Initial Online Therapy Consent Made Easy

Esign online therapy consent

good afternoon everybody and welcome to this week's telehealth secrets with our special guest Roy Huggins just a few housekeeping announcements before you get started my name is Ann you can't see me but maybe I can get a show of hands first if you're if everyone gonna hear okay so you should be able to see a hand raising thing we got okay great sounds like we're having you're doing okay I'm hearing all right so just a reminder that this session will be recorded and the slides are available in the handout section right now if you want to download them and they'll also be made available in the next few days please submit your questions via chat we'll be answering them at the end and if we can we'll answer them during oh we have a bunch of staff back here and also please check out our past webinars we have really good stuff on I'll practice coding and billing and tell us like how free and stuff like that so and with that let me go ahead and give the time over to Milton thanks Sam either thank you so much everyone I said welcome to this with telehealth secret sign my name is Milton I'm the seal of VC and for the people who have not join us before is the way that telehealth company behind a lot of the big brands like Martin McKesson a bunch of others and so this week I was really excited to welcome our guest this week so he's a long time we see you sir and one of the pioneers in telehealth and I think if a lot of you guys have seen his writings and he said I just mix really in flesh now so he's a founder of person-centered tag boyega so Roy is a web developer turn councillor and now directs a person-centered can again give one of the person uniquely from starting from the technology and blending into a counselor and we do this which is rather unique I think perspective on this thing again I think he's inside on how do you actually create an online practice how do you grow our conditions understand the internet and the cities were like electronic communication aliens was this practice the future I think will be really really insightful so we're super lucky to have him and when one of the fun fact about him is he has I can perform Carnegie Carnegie Hall before yeah sometime I'll just tell us about the yeah is I love giving that as my fun fact because it it's a in in college I went to Grinnell College in the mid-90s and 1995 was the 150th anniversary of the state of Iowa where Grinnell is and so my college choir the Grinnell singers performed a piece by my advisor at Carnegie Hall and also at the Des Moines Symphony Hall at celebration of the state it was great awesome there's actually incredible to be honest but yes [Laughter] turn the floor three-year and the pker just share some you're inside sounds good I have a neat little slide deck here I'll just go through that and and we'll get talking and doing questions so the top ten hits tips for running your online therapy practice it's supposed to present for about 10 to 15 minutes and then have time for Q&A which I think it's a great way to do it and so this is a very packed slide deck so I won't really get into exploring everything I look at because I want it to be a useful reference for you all I know Ann has put it in the handouts piece in your control panel so you can download it right now and I'm sure there'll be other ways to get it too if you don't find it there so let's talk about that we're going to talk about teletherapy that i have noticed by the way is during the coated times emerging as the word people are using to refer to doing therapy psychotherapy counseling the various terms via telehealth tell a behavioral health element Health online counseling distance counseling telepsychology there I think J Ostrowski did a survey once and found like 42 different terms being used for this and I have discovered and I didn't expect this that in the Cova times the big emerging word was teletherapy so that's what I call it now that's what I'm going to say teletherapy all right we're going to talk about choosing tech HIPPA and security informed consent with teletherapy crossed a practice setting up a program for Kelly behavior health Otello therapy and what's going on with the co good times a little bit about what's different now and some ethical considerations you might want to think about as we're exiting the Cova times because starting to think about it now could be important alright so get into that what we won't talk about just make sure you understand because the televi Haverhill health includes these things but I don't talk about them things specific to psychiatry I tell it prescribing I don't even want to try to touch that nothing good I tell you some things billing and coding for tel-aviv Ural Health not that I don't know anything about it but I'm not an expert and I'd rather not try to advise but I've got a link here to a fantastic video that the simple practice folks did that's just really laid it out really clearly so I also don't see a reason to repeat the repeat their wheel invention there just click that and it's a great video it will explain almost everything if that doesn't explain everything you know also check out you know medicare has guides for billing and they will explain how to do Medicare teletherapy building as well it's actually the billing and coding is pretty straightforward the thing gets complicated is how every different insurance plan wants to do everything differently that's where things get complicated and the only thing a person like me can tell you there is ask them which is not very fun but it is what you got to do yeah we actually just an audience member we also have one of the earlier speaker we had on the show essentially on the deep diving there's like in the security shield was something like when these common mistakes and so on and the good news is he's available for consulting service if you want to so we definitely highly recommend it just like you want to take little payment piece they're not them I recommend that too then that's perfect okay has to leave to that for the audience vendor is that particular yeah so choosing tech so when you're choosing tech we are focusing on the idea of online therapy teletherapy through video conferencing and this matters because if you start to really study teletherapy and telemental health will you discover is that there's actually a huge just you know well of opportunities for ways you could deliver healthcare and deliver psychological services and care to people getting into working with avatars inhabit our space or you know the ways in which you can get out of the idea out of that box of just having like a 45 or 50 minute session where you just do counseling there's so many things you can do with this concept of the technology assisted therapy and teletherapy that's just this is huge world that we as a field are still not really ready to enter but people who are really specialize in teletherapy may be there but the reasons why we focus on just videoconferencing like i do with vc is one its what medicare has done all the research on and they feel confident about it and there's a lot of research that makes us feel confident about it as a medium for delivering the kind of therapy modalities and skills we already learn in school because in school we're learning something focused on the idea sitting in a room across from somebody and i'm talking to them and that being how we deliver care primarily primarily and so videoconferencing is a functional equivalent telehealth functional equivalent of the classic therapy medium that we are trained in and so i think that's a big part of why it became that kind of gold standard for how we do things hopefully over time the whole field will start to really get into the fact that there's so much more possibility there but certainly it does make sense that as we start and try to get everybody in therapy starting to work with tech tech assisted therapy and remote therapy that we start with video conferencing although many would argue is you start with phone sessions but that's a whole other question because of insurance coverage for phone sessions and such in regular I love a slide later about how that is better covered during Kobe times so based on that videoconferencing that's what we're doing the hardware in general you want to think about is computers with monitors and I discourage you from using small screens a thing I'm seeing a lot during the kovat emergency is people depending on tablets like iPads and even worse smartphones for delivering care there are a lot of reasons why that's not the best idea the most convincing one for me is that research on clinical effectiveness indicates that you're you're most likely to be able to accurately assess a person's mental status an effect with a monitor that's at least 20 or 22 inches depending on how you measure the size of the monitor right the the original research on this actually said 16 inches but that's back when monitors were almost square shaped like four by three these days are more sixteen by nine then we're letterbox shaped so the letterbox version of that is like a 20 or 22 inch monitor I am on such a monitor right now talking to you and it's how I see all my clients sometimes I use a 15-inch laptop monitor and that does all right especially the clients that I already know well I have a strong understanding what's going on for them especially if you're seeing someone new big monitor even bigger is better the idea of small monitors and small screens I know we love our mobile devices but we want to consider that's not as clinically effective right there are a lot of mitigating factors there that you want to learn about as learn more about telehealth and fellows era P but your baseline is big monitor their rate lets you see your client and of course you want webcams and microphones sometimes one device does both things well since I'm talking about having you get a monitor you would need a webcam people ask about the webcam that's built into their computer sometimes those are great and it works fine but you want to test them in different environments like for example we have found that the camera built into MacBooks as a tendency to create a lot of tracers on people on the screen and you may not really notice that until you're trying to really do therapy to standard of care on sizeable monitor and you realize that you know you're actually kind of you know they say that you're actually kind of fuzzy as you move around you don't notice these things when you're just talking to your friends on skype or doing other things that the general public those with videoconferencing when you start to really get discriminating and really high professional about how you're doing therapy over video and you start looking for the little differences that help kind of make the video disappear so that you're engaging directly with the person you notice that those little differences in quality can really mess things up it's not going to ruin your therapy but it does it does put more of a barrier in and you want to remove barriers like we're trying to do everything we can to remove the remove anything that gets in the way of the direct human to human connection it's a video so that's part of why I do encourage you to look into just having an external webcam and potentially asking clients about that as well but also I should say you know the new iPad cameras are amazing all right so like some people you denied that probe which is a nice big screen as an amazing camera and they set it up well it works fine so I want to make sure I do acknowledge that but in general you want to be really thoughtful about the quality of your hardware and how it actually impacts your ability to remove the tech as a barrier or a thing that it distracts and catches attention when you're trying to connect from human to human and the other is lights get lights like have a light that shines on your face if you do therapy in front of a window and you have natural light on your face awesome but you can't rely on that it gets cloudy or you have to see someone late in the day the weather changes seasons change having lights that you can shine it can be a really big difference and of course when you're modeling to your client good lighting and cameras that really bring across a clear picture you know they're more likely to follow your instructions we're saying hey can we get a I need to see you clearly there's shadows in your eyes that are on your nose that make it harder for me to really know what's going on with you is there a way to get yourself in front of a light you know that's useful so that's like your basic hardware software services you of course need video conferencing software such as VC which is what I use electronic payment and you need secure email and or texting usually but you need something for communicating between sessions if you're doing fine with a telephone great that's no problem but usually clients need more you need more that's usually a textual and so some kind of secure communication between sessions is useful VC has in it secure messaging I know people who use the VC app on their phones to actually message with clients that's not usually how the VC app is used but it can be used that way by the way I often use signal with my clients but I would only recommend signal for solo practices if you have a group practice or agency I wouldn't recommend using signal because it's really hard to actually it's impossible literally to maintain discoverability of data which you need when you have to be compliant with HIPAA and if you're a public agency you you usually need discoverability in order to comply with your your government's rules and laws so signal would not be an option there but for solo practices signal can be great because signals nice open source free secure texting option and of course if you and your clients are already using VC together anyways you could use the Visia those are great ways to have secure textual communication with each other so speaking of security let's talk about HIPAA so the first thing I want to make sure everyone knows what HIPAA this is really important is that HIPAA security compliance like being HIPAA compliant is not related to what software you choose or is related but it's not about that at all all right there's no such thing as a product that's HIPAA compliant and I know actually VC used to advertise as HIPPA secure the phrase I like these I'm sure the reason they'll say HIPAA compliant is because that's what people are looking for people want the product to say hid the compliant on the website and I think this is true of the vast majority of products that we as therapists use is that they'll put the word HIPAA compliant on their website because that's what we've been told to look for but many companies know better that I know Milton has always been very good about this it's one of the reasons I've always been a fan of VC is that VC and Milton have always been very good about trying to make sure that people who use their software understand that being HIPAA compliance is more than just picking the right software Oh picking the right where is a big part of that yeah when you see that a software product that involves a service you did a cloud service when you see this HIPAA compliant phrase on the website what that usually means and what you're hoping it means is that they will execute with you HIPAA business associate agreements and that's actually been one of the big pieces of history between DC and the mental health community is that VC was willing to execute business associate agreements even on the free tier of their software going way back that changed with the huge changes with Cova which completely understandable and that's a whole new thing but for years there that was a big part of VC giving into the community was being like we will do this because it's what you need it's the right thing and it's how you how is service vendor helps with HIPAA security compliance for us but it's not the whole thing because complying with HIPAA is actually a whole process an ongoing process that we do and I think a thing for both solo therapists and group practice therapists that we often kind of need to understand we're not told we're not taught in school and it's really hard to get anyone to tell us this at all is that complying with HIPAA is is basically a business process it's an organizational business process all right it's not really it's not like an ethical thing like I just finished teaching my seventh year of teaching counseling ethics at Portland State University's counseling program and when I teach ethic you know students want to know about HIPAA compliance and the big thing I note with the students is we were just talking about ethics which is like an aspect of professionalism is very philosophical right as well as being very practical it's something that we do a lot of discussion about and you try to like unpack things understand things HIPAA is a regulation the the way HIPAA is written it assumes that this philosophical concept of ethics is really just not in the cards at all all right HIPAA assumes that someone in your practice is there to run the organization like someone like picks tech and picks processes and designs policies yada yada Hippos written on the assumption that your practice has someone doing that stuff and so it's written for that person he says okay you the person who runs the organization these are the things your organization needs to do these are policies and procedures you need to have and here are the things that those policies or procedures need to make sure you're doing and here are the updates and like up keep things you're supposed to do and so HIPAA has a Privacy Rule which most of us are more familiar with and it's the realm of attorneys and you have to have privacy policies now these are written policies about how you do privacy practices you need to have a notice of privacy practices we often call it the HIPAA form which is you know that document you get the clients that tells them what your privacy practices are and you need to by the way posts your your notice on your website if you have a website post your HIPAA form there and add other stuff there too but that's that and then there's a security rule which works very differently that's generally the realm of information security technicians and that's where I work when people talk about me being a HIPAA expiry pass Security Rule expert I know enough about the Privacy Rule to be dangerous but basically I know enough in order to make the security stuff work and like what what person Center tech does is primarily the security and tech standards and to comply with a security rule you have to perform a security risk analysis develop risk mitigation plans and write security policies and procedures based on your risk analysis if you haven't done those things your practice is not HIPAA compliant all right I'm gonna say that again no matter what products you use including the excellent VC right if you haven't done these things your practice is not HIPAA compliant I HIPAA compliance requires doing these things and in the process of doing these things according to HIPAA standards you will choose services like we see that are HIPAA friendly and hip is secure you know they give you business associate agreements and such like that all right and you will make policies and procedures for how you use those services in a way that maintains your HIPAA compliance all right luckily most video conferencing services like VC using them in a way that matches your HIPAA comply is pretty easy like there's not a lot of complexity there which is nice but for example using a product like Google G suite which can offer you HIPAA from the email is pretty complicated but using that in a HIPAA compliant way actually requires some procedures because even though Google will give you a HIPAA business associate agreement when you get G suite if you send an email from your HIPAA friendly G suite it's still just an email I think it's still not secure all right so at that point the fact that it's super friendly and how you used it for friendliness begets complicated right so there's differences from the services you use in how HIPAA compliance is or isn't complicated when you use it all right informed consent so that's HIPAA compliance that's the whole thing right there I told you in five minutes all right this hope if we're we said most states are licensing boards actually require you give special informed consent for telehealth some of them and actually define things I have to go into your informed consent the American counseling Association and National Association of Social Workers ACA NASW there are codes of ethics requires special informed consent I know the ACA code actually has items that must go into your informed consent if you're going to do telehealth we have an incentive tech we have a free sample of the informed consent document we made for our tellement the whole certificate program you can go download it during when Kovan came along we realized everyone needed that really fast so we just released it for free and go to our front page and you can find it there in our code 19 telehealth resources the informed consent document for telehealth one that actually covers all the things you might need to cover it's pretty long it's a few pages you might be surprised at how much stuff you need to add to your informed consent that's just for the teletherapy but if you go read it to trust me it will all start to make sense you'll start to realize oh yeah of course you would need to do that or if that makes sense but that client would need to know that that's what's gonna happen all right so go check out ours it'll make a good reference and of course you can use it in your practice the one we have is suitable for solo practices and for group practices so please use it in good health is available for everyone is cross state practice is always it's the biggest thing we try to talk people about all the time and it's always evolving which is interesting so the real important thing to know about cross state practice is that licensing boards exist to protect their public not to support us that is not the purpose of a licensing board like licensing board doesn't care about us or our needs well that's fine Italian people do but the the organization doesn't right like that's not where they're for right so that's they're there just to protect their public and that's why the kind of weirdness across they practice makes more sense and I in light of that and so that's why we've ended up with this situation where the thing that determines the laws when you have a cross state session is primarily the clients location at the time of session and well the reason I say that is that wherever the client is physically located like that licensing board gets to decide whether or not it's legal to work with that person like I'm an Oregon I'm in Portland Oregon I know Milton's in California not far away right it is not unreasonable for one of my clients to take a trip down to the Bay Bay Area where I know no one is nearby and they may want to do a session while they're on vacation well they're in California and the California counseling board because I'm a counselor and I do counseling they're gonna have a say about that in fact I happen to know that what they will say about that is you may not do it they will say that I'll be breaking California law if I do my counseling session with that client while they're in the Bay Area that's just the way it is what's and they also during the kovat emergency they have not changed that however if that same client took a trip to Phoenix Arizona no the sunny state of Arizona this client likes to go sunny places organs not usually a sunny place right they go to Arizona I go look up the the counseling board rules for Arizona for the counseling board I'm a counselor and they actually give me permission to work with that person temporarily they actually give me a lot of permission they're really permissive with allowing me to continue working with that person while they travel in Arizona I've looked at the law a document that I did and I do my session with that client so it's not just that you can't practice across states it's that wherever the client is and wherever you are has jurisdiction on the session and so the things with enforcement power is where is a client physically located where is the clinician licensed and where is the clinician physically located so I'm licensed in Oregon I'm in Portland Oregon if you're not familiar Portland Oregon is right next to the state of Washington we're like up against the border I can go right across the river into southern Washington let's say I'm visiting my aunts who lives there and I want to see my clients from there technically speaking I'm in Washington if the state of Washington wants to tell me hey we we have jurisdiction over your session cuz you're here here's what you have to do they can do that so can Oregon because I'm licensed there and that's the license I'm working with and let's say my client is in Arizona so Arizona has a say as well right is it messy yes is it American yes it is all American is that the grassroots governments that America is built on has some ups and downs and this is one of the talents of how that goes things like that are changing if you if you're not familiar sigh pact if you're a psychologist you should know about SCI pact SCI pact is a basically it's been a years in the making and it's gonna activate on July 1st so we're recording this on June 11th all right and a couple weeks few weeks this is going to go active the details we don't know but there are a growing number of states that are part of the site that and if you're if you're psychologists in a state license in a state I should say that does the side pact then you'll have the ability to go pass an exam under asppb which i believe it's the same exam you take just to get the asppb letters after your name if you want to do that if you pass that you can apply for what's called the e passport and the e passport is a special like certification under the SCI pact that lets you do telepsychology anywhere in the entire side pact any state in the Sypek there are currently I think 13 states in the side pact and a couple more coming in including Washington which I referenced earlier which is a big deal by the way so if you're in a Sypek state neuropsychologist lucky you right that'll definitely help change things about this so here are must use resources if you're looking at cross state practice which right now you probably are because everyone is like gone home for for quarantine the Epstein Becker Green Survey is super valuable this is an app from a national law firm called Epstein Becker Green every couple years they update the survey of telemental health laws for all the professions that do telemental health including psychiatry and nurse practitioners and several others as well look up your profession the state where your client is and they'll help you find the law also a person-centered tech my company has our own survey that's slightly different from the Epstein Becker Green you know the person-centered tech comm and see that it's it's a survey of the emergency rules the code of emergency rules and the Evergreen all the time rules for temporary practice so a temporary out of state practice so if you got a client who's traveling you want to find out if temporary out of state practice is currently permitted where they go go check out our survey it will tell you about that and ours we were trying to continuously update all right so if you guys have a program how you do it if you're a solo practitioner primarily you go check out the stuff I said earlier this is for group practice or agency we strongly recommend through a lot of experience with building programs and agencies and building programs with group practices especially private practices we've done a lot of those really recommend having a procedure manual and a policy manual for your telehealth program and the reason we like that is it can really eliminate the amount of extra training and work your clinicians have to do if the manual tells them all the things you're going to do like if you define this is the tech we're going to use we're getting the software that we're going to use and we're going to supply it to everybody we're gonna have standards for hardware we're gonna have standards for making sure everybody's prepared to work on camera skillfully using the on-camera skills that we want to learn and we're going to have a standard for how we handle you know time of session documentation and cyclic psychological safety assessment and a assessment which are all standards of care for telehealth where we have a standard for dealing across jurisdiction we have a standard for you know if if a client is in a state that requires us to do a risk assessment or other assessments before we start telehealth which some states require that they probably don't vary in the co Boone emergency but they may require it again after the code emergency it just defines all that so people don't have to be taking news new new classes or studying something new or figuring out a whole new way of doing things every time a claim moves around which happens a lot when you're doing a telehealth program you just have a manual to lay that all out we really strongly recommend that as you can probably guess we do sell those yes we do but I also strongly recommend it if you can make your own either way trust me it'll save a lot of time because for teletherapy the kind of standard for a continuing education program to get a therapist from not really knowing anything anything about it to being qualified to do teletherapy the standard for that is anywhere between 12 and 15 hours depending on which organization you're looking at like mvcc's program is 12 hours that's the BCE TM HP the board certified tell them at the health provider that's 12 hours but a.m. fer B which is the marriage of Family Research Board so that's like marriage family licensing boards Association they have a really great document about what they see is the standards for American family therapists to do telehealth and they recommend a program of 15 hours so like in Louisiana and Texas the marriage of family board requires everyone has 15 hours of training before they're allowed to do teletherapy for example all right that all makes sense in the context of assuming the thing we tend to assume in mental health which is the assumption that the clinician is operating on their own like even if they're in a group practice or agency the assumption is that the clinician does everything for themselves and though and doesn't learn new things or sorry doesn't let someone else teach them or take care of stuff they're supposed to know everything themselves would like be like an island in that case 12 to 15 hours makes a lot of sense to me like our program is our certificate program is 17 hours right you know we really see that there's a lot to learn but in a agency or group practice you can actually eliminate the need for a lot of that training by figuring the stuff out for the clinicians because even in our certificate program like 12 hours of our program is logistical stuff you know it's technology choices it's how you do a crusty practice stuff it's all these issues that you can predefine for your clinicians and when the issue comes up for them a supervisor can help them make a decision so the clinician doesn't have to be an independent expert on telehealth they just need to know how to deliver care skillfully through the video like that's all they really need to learn to do if all the logistical stuff is taken care of by the practice right so like we found in our setup the supervisors take like this you know 12 to 17 hour programme they take the full program but then clinicians all I need three or four hours because that's how long it takes to deliver trainings on being effective on camera clinically effective on camera and the kind of thing is the clinician needs to know legally and ethically for when they're working with someone who's remote it's a much shorter program they're doing a full certificate program now of course this model doesn't work in every state because for example Louisiana and Texas FFTs have to take 15 hours they can't be given a shortened program but in a lot of the cases you can do that and it really makes your program a lot more efficient a lot more uniform we find doing that really helps a lot right really it helps clinicians who are not very tech savvy feel confidence you know they have uniformity they know who to talk to and ask questions too they can talk to their colleagues about what they're doing because everyone's doing the same program they're doing everything the same way according to the manual it's much easier to get support and help people feel supported and of course research indicates that one of the biggest factors in the success of technology assisted therapy is the therapists own attitude towards the tech you're using and when you can help your clinicians feel confident about using tech because you've given them this kind of safe container of practices and procedures they tend to perform better that's the sorry anecdotal experience but we also recommend that you decide on what hardware people are going to use and what services people are going to use and like assign them okay lastly the emergency considerations for kovat time so a lot of states are opening up for out-of-state license e's so like not every state for example of california did not decide to do that for counselors MFT s and social workers neither did washington no i'm not better not at all but most of the american states have done emergency declarations usually a executive order from the governor sometimes a special decision from the Department of Health that opens up practice to people in other states during the emergency so that we can deliver care to those places so there is a temporary heavy openness in terms of able to crack practice across state lines but something you want to consider there in terms of like ethical considerations is should you take a new client from out of state if that client if it will eventually become illegal to work with that client well so for example Wisconsin is example just getting them at my mind Wisconsin is an example of a state that temporarily opened up to out-of-state practice but normally does not allow me to have temporary practice and there's their borders so outside the emergency I would not be able to practice with someone Wisconsin and so someone from Wisconsin reaches out to me and says I want to start therapy with you should I take that client knowing that whenever the emergency is lifted I will not legally be able to practice with them so that point there's a risk that I will either end up having a inappropriate termination event you know an abandonment event with that client because I have to stop or I'll be breaking Wisconsin law by continuing to work with them it's not great either way so something you want to consider when you're thinking about taking new clients on during the emergency who are out-of-state most insurance plans are going to cover television real health for the emergency pretty much all of them are doing so and many are even covering phone sessions which i think is really good they should always do that in my opinion but that's a whole other the so and this is another thing about like access to care and abandonment once again the the kind of frustration here is now the insurance companies are kind of holding the health of their insurers in their hands because this is an excellent thing for making sure people can still get access to care without putting themselves at risk of infection by coming to an office when the insurance companies stopped doing emergency coverage if they if they stopped doing an emergency coverage of telehealth before we like have a vaccine or whatever it is that makes the coronavirus really not a threat anymore like really not a threat like if they cut if they stop doing the coverage before then what will you do with your clients who need access to care but are at risk if they get infected and probably shouldn't come to your office alright so many insurance plans are saying that they're not going to do that they're going to try not to do that but some insurance plans are kind of doing that so you might want to think about if you're dependent on the emergency insurance coverage you might want to think about okay how what's a contingency plan for if some of these insurance plans stop doing this coverage and my clients certain clients who are at higher risk of of coronavirus infection if they if they suddenly don't have telehealth coverage how am I going to get them help am I going to reduce my fees do a sliding scale are we going to do something else how are we gonna you know if it's not safe from the comvee office how am I gonna handle that so that's something you probably want to think about or at least have in your mind right now so here are some must use resources for that once again the person-centered tech survey about temporary practice also a hip which is like a professional association for insurance providers they have a they actually have a page in which they're trying to keep up to date what all the different insurance companies are doing for emergency coverage so this is a pretty useful resource we're trying to get an idea of what the insurance fans you work with are doing and whether or not they're doing emergency coverage so go check that up it is from their professional association so they're very pro insurance but it's still very useful survey and that's that sorry I went over the 15 minutes sorry about that let's do some Q&A I think I really appreciate I think you give a like really really insightful just but I really like to come about the size of the you know it's like this all going back to so why do my PhD whatever research into my trust things knowing the size of the somewhere the data on that comes from Milton himself like you know to get a free trip to Iceland and pursue research but thank you so much that was really really insightful about we have basic for all these embers in those area feel free to start pouring the questions in there so we have a question for Sheila she's asking what about using the headphones in there do you have any commas in terms there's to Nauticus there's like yeah where's bulky careful would that make the patient's feel weird where you want to make a tiny small liquid right when I do that I use your butts this is my earbuds they're all talking about finish up like this doesn't it like this look is a lot less obtrusive than the headphone look just fine the others to consider you know the reason why we care about that mostly is to avoid echo which is actually really important if you got echo let's get ruin your therapy session but I've got my here's my microphone I got a Yeti oh my speaker is right here finish no it's too short but you know if that's a problem I the Yeti is directional like it only records in front of it because I've set it to cardioid which I was a music major as you probably guessed and so I know how microphones work but like but like the cardioid setting only records in front and so it's it's less likely to catch this out and as you know Milton like of course the software you're using is trying to filter out echo yes so that those two things combined if you can consistently get a setup that doesn't create echo you won't need them but with clients you often welcome to wear something I think another thing is just getting used to have headphones as as fashion and just being like a certain client that like when I imagine them in my head I always imagine what these big bulky headphones she always wore for every session so to me that's just where she lives but I think I said that in terms of the audio I think that all the modern are these were software they do to the echo cancellation but some K does not work as well so we definitely recommend like I think if you actually have this has said that you can improve experience I'm quite a good if you know things when you're so handsome something is also where the microphone pick up I think as I do I think measure some of these new iPad is not only great camera amazing microphone be if you use some laptop Weston case is something a lot for the microphone that the quality just is okay it's just a little bit not as good just try to get an external thing and we recommend you if it could be close about one inch to the last or below your mouth at just tender beer you doing the about expensive microphone but just a physical this and just give you much much cleaner on experience definitely yeah another thing I'm really excited to share with you is like we've been friends for such a long time in fact during the whole Culliver we feel very bad our server just a hole over one where I took the free version also ah the goodness we've been like working like crazy our server things we actually free we see baa everything your love before this back okay I'll ask you more about that later because I thought that there's a limited availability I'll get more data about that so yeah you was we felt to be on we felt like just absolutely terrible in there because we are very very committed to having free servers as HIPAA compliant skip is secure we signed the BAA we're very committed to that do it we're just like our server just hosted because we had to pay look at how much we're paying Amazon saying oh well we do no judgment at all zero but we just felt like we're two killed here but the good news is like there do a lot of things Chester dollars is free in fact the free versions even better we're actually costing more features into the free option too so that idea is just like gonna give something like I'm a better class right I'm like I used the paid version should I be using the free would love for users so we have a question for Erica asking sir she said she's in Texas so she says she's seen the spouse of a soldier that live in another state in North Carolina okay so she's been seen this life before hosta was in Station Texas and now she would York North Carolina and does the the patient covered by Humana military and then the Humana manager yeah okay great the real time houseful the misuse of Humana military soldier moves so frequently in there so they have a special provision for soldiers and their family to receive counseling between across names like you sure like do you know anything that for military family that's it you might have a different set of rules follow the general on mental health yeah okay so the it's too bad okay it's for temporary practice provisions for now might see you two clear with 19 so there might be emergency looks like there's quite emerging coverage but the so this is questioning a lot as military questions right because the you know one it's you know this situation of a state siloing really hurts military cuz I move around it also hurts military therapists by the way like Oregon's counseling board just passed a rule for temporary licensure for you know therapists who are any military family so that when they move to Oregon you know their license will transfer they can keep practicing but the the challenge here is I can't speak to the details of like when the person is on bass and how that works legally because that's more complicated about than I understand that then I can get into but like they are in North Carolina and so North Carolina that they're gonna have well they have a law like they're the ones you get to determine it and so the thing that's right I think is really important for clinicians to remember is that insurance coverage and license I have absolutely no relationship to each other so like the this is the bit that confuses because we have a tendency the insurance practices have such a strong reliance on one insurance company programs do that we start to think of the insurance company like it's our licensing board as if they're the ones giving us permission to practice and I don't like that dynamic because insurance companies are private companies and what they wanted anyway that's all other thing but like it's important to remember they actually you know the your your legal right to practice your profession is actually not related to insurance carriers at all alright so like that's a really important thing to remember but of course like your ability to practice because you can't get paid it's a whole other thing right so like I totally get the reason so North Carolina according to our survey here does you know we're seeing the none of the North Carolina boards in a normal in a normal time allow out-of-state licensees to practice their they had no temporary practice permission okay but here I mean we're seeing a emergency declaration so you probably check it out like I'm coming you gotta read the emergency declaration but it seems like there's a good chance that at least during the emergency that's legal thank you so much Jack our audience is asking me because like in Asia what about you to any asset for consideration for cross national bond treatise you have a patient who sound like moved to different countries now why sometimes it's easier okay so my entire my little history here is one of the reasons I've always stuck with VC as my before Ovid my entire telehealth practice was with English speakers in Japan like because I used to live in Japan and I'm gonna when I came back and started trying to my private practice I was getting my license and my supervisor was why stop saying people in Japan there like no counselors there especially you speak English and I did all that new diligence and so what happens there is a pattern you'll see quite a bit which is Japan does not regulate psychotherapy or counseling at all right they regulate medicine so if you're a psychiatrist it would be illegal to practice in Japan without that license but or maybe a nurse practitioner but Nursing is very different Japan so like the you know I you know I did a lot of diligence talk to a psychiatrist in Tokyo I was in and he gave me great advice about you know thinking about that and talk to Japanese police because Japanese can't do welfare checks it's that's a very currently kind of North American maybe European concept of police doing welfare checks I'm like so you gotta know like if you don't know these things think your things to go awry in a really bad way there are there are very different risk management considerations when you're working without regulation like with no regulation but the advantage is you're not prevented from practicing that ultimately is a big advantage if there's no regulation but beware it also means you're not recognized the Tokyo psychiatrist gave me a great advice he made a really good point he's like what if your client suicides and the family sues you as a Japanese Court gonna think anything of your skills and training probably not if your malpractice insurance gonna cover you against the Japanese Court guaranteed not and in general if you ask your my practice and insurance they will say they will not cover you if you have any legal proceedings outside the US so there's risks you take and some nations do regulate and it would be illegal finding out can be a pain in the ass so the process I like to do is find a English speaking preferably if you can like American maybe an Australian because Australia's super system owners like Australians trained clinician like therapist who works in that country and see it email them and ask hey are you willing to help me understand the regulatory environment like do you have your license are certified in order for it to be legal like for example when I did that for Germany because I'd a client going back to Germany he just wanted some transitional sessions I found an American trained psychologist who works in Germany I asked they were like oh yeah Germany's not that Oh any of their citizens who the can't get therapy from they're just not gonna pay you for it and I was like great my clients already paying me so there's a lot of considerations but that's the basic idea got a terrific well so we have a question from work so she's asking it so she's thinking about moving out of her physical office space and do a hundred percent a therapy so she's characters like have you do have any data on the consumers preference between in person and a virtual therapy again this is a to Mesa take the Culver situation holida equation just what do consumers prefer we we have I actually don't know much of data on that all its realize but we're seeing a ton a totally because suddenly everyone needs to go to teletherapy so the the what I'm getting kind of goes back to what I said earlier which was the success of teletherapy for clients the bigger factor than their preferences is the attitude and leadership of the therapists towards a technology mediated approach to therapy so like therapists who found themselves nervous about doing telehealth and kind of timid about it they would tell us as little as 10 percent retention commands before coat therapists who are really confident in it they've been doing like our programs for a long time and like already felt fine now that is going from heart to full that they talked about I found generative this the floor on those the dizzle anecdotal but like trying the floor on those was like seventy five percent retention or better was those at the conference and so that tells me of course it's not all confidence like I about 85 percent I still got some clients like not interested am i cool that's why clients have to say for years every week they're like I'll see you afterwards that's right but you know it's only about 15% so that tells you how much of the factor is the your ability to lead clients into feeling hell with the concept yeah it's a Brooklyn thing but I'll just add on Twitter so does that go back to my PhD research at Stanford so actually my research was were you I was studying conversational cues over video and that's compared to all the only Chad and Cicely to an in-person experience and so my some of my finding is the in person of course is always amazing in there but there are certain cases where by these are video mediated communication like it's a technical jargon assigned clearances certain times actually make it better in a sense a certain scenario they're more likely to open up to you because there's a it's like the intimacy in there then feel like slightly these almost of certain issues they need to be slightly less internet to for them to open this up now the the complement to that is is the sense of private in there so for example right now like if you're just like you turn on the news all this thing you're here about soon hacking good zoom this thing you know your parasol that'd newest latest a babylon health and here's a two billion dollar company now there you can watch other people's conversation on there like considering that you just like sonali it's like people bombarded by this you say look so people are worried about like if i do a session with you are you using a to dance trusted what did you get like the cheapest version out there and if they had that people felt like well like it's just they're sorting in the back of their minds if this conversation will leak out to somewhere else like you know am I in danger gun so this is something where you want to be aware and mindful that because you want to say take people's privacy and put yourself in the consumer mind right there listening to how can they do anything they just were assuming is slightly nervous in there and so you should wait a monitoring addresses again does it going back to you by the way the thing about has said and the speaker was interesting is even if audio is another issue the fact you were has said they sort of know that audio there's like there's not someone off the camera they can listen on this conversation in fact you only come to your year is allowed to like a boy trust with the environment so Brook have a following question what am I do you have any recommendations for like a remote document signing you can use doc use okay so the document signing software is gonna be a cloud-based service usually so there's people behind it which means to do it with clients because you probably want your intake documents that kind of thing you need a business associate agreement because you need HIPAA compliance like you need to remain compliant using the service that's expensive with document something like DocuSign will do business associate agreements if you pay a five thousand bazillion dollars so like we find that that's not the document signing services they plus HIPAA we find creates a pretty untenable situation you can do if you want spend the money but the usually the better way to accomplish what you want is to use if you have a practice management system that does documents electronic signatures now how would all of them do but more of them are starting to get into that because with COBIT times that is one of the things you need in a telehealth practice is remote ability to do forms forgot that I'm a below the list so like more the practice management systems are adding that like therapy notes just added that as a as a beta or it's in production right now for example but there are also two ways you can you do that Alucard you know one is hush mails secure forms like hush mail secure forms does electronic signatures now and intake queue is actually this thing that started as just being very robust intake forms and there to come like a full-blown EHR it's pretty Incred incredible but you know which ones one of the better option for you depends on what you're already using and how much you want to spend on it thanks for right another thing I did slightly plug so for part of the BC software we actually hope you can actually upload these forums so we have a signing process for those so this also help your potential I'm sorry to know that man I go a lot of them when we have a one question from the audience is really she said banana Leah so she starts hanging on so what's your opinion of having like a like a moving desktop for the monitoring session so specifically if the defense thank you so you're sort of standing in front of this you're sitting down yeah yeah you know it's funny a lot of people that's that like people are concerned like if I'm standing for the session what's that gonna do I think it's gonna be because you would never stand if the person comes into your office because they have to stand together right I'm gonna bet it's good to be very client by client what it does Universal but it will be a change and as you know even if I like I just been a new clock the clients are gonna be like new clock what does this mean my therapists office has changed but I think one one thing about this is that you know everything's changing right now about how we do stuff so it's transitioning to your standing in the session I bet would be very different from if you had just done it spontaneously and kind of work on a normal time I think of clients a response to it at the risk for the therapy mill personally I've got interesting and said what do you notice about that is is it funny for you then I'm standing do you feel like you need to stand if you do oh why do you feel like you need to you know it's very psychodynamic humanistic therapists so to me I'd be like really interested in how the client responds to that yeah okay Supriya but in terms of like a payment piece I know payments is that one of the big pieces in this time that's right so you've okay you're seeing something like a PayPal or song that's not a HIPAA compliant payment system is that acceptable it is with limits right because the HIPAA actually gives an exception to financial services for the very very specific actions of like moving money around because if you think about it for example depositing a check if you take a check to the bank and deposit it that check is loaded with protected health information yeah and you don't have a business associate agreement with the bank yeah gives a specific except into that situation right so like and this I don't mean the fact that HIPPA gives you allows you to disclose phi4 payment purposes that is actually also a thing too I mean beyond that there's also an exception for the financial institutions so like if you if a client sends you money by paypal you just tell them your people address and they just send you money that's legit that's fine but if you like send them a PayPal invoice PayPal is doing something in addition to just moving money which will be HIPAA territory and that's technically a violation I think it's so much body pitch I feel like enough of all these can help you actually said nitty-gritty no subtlety this is like what I highly recommend to everyone you can't like you know go to our website and learn more and that's we in the final minute as we record by that apologize to skip under questioning the audience we didn't get to your college I didn't get to you well pastor Roy will post on the answers Uncle session but would be embarrassed we're rapping about you should like so many really interesting thing what is that one thing that's most important on the leaf but that takeaway for the audience I think you know the big thing I've been thinking about that's really important is it's all changed nothing's gonna go back to normal there's no such thing as going back to normal and I bet most of you are watching this have decided by now you don't necessarily want it to that's what we're getting from our audience is that like now that people are getting used to telehealth they don't necessarily want to go back to what it was before they want they want some of their clients in their office there's certain clients that would be perfect but like so I think what's gonna come with that is so one of the pieces that's like a standard for telehealth is assessing the client for appropriateness yeah medium of telehealth and like I've always found that particular the way different states or associations expressed that I've always found it to be very ham-fisted like it's very too simplistic although it's still it's accurate you do need to do it but it's too simplistic the way to think about it because for example we'll say oh that their phrase it as is this client appropriate I say well their appropriateness is partly dependent on what I'm doing like am i skilled enough do I have the right setup am i able to deliver something to them it doesn't get in the way and make teletherapy useless to them I'm as much involved in that as they are it's dyadic it's not just the person and so the thing that's I've come to realize I was talking to Deanna Nagle about this on Facebook the other day you know what not everyone is appropriate for in persons there either but we don't have to no one asks us to assess that right there are a lot of people as you pointed out that are gonna do far better through the video conference or they're gonna do far better with an avatar which is a whole other thing and so I think the thing we all should be thinking about is therapy is not just sitting in a room talking to each other face-to-face it's not anymore all right there's so many ways to do it and when we think about appropriateness of medium and client fit we need to think of whatever medium we're doing as as like is this appropriate for the client and like teletherapy is not secondary to impersonal it's just it's adjacent and they're they're both important and useful just like eco therapy going out in the woods and walking and talking you know all these things they're all adjacent to each other I just want to so I think we're now having to think that way and it's much now as a moment when I say that that people understand what I'm saying so I'm saying but maybe we're just like the rapid-fire just I'll shoot that well - final question that we radford that I guess yeah yeah question is for example now you mean you're one of the like industry experts on you've been doing telehealth and like many many years before and I become a hobby and what is this like one thing that you believe about telehealth but the rest of the world do not believe Lange that online friends are also real friends and online clients are real appliance like I am I don't know if you like when you were a kid like what kind of sign oh you've clearly been in tech a long time you're a doctor computer like when I was a kid I was 14 like it was before the web right actually like as the web was just being made basically and like I had a modem and a computer and my computer would make phone calls to other computer my local area because if I made a long-distance call money right and we did BBS's just like you saw in the movie wargames and I made a lot of friends that way it's not they didn't have real-life friends I had friends everywhere and the friends I made there I later met when I changed high schools and those they were still my good friends they're my best friends at the new high school why because we were already friends and so like we don't if you don't grow up understanding that then you don't grow up learning how to modulate your your body and your minds responses to the knife you're seeing on the screen and if that's not how you've grown up that's okay but be aware of that fact that you can you can change it by learning to like I'm seeing mill and I know Milton I've never met you in person but you're my friend I know you if I may in person it would be different but not less than yeah wonder then the final question is now the covariances that can make a lot of change to the health care in there and if you could get to pick one permanent change like you know fast it would be does one permanent change you want clover to a brand it would be that I'm trying to figure out it I'm kind of reiterating what I've already said basically I think the one change and it brings about is that every therapist is used to the idea that therapy has multiple ways to happen that it can be sitting in a room it can be on a screen and yet walking and if you decide that you just want to go back to sitting in a room because that works better for you fantastic but at least come of it helps educate you instead of you doing it from a place of fear or lack of understanding or naivete if you did it because you did it and you're educating understand and you know that's what's gonna work better that makes me happy okay terrific right thank you so much either way rather a little tougher you're just like a psycho crazy loud really really excited to have you on this thank you so much I really appreciate it you