As people in a helping profession, many counselors know the frustration of something getting in the way of us being there for our clients. At some point in our careers, we all must deal with scheduling conflicts, illnesses, weather delays and other events outside of our control. Typically, these are temporary setbacks, and we find a way to adjust. Other situations, especially those we don’t feel make sense from a client care perspective, can be particularly frustrating, however.

A modern, timely example of this is when trying to help clients from outside of our own state. Many situations can cause this to occur. Among the examples I have personally encountered include:

• Working with an adolescent who later went off to college in another state
• Working with a businessperson whose career required being out of state for weeks at a time
• Working with a military family that was reassigned to a new location in another country

The list of potentially similar circumstances is endless. The good news is that modern technology makes it possible to continue working with these clients through telehealth (i.e., using secure video while complying with the Health Insurance Portability and Accountability Act). In fact, there is mounting evidence that counseling services delivered via telehealth can be as effective as in-person services (see ncbi.nlm.nih.gov/pmc/articles/PMC5723163). Problem solved, right?

The barrier to telehealth

Unfortunately, there continues to be a significant barrier to this interstate solution: the lack of counselor licensure portability/reciprocity between states. Our professional licensure is “state based,” meaning that we have to apply for licensure in each state individually. Even if we are licensed in one state, we start from scratch in applying in another. Currently, our licensure will not transfer. (Note: In October, the American Counseling Association Governing Council approved the initial endorsement and funding of a professional occupation interstate compact for professional counselors that could help to make licensure portability a reality in the future.) This matters for telehealth because we can’t practice counseling in a state in which we are not licensed, at least not without permission. More on that in a bit.

I’ve often come across counselors who have made assumptions such as: “Well, my client is going to be there for only a couple of weeks, so it shouldn’t matter” or “My client’s not going to be an official resident of that state for a while.” Both of these assumptions, as well as other related assumptions, are problematic.

Here’s the simple reason why: State counseling licensure boards exist to protect everyone in that particular state. It ultimately doesn’t matter how long that person is there.

Yes, state counseling licensure boards do things such as process our applications and ensure that we are getting enough continuing education. But they do these things to serve their primary purpose: protecting the public. The laws they enforce won’t allow just anyone to call himself or herself a licensed professional counselor, which helps ensure that the public receives proper, ethical care. Following that logic, to protect people within their borders, these boards won’t allow just anyone to “telehealth in” from another state to provide care.

Yes, we can argue that this sometimes presents a barrier to providing clients needed care. Yes, we can argue that it’s a barrier to quality mental health care in general. Hopefully, we can take it many steps further, arguing vociferously until we have a national counseling licensure or at least reciprocity between states. In the meantime, however, we cannot ignore the legalities and liabilities of the situation. And it doesn’t mean that we are currently without options. Some states will allow counselors to practice there temporarily, but this will require you to do some research and to make some contacts.

Tracking telehealth laws

A good starting point is Epstein Becker Green’s telemental/telebehavioral health survey (see ebglaw.com/telemental-telebehavioral-survey). This survey endeavors to track telehealth laws as they pertain to the provision of mental health care in all 50 states. It breaks down telemental health laws not only by state but also by professional licensure. The survey includes information on whether each individual state allows out-of-state providers to temporarily practice within the state, and it also includes links to governing boards.

It is important to note the following caveat: The original survey was done in 2016 and has been updated with a 2017 appendix that is 316 pages long. Telehealth laws are changing that quickly. Given that fact, it will be important that you:

1) Visit the state board website in question to investigate whether any changes or new information have been added

2) Contact that state board and ask it directly about your situation and the granting of temporary privileges

3) Document everything

It is also important to be aware of your own state’s licensure laws to ensure that they don’t include any restrictions that might affect you. As always, consultations with your attorney and your liability insurance company are also advised. You must also be aware of other ethical, legal and counseling ramifications before providing telehealth services (for more, see tameyourpractice.com/telehealth). With a bit of due diligence, you may be able to continue providing care to clients in many interstate situations.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Having a website is a building block that is integral to most successful businesses these days. This is no different for counselors running a nonprofit, agency, private practice or other venture. Increasingly, people are connecting with their service providers by first encountering them online through directory listings and websites. Even when referred directly to a counselor by someone else, many prospective clients want to read more about the counselor before making contact.

The expanding importance of websites leads to various topics, including creating quality content that attracts, and connects with, the people for whom you or your organization are best suited to provide services. Before that can happen, however, people need to be able to find your website.

To that end, I want to discuss some important recent developments that affect the visibility of websites. For good measure, I’ll also cover some items you should review to ensure compliance with the 2014 ACA Code of Ethics.

What’s the big deal about SSL?

SSL, or Secure Sockets Layer, is the encryption protocol for websites and browsers. If a site is using SSL, you will see “https” instead of “http” in front of the internet address/URL. Depending on your browser, you may also see a lock, the word “Secure” or both.

In the past, SSL was used primarily on e-commerce sites. The prevailing logic at the time was that the SSL level of security was necessary only when carrying out financial transactions. Later, any site featuring accounts or logins was added to the list of those needing this higher level of security.

Now, however, it is important for every site that collects information to use SSL. This is true even if you have only a simple contact form. Here’s why:

• Security: The use of SSL can help prevent malware/viruses on your website. Even if the only way that people submit information through your website is a contact form, you don’t want someone to have the potential of spying on everything submitted via that form.
• Search engine optimization (SEO): SEO is the process of improving how your website performs in searches. In short, you want your website at or near the top of the page when people search for specific terms (for example, “counselor your town”). Google “punishes” sites in search results that don’t use SSL. This means that your website may be less likely to be found by potential clients if you aren’t using SSL.
• Ethics and professional appearance: This past July, Google Chrome started showing sites as “Not Secure,” along with a red caution triangle, in the Chrome web address bar if they aren’t using SSL. This isn’t likely to make a good first impression on potential clients who are investigating your services. Furthermore, the 2014 ACA Code of Ethics requires that we take reasonable measures to protect people’s privacy and confidentiality.

Standard H.2.d. states: “Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.”

Fortunately, SSL has become much easier to implement, and many web hosts offer it for little or no cost. One program that many participate in is called Let’s Encrypt (letsencrypt.org). Be sure to check with your web host or web developer to address this if you haven’t already.

Pro tip: To learn more about SEO, check out the excellent beginner’s tutorial at moz.com/beginners-guide-to-seo.

Pro tip 2: Now is the time to incorporate video. Not only does video provide an opportunity to let clients “meet” you and your organization, but it also tends to help with SEO. Counselors in private practice have reported significant success in having videos of themselves speaking about counseling and their approach or even giving tours of their office. Videos along these lines can help clients connect with us and feel more at ease about contacting us.

On the ethics side

While looking at potential improvements to your website, you have the perfect opportunity to also ensure that you’re taking steps to comply with the 2014 ACA Code of Ethics. Here are a few of the things to have on your checklist:

Post your informed consent, policies and licensure information

Standard H.5.b. of the ACA Code of Ethics says: “Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.”

There isn’t necessarily a specific way or format in which these need to be posted, but they should be readily accessible. It may be a good idea to have them somewhere in your menu structure to ensure that you have accessibility covered.

Testimonials and reviews

Do you have testimonials or reviews posted on your site? Although these can be incredibly helpful for most businesses, there are some very important restrictions and caveats that counselors must follow. (For more, see ct.counseling.org/2015/04/ethical-pitfalls-of-online-testimonials-and-reviews/). Now is a great time to add some testimonials from colleagues and referral sources.

Social media policy

You likely have social media such as your Facebook page linked from your website. So, be sure that you also have an updated social media policy available on your site.

Standard H.6.b. states: “Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations and boundaries of the use of social media.”

Secure contact form

Although SSL will secure data sent from a client’s computer to your web server, the protection ends there. Depending on your web host and package, there may be no encryption on the server or on the delivery of the contact form contents to your email address. This is the one point of data collection almost every counselor and counseling-related organization has on their site that can be considered a point of potential vulnerability. The good news is that there are easy and inexpensive ways to secure contact form submissions. (See tameyourpractice.com/email for more information.)

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Want to know more about improving your website? Do you have specific questions? Do you have suggestions for what to cover in a future Technology Tutor column? Drop me a line.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Because most counselors have flown under the “meaningful use” radar so far, they may not be familiar with the term health information exchange (HIE). Moving forward, however, it will be important for counselors to educate themselves because the model for provision of care in the United States continues to move toward that of interoperability and integrated care. In this article, I discuss the basics of HIE and the reasons that counselors need to understand it.

Interoperability

The picture of how HIE came about is complex. It developed over many years and includes previously existing Medicare and Medicaid programs, programs created by the Affordable Care Act, as well as the Health Information Technology for Economic and Clinical Health (HITECH) Act. The overarching goal that resulted in the genesis of HIE was that of interoperability as a critical component of improving the quality, efficiency and safety of health care delivery while reducing its overall costs.

As described on the HealthIT.gov website, interoperability is generally accepted to mean the ability of two or more systems or components to 1) exchange information and 2) use the information that has been exchanged.

The promise of interoperability is that health care providers can readily share and use each other’s information in the provision of services. This means that if you visit your primary care physician (PCP), who then sends you to a specialist, that specialist should be able to receive your records from your PCP before you arrive. In other words, there is no need for you to cart your records around and report the entire story over again. There is no need to repeat tests that have already been completed. This also means that in emergency situations, a hospital should be able to quickly access your medical history and know exactly what medications you are currently taking.

From a big-picture standpoint, interoperability also means that data can be aggregated more quickly and effectively to track things such as outbreaks of the flu or other illnesses. These are just a few examples of the benefits of interoperability, but they illustrate why it is considered critical to the mission of the Affordable Care and HITECH acts.

The Meaningful Use program and HIEs

How critical is interoperability? In 2010, the State Health Information Exchange Cooperative Agreement Program was created, which led to $548 million being awarded to states for the purposes of establishing and improving state-managed HIEs. In April 2015, Congress declared it “a national objective to achieve widespread exchange of health information through interoperable certified EHR [electronic health record] technology nationwide by December 31, 2018.”

The Meaningful Use program was created to provide incentives for EHR adoption by eligible professionals. The program also includes reimbursement penalties for those who do not participate. (For more, see tameyourpractice.com/blog/meaningful-use-and-mental-health-professionals.) Although the Meaningful Use program tasked providers with adopting EHRs that could exchange information, that process has been slow, and it is not always efficient or effective. In addition, counselors have not been included in the incentives or penalties for meaningful use (the same holds true for all mental health providers apart from those who prescribe medications).

HIEs are meant to speed up the achievement of interoperability while also filling in gaps and providing a central repository of records. Providers who haven’t fully achieved the ability to exchange information with other providers can at least provide it to the HIE. For example, rather than a hospital having to query multiple providers for records, it can query just one system, the HIE, to get vital information about a patient. The time savings in emergency situations can also save lives.

Implications for counselors

So, if counselors haven’t been a part of meaningful use, why do we need to pay attention to it? The fact is that despite of our exclusion from the Meaningful Use program, the national engine pushing for all health care providers to achieve interoperability has still been running. States have been incentivized to help move that engine along too, and their ability to continue to fund their programs is attached to milestones.

To that end, states are increasingly enacting measures requiring participation in HIEs or other programs in an effort to achieve widespread interoperability. For example, here in North Carolina where I am located, participation in HIE has been mandated for any health care provider receiving state funds. This includes not only those who accept Medicaid, but also those who work with employees of the state (through a plan currently managed by Blue Cross Blue Shield of North Carolina). As of this writing there are over 700,000 people in North Carolina dependent on the State Employees’ Health plan and almost 2 million Medicaid recipients. Counselors will be able to continue serving those clients only if they meet the HIE mandate deadlines (currently June 1, 2018, for Medicaid and June 1, 2019, for state employees).

Other states have or are pursuing similar measures. The following website links to each state’s respective HIE website so that counselors can stay up to date on developments: healthit.gov/topic/onc-hitech-programs/state-health-information-exchange.

Before proclaiming, “I don’t accept insurance” and turning the page, read on. In some states (such as Minnesota), mandates have been applied to all providers, regardless of how payments are received. (Minnesota’s mandate has since been amended to provide some exceptions and currently carries no penalties.)

Perhaps more important, as other providers experience the benefits of efficient and timely exchange of health information, they are looking to partner with other providers who already possess this capability. In the future, providers who cannot exchange health care information through their EHRs or HIE may find themselves receiving fewer referrals from other health care providers. This same effect may also be experienced with clients as they begin to understand and appreciate the value of having all of their health care data conveniently accessible in one location, most likely through their PCP.

The momentum for EHRs and interoperability is also being bolstered by other initiatives, including reimbursement based on outcomes. As part of the Affordable Care Act — and currently primarily associated with the Medicare Access and CHIP Reauthorization Act of 2015 (see tinyurl.com/MACRA2015) — is a move toward merit-based payments for providers, as opposed to the current service-based payments.

In a merit-based payment program, providers are paid more when achieving efficient, effective outcomes instead of being paid for providing individual services. In other words, providers are incentivized to work harder to help clients achieve positive outcomes rather than “rack up charges” by providing multiple services. Participation in these programs currently requires a data management system that can not only track but also report outcomes electronically. It is likely that similar programs will find their way into the commercial insurance market and beyond in the future.

Exploration of this topic would require an article of its own. I bring it up here to note that the forces behind this movement — and their reasons for pushing for all health care providers to use electronic records and achieve interoperability — are myriad and regularly making progress.

These topics take on additional weight when combined with other initiatives. For example, we can strengthen our argument that counselors should be able to join the ranks of mental health professionals who provide services for Medicare recipients if we demonstrate an understanding of current reporting and reimbursement policies.

As the world becomes further steeped in technology, it is important that counselors keep up. This will allow us not only to keep pace as providers and businesspeople but also to better serve our clients.

Resources

• I recently did a webinar with the American Counseling Association titled “Private Practice: Choosing a Best-Fit EHR.” It was telecast May 16 and is now available on demand. In the webinar, I explain how counselors can select electronic practice management resources to meet the unique needs of their practice and explore how to avoid costly mistakes.
• Are you considering an EHR to meet your technology/HIE needs? Be sure to check out the freely available reviews on my website at tameyourpractice.com/EHRReviews.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.