Plan for Today’s Talk How practice patterns are changing or will change and what ethical challenges lie ahead Regulatory trends Psychological practice/interaction in health care systems and inter- professional practice Electronic records and interactions with “the cloud” Telehealth issues Social media and marketing
How Is Practice Changing Psychiatric practice and training has changed More drugs, less therapy Questionable EBPs e.g., high frequency prescription of “anti-psychotic” meds for anxiety Applications of “personalized medicine” More people and more diverse populations covered Direct to consumer marketing Increased engagement of behavioral health in primary care Specialty health services e.g., pain, sleep, non-adherence in chronic health conditions Telehealth practice
Are you prepared for the Ethical Challenges of ACOs and PCMHs? (Accountable Care Organizations and Patient Centered Medical Homes) Organizational models for primary care that will improve our health care system (?) 7 Robocop and mermaid pet a unicorn.
Integrated Inter-professional Care Understanding the culture of interprofessional health care practice and functioning as a team player Communicating more frequently and directly than in traditional mental health practice Working with patients who have medical, mental health, behavioral health, and co-morbid problems in a fast-paced primary care context Working with a more diverse (ethnically, socially, and economically) population than ever before Ability to document the value added by psychologists’ (behavioral health specialist) engagement 8
Discussing confidential material with colleagues Inside or outside the institutional context? Properly sanitized health care information is not protected under HIPAA regulations (45 C.F.R. §164.514). The following identifiers should be removed or altered when preparing material for release or discussion in public statements, teaching, or research: 1. Names 2. Geographic subdivisions smaller than a state (although the initial three digits of a zip code may be used) 3. Any dates (except years) directly related to an individual 4. Telephone, fax, social security, medical record, health plan identification, account, medical device identification, or license numbers 5. E-mail addresses web universal resource locators (URLs), Internet Protocol (IP) addresses 6. Biometric identifiers including finger and voice prints 7. Full face photographic or comparable images 8. Any other unique identifying number, characteristic, or code 9
Administrative and Financial Accountability and Autonomy will shift Are you prepare to: Seek additional credentials? Board certification Integrate your practice? Co-locate? Contract and accept risk? Become an employee? 10
How will reimbursement systems change? Medicare Medicaid Insurance exchanges Global payment systems Who takes the risks? Who makes “medical necessity” decisions? New billing an diagnostic codes Who’s codes rule? 11
Evolving Professional Roles and Conflicts of Interest in Emerging Payment Systems What will happen as fee-for-service systems become supplanted by incentivized integrated care or “global payment” systems or will we suffer the ills of poorly run capitation systems? Can we focus on the “virtuous circle of care” and value based competition? Will we manage ethically? Porter, M.E. & Teisberg, E.O. (2006) "Redefining Health Care: Creating Value-Based Competition On Results", Harvard Business School Press, 2006.
Strangers in a Strange Land The content and culture of training programs in psychology differ substantially from medicine and nursing. We use: Different core content Different educational sequences and pedagogy Different socialization approaches Different regulatory models Different specialization models
Strangers in a Strange Land We sometimes don’t even speak the same language. a “progressive disease” is one that gets worse and “positive findings” are a bad sign when discovered during a physical examination Some physicians seem too willing to see physical complaints as psychological, and some mental health practitioners seem all too eager to go along with them. The game is changing and the rules are not clear
Diagnosis and Procedure Codes Science versus Politics Uncomplicated Bereavement Pediatric Bi-Polar Illness Syndromes Down’s Syndrome Parent-Child Alienation Syndrome DSM vs ICD The “psychoanalyst” approach
Will the ICD Replace the DSM? New ICD-10 Codes V97.33XD: Sucked into jet engine, subsequent encounter. Y93.D: Activities involved arts and handcrafts. SW55.41XA: Bitten by pig, initial encounter . W61.62XD: Struck by duck, subsequent encounter. Z63.1: Problems in relationship with in-laws. W220.2XD: Walked into lamppost, subsequent encounter. Y93.D: V91.07XD: Burn due to water-skis on fire, subsequent encounter . W55.29XA: Other contact with cow, subsequent encounter. W22.02XD: V95.43XS: Spacecraft collision injuring occupant. W61.12XA: Struck by macaw, initial encounter. R46.1: Bizarre personal appearance. 16
The Bad news: Psychologists’ education and training has typically not prepared us well to function within the culture of the health care system. Non-physicians in a physician dominated system. Psychiatry has at times played the role of and ambivalent partner or outright adversary. Ally in coverage advocacy Opponent in Rx privileges
But the Times They are a Changing “Most of the prescribing of psychotropic medications has been dominated by general physicians who do the bulk of prescribing, estimated at more than 75 percent of all prescriptions for psychiatric medications in the U.S…(Sharfstein, 2006) “Psychiatric residents increasingly claim that they have no interest in psychotherapy and therefore see no point in attending seminars on the subject or meeting with a psychotherapy supervisor for one-to-one instruction... “(Gabbard, 2005)
In 2013 only 50.1% of the 1,360 psychiatric residency slots were filled by U.S. medical school graduates. 30 slots went unfilled and the rest were filled by International Medical Graduates (219 with U.S. and 186 with non-U.S. graduates). [Culture shift FMG to OMG to IMG]
The Better News Psychological techniques and approaches have attracted significant attention among non-psychiatric physicians. Integrated care service models will increasingly draw on psychological practitioners. Interprofessional practice has become a “buzz word.”
The Central Issues in Health Care Ethics What problems should we try to solve? What problems can we solve? Who drives the agenda?
Interprofessional Ethics in Health Care Quality of Care Communication Integration and collaboration respect for conflicting points of view Solution focused Follow through Patient Choice Access to information versus understanding Non-medical variables (e.g., personal preference, quality of life, spirituality)
Sample Issues Where Psychological Care Adds value Autistic Spectrum Disorders Caregiver Stress (Distress!) Child Abuse/Neglect Dementia Disability Evaluation Requests End of Life Habit-related health problems Pain Payment and Diagnosis Issues Procedure Eligibility (bariatric surgery, transplantation)
Integrated Record Systems: The eMR, ePHI, and e-billing Do you want to share your psychotherapy records with your proctologist? How can you avoid accidentally e-mailing sensitive material? What problems have we seen most commonly documented? 24
Potential Roles Screening for risks or procedures (e.g., depression, procedure tolerance) Procedure management (e.g., preparation, real-time, follow-up) Patient education Enhancing professional communication across diverse populations. Managing non-adherence Symptom control (e.g., anxiety, depression, pain, sleep disturbance) Prevention (e.g., anticipation of stressors, bereavement interventions) Outcome, Quality of Life (QoL), and Quality Improvement (QI) tracking research
Disagreement with Treatment Advice Coping with cultural diversity If you only have a hammer, every problem looks like a nail. Cardiac surgery versus Interventional Cardiology You want me to take drugs for that? Using data and patient preference to drive the agenda.
Key Ethical Issues Overall Competence (including new skills acquisition, when necessary) Consent (making sure patients understand and agree with shifts) Contracting integrity that serves the patient
Some things have not changed Want to cut your risk of an “adverse incident” by 95%? Don’t engage in sexual with current or former clients or their relatives. Don’t do anything that someone might mistake for a “forensic assessment,” without adequate training, informed consent, and thorough data collection. Don’t switch roles in a professional relationship without well documented consent by all parties. 50
121 issues raised in 112 separate cases ChargeNTypical Penalty Alcohol or substance abuse3Surrender or revocation of license Allowing unlicensed practice5 Reprimand/Censure/Public Reproval/Letter of Admonition, monetary penalty Failure to comply with CE or competency requirements59Additional education, monetary penalty Improper or abusive billing2Probation, supervised practice Inadequate records8Supervised practice, additional education required. Probation Incompetence, negligent, or unprofessional conduct3Probation, supervised practice or Surrender of license Misrepresentation of credentials7Monetary penalty Practicing beyond scope of practice1Probation, supervised practice Practicing with an expired license11Additional education, monetary penalty Practicing without a license13Cease and desist, Monetary Penalty Sexual misconduct4Surrender or revocation of license Substandard testing/assessment1Probation Other4Reprimand, censure, public reproval, letter of admonition
Sample Actions by Massachusetts Board of Registration Joseph F. Doherty, Cambridge The Board placed Doherty's license on probation for one year following allegations that he failed to conduct a proper client evaluation and failed to maintain adequate and accurate treatment records. In addition, Doherty's practice was placed under review by a consulting psychologist during the one-year probation period. Ellen Leigh, Arlington The Board issued a civil administrative penalty against Leigh in the amount of $1,500 for engaging in unlicensed practice of psychology. Leigh performed the functions of a psychologist when the Board had not issued her a license. Leigh also agreed to complete a continuing education class in the area of ethics/risk management. Mitchell Abblett, Newton Under a consent agreement, Abblett accepted imposition of a civil administrative fine of $5,000. In the agreement, Abblett acknowledged that in the course of his previous employment at the Judge Rotenberg Educational Center, he was assigned and had utilized the title "psychologist;" and that his use of that title prior to his licensure constitutes a basis for disciplinary action.
Kentucky http://psy.ky.gov/Pages/disciplinary.aspx Final Order7/3/2014 Final Order and Settlement Agreement5/7/2014 Final Order3/21/2014 Cease and Desist2/28/2013 Settlement Agreement7/23/2012 Settlement Agreement4/2/2012 Settlement Agreement11/10/2011 Settlement Agreement10/3/2011 Settlement Agreement9/12/2011 Settlement Agreement8/23/2011 Final Order3/7/2011 Cease and Desist12/30/2010 Settlement Agreement8/9/2010 Settlement Agreement3/1/2010 Final Order1/4/2010
Context Regulatory Jurisdictional HIPAA Compliant Technical Platforms Connections Protections Clinical What can I (do I want to) Treat
Personal Risk Assessment Consider: Patient Risk Characteristics Situation or Contextual Risk Potential Disciplinary Consequences Modified by: Therapist’s “Personal Toolbox of Skills”
Patient Risk Characteristics Nature of Problem History Diagnosis and Level of Function Expectations Therapeutic readiness Financial Resources Including Insurance Coverage Litigiousness/court involvement Social Support Network
Situational Risk Factors Nature of relationship Therapeutic alliance Real world consequences Setting Rural versus urban Solo practice versus institutional practice Type of service requested CBT Family therapy Forensic Evaluation
Therapist’s personal toolbox of skills Psychological makeup/personal issues Personal and professional stress levels Training background/qualifications Experience Resources Consultation Access to other providers Involvement with professional groups
So what should I do? Know the ethical and legal standards that apply. Pay attention to practice guidelines. Provide comprehensive informed consent. Conduct a conservative evaluation of your competence with clinical populations and activities: Knowledge and clinical competence Technical competence Emotional competence Belaboring The obvious?
Communicating by Text: example 1 “Some of my adolescent patients are inclined to sometimes touch base with me during the day via text messages. It's usually pretty intermittent, (i.e., the text conversations are not lengthy or detailed, just brief check-ins). Clinically, this seems appropriately supportive to me, but I wonder about the ethical side of it vis-a-vis confidentiality. I never use my name in the text messages, but they may have my full name entered into their phone which would then show up on their screen. I will be interested to hear your thoughts about this.”
Communicating by Text: example 2 “A variation on this occurred when I treated a young adult with a flying phobia. She had to travel by plane with several colleagues and so we worked through a graduated desensitization treatment plan. Before the actual trip she asked me to text with her while she was in the airport to get some surreptitious coping support during the most anxiety-provoking part of the intervention. I did this and it seemed to help her get through the experience successfully. But, again, I wondered about possible ethical violations. Thank you for considering this scenario as well.”
Ask yourself How will doing this aid the client? Empathic connection? Support between sessions? What hazards does this pose for the client? Confidentiality? Dependence? What hazards does it pose for the practitioner? Unrealistic client expectation? Clear limitations? Standard of care?
The “Crisis Text” What is the “crisis.” Is a text message, Skype, phone call, enough? What is the response expectation? What are the patient’s circumstances
Cloud Computing Where’s the cloud How robust is the cloud What’s in the cloud Software Data storage Who has access to the cloud Accessing remote computers 78
No mandate for psychologists (outside hospitals) yet, but when it comes how will blended access influence what you write? Multi-practitioner access Patient real-time access HIPAA and HITECH both mandate role segregation Special mental health data segregation to be developed 79
Legal Hazards Associated with EMRs Risk: Because EMRs allow users to move quickly through patient records, cutting and pasting information along the way, incorrect information can easily get repeated. Prevention: Avoid cutting and pasting data in EMRs, and use caution when moving from one patient’s record to the next. Risk: Practitioners charting in EMRs may lead to some less thorough documentation than with than paper charts.. Prevention: Electronic notes should include full and careful documentation.
Risk: Computerized expert systems can offer actuarial guidance in deferential diagnosis and clinical decision making, but they cannot possibly cover all contingencies. Prevention: Avoid over reliance electronic assessment and diagnostic aids. Risk: Safeguard confidential electronic patient data can prove challenging. Prevention: Use encryption and secure access on all electronic access devices and discourage employees from taking records or unsecured content out of the office.
Risk: Some EMR systems may not clearly document changes to records. Prevention: Optimal systems should document modifications and have a program lockout period after which no further modifications can be made to a record. Risk: Many states have notification requirements in the event of a data breach. Prevention: Understand and follow state law requires if a data breach occurs, making sure that all employees understand and follow requirements.
Risk: Destruction or delete of electronic records can easily occur by accident or sometimes intentionally if a lawsuit looms. Prevention: If sued, all records (including electronic data) related to the patient in question must be preserved, including emails, phone messages and computer records. http://www.ama- assn.org/amednews/2012/03/05/prsa0305.htm http://www.ama- assn.org/amednews/2012/03/05/prsa0305.htm
I don’t want to get Yelped! What can I do? Monitor your web presence Use an optimized professional web site and similar publicity to suppress adverse search returns Hire an attorney to raise defamation claims with the website Consider contractual prevention strategies Consider the services or a reputation protection company (e.g., Reputationdefender.com and Medical Justice.com) Solicit positive reviews from colleagues Try to ignore them and hope they won influence consumers.
I’ve been Yelped Response strategies Respond on the site without breaching confidentiality. Remind readers that there are two sides to every story and that you owe all clients a duty of confidentiality Don’t mention any specifics or identifying information about the patient. Develop an active positive branding program Collect consumer satisfaction data. Don’t make promises you can’t keep. Remember that the Internet is forever
Professional Web Sites: When you control the message Access to Information Marketing your practice/products Directions to your office Downloads Access to Documentation Efficient communication Effective promotion of psychologist’s skills, experience, and competencies/specialties.
But beware… Site security Boundary issues Appropriate marketing Blogging challenges File transfer and e-mail confidentiality
Facebook, LinkedIn, Twitter, Google Voice, What’s Next? Security Issues Retention of Files Friends of Friends boundary issues Fan? Harassment Stalking PHI Failure to terminate
Do you Need a Friending Policy Sample per The Trust: “I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.”
The Trust’s Suggestion on “Following” Policy “I publish a blog on my website and I post psychology news on Twitter. I have no expectation that you as a client will want to follow my blog or Twitter stream. However, if you use an easily recognizable name on Twitter and I happen to notice that you’ve followed me there, we may briefly discuss it and its potential impact on our working relationship. My primary concern is your privacy.”
More on Following “Note that I will not follow you back. I only follow other health professionals on Twitter and I do not follow current or former clients on blogs or Twitter. My reasoning is that I believe casual viewing of clients’ online content outside of the therapy hour can create confusion in regard to whether it’s being done as a part of your treatment or to satisfy my personal curiosity”
Zur Institute on Modern Day Digital Revenge file:///G:/Documents/MPA/Workshop/Modern%20Day%20Digital%20Reven ge%20on%20sites%20such%20as%20LinkedIn,%20Google+%20and%20Ye lp.htm file:///G:/Documents/MPA/Workshop/Modern%20Day%20Digital%20Reven ge%20on%20sites%20such%20as%20LinkedIn,%20Google+%20and%20Ye lp.htm
Dealing With Licensing Board and Ethics Complaints Know who you are dealing with and understand the nature of the complaint and the potential consequences before responding Licensing board or professional association? Psychologist of non-psychologist investigator? Formal or “informal” inquiry?
Understand the Precise Nature of the Complaint and Rules That Apply to Responses and Any Proposed Actions Have you been given a detailed and comprehensible rendition of the complaint made against you? Have you been provided with copies of the rules, procedures, or policies under which the panel operates? Do not contact the complainant directly or indirectly. If the complaint involves a current or former client, make certain that the authorities have obtained and provided you with a waiver of confidentiality signed by the client. Obtain consultation before responding.
Organize Your Defense and Response to the Charges Carefully and Thoughtfully Assess the credibility of the charge. Compile and organize your records and the relevant chronology of events. Respond respectfully and fully to the questions or charges within the allotted time frame. If asked to provide unusual materials during the investigatory process, do not comply without first seeking legal consultation If offered a settlement, “consent decree,” or any resolution short of full dismissal of the case against you, obtain additional professional and legal consultation.
If you need more time to gather materials and respond, ask for it. Be sure to retain copies of everything you send in response to the inquiry. Do not take the position that the best defense is a thundering offense. This will polarize the proceedings and reduce the chances for a collegial solution. If you believe that you have been wrongly or erroneously charged, state your case clearly and provide any appropriate documentation. If the complaint accurately represents the events, but does not accurately interpret them, provide your own account and interpretation with as much documentation as you can. If you have committed the offense charged, document the events and start appropriate remediation actions immediately (e.g., seek professional supervision to deal with any areas of professional weakness, enter psychotherapy for any If a charge or complaint is sustained and you are asked to accept disciplinary measures without a formal hearing, you may want to consider reviewing the potential consequences of the measures with an attorney before making a decision. Know your rights of appeal.
Take Steps to Support Yourself Emotionally Over What Is Likely to Be a Stressful Process Extending Over Several Months Be patient. It is likely that you will have to wait for what will seem like a long while before the matter is resolved. It is perfectly acceptable to respectfully inquire regarding the status of the matter from time to time. If appropriate, confide in a colleague or therapist who will be emotionally supportive through the process. Your relationship with your therapist may be protected by privilege. We strongly suggest, however, that you refrain from discussing the charges against you with many others. Doing so may increase your own tension and likely produce an adverse impact as more and more individuals become aware of your situation and may possibly raise additional problems regarding confidentiality issues. In no instance should you identify the complainant to others, aside from the board or committee making the inquiry (after they produce a signed release) and your attorney. Take active, constructive steps to minimize your own anxiety and stress levels. If this matter is interfering with your ability to function, you might benefit from a professional counseling relationship in a privileged context.