technology.

The use of telehealth remained consistently high one year later, according to another APA-sponsored online survey; it found that nearly 4 in 10 respondents (38%) had used telehealth services to meet with a medical or mental health professional since the start of the pandemic, up from 31% in the fall of 2020. Remarkably, 38% of respondents used the telephone only. Access to care through telehealth was particularly important for African Americans and Hispanics as well as for younger adults of various races and ethnicities who had had difficulty for years in scheduling appointments through traditional routes. Interestingly, 43% of adults surveyed said they wanted to continue using telehealth services when the pandemic is over, and 34% said they would prefer telehealth services over in-person doctor visits, up from 31% in 2020. Among younger adults aged 18 to 44, 45% said they preferred telehealth services to in-person visits.

These findings are not surprising. Telehealth services are convenient for both psychiatrists and patients. For example, psychiatrists can see patients from the comfort of their home or even while attending a conference, experience fewer no-shows, and have the opportunity to see patients in their home environments; patients avoid the hassle and cost of transportation and decreased time away from work or other commitments. However, such convenience should be weighed against the benefits of in-person visits at the doctor’s office or other designated spaces. During in-person visits, the patient meets with the psychiatrist in a therapeutic space and without distractions. Roles and boundaries are clearly defined. Other individuals may be included in the session but only at the expressed permission of patients. Likewise, overbearing, controlling, or abusive family members of vulnerable patients can be excluded with the support of the psychiatrist. In-person visits are particularly important for individuals with unstable housing or homelessness.

At the visit, the psychiatrist can observe the whole person, including the patient’s appearance, affect, mobility, nonverbal communication, and other important characteristics as part of a mental status examination.

Telehealth seems to have upended these valuable traditions. In video meetings, the ability to observe facial features or gestures depends on the resolution of the video. Likewise, since video mostly shows the face and upper torso, the ability to see signs of agitation such as clenched fists or fidgety legs may be limited. Further, psychiatrists cannot always tell whether someone else is in the room off camera and listening to confidential information or influencing the patient’s responses or behavior. Audio-only devices present additional challenges. A psychiatrist colleague in private practice described some of them. Patients sometimes multitask by engaging in everyday activities during appointments, such as grocery shopping, riding in a bus or car with others present, playing video games, or driving a car. The most alarming case of which I’m aware was the patient who was driving a taxi with a passenger while engaging in therapy.

The APA Ethics Committee, cognizant of these challenges, has provided guidance on the ethical use of telehealth for psychiatric services:

“The availability of technology is incredibly helpful during this public health crisis as it allows psychiatrists and patients to continue treatment while apart because of physical distancing. While using these technologies, psychiatrists have an ongoing ethical responsibility to maintain patient confidentiality and proper therapeutic boundaries. Psychiatrists should inform patients that there may be limits to confidentiality given the risks inherent to the use of the internet that would not necessarily exist for an in-person session and establish the expectations of the changed treatment relationship by informing patients that telehealth sessions are treatment sessions in the course of care and will be billed as such.”

Therefore, psychiatrists conducting telehealth meetings for psychotherapy or medication management should consider the following practices:

• Have patients sign a contract ensuring reservation of scheduled meeting times for therapy/treatment activities only and nothing else.

• Ask patients to be in a space during appointments where they can be assured of privacy and no interruptions.

• Ask patients at each visit whether anyone else is in the room and whether there is a possibility that someone might enter the room during the appointment.

• Terminate therapy when patients are in unsafe situations or situations that interfere with their attention.

• Be sensitive to other potentially problematic situations.

Psychiatrists should be acutely aware that familiarity brought on by telehealth may lead to erosion of boundaries due to role diffusion.

Telehealth is here to stay and rightfully so—it is undeniably a crucial vehicle for providing services and ensuring continuity of care. However, psychiatrists should remain vigilant during its use to avoid a potential ethics breach. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also an associate professor of psychiatry and co-director of the Law and Psychiatry Division at the Yale University School of Medicine.