Some clients may be less comfortable with or have less experience using technology. Some individuals, such as those who are elderly or who are below the poverty threshold, may be reluctant to engage in treatment using remote technologies. Clinicians should be aware of the impact that the use of technology may have on the client. For example, clients and practitioners can experience eye strain or physical fatigue when using technology. The individual may need technological aids, such as a headset or screen magnification, to use the equipment effectively (Luxton, Nelson, & Maheu, 2016). Individuals may have different levels of knowledge about technology, including vocabulary, device settings, and troubleshooting skills. These facets of telemental health should be addressed and discussed prior to beginning treatment. Many studies of telemental health services show similar clinical effectiveness to traditional face-to-face services. However, the parameters of telemental health’s effects are less studied and not well understood (Agboola & Kvedar, 2016; Comers & Myers, 2016; Daniel & Sulmasy, 2015). Traditional clinical trial designs testing relative efficacies between remote and clinic-based formats may only offer a partial understanding of the effects of telemental health use (Comers & Myers, 2016). For example, studies of telemental health services provided to children for behavioral problems show advantages over clinic-based therapy because telemental health services can be provided in the home where the behaviors are occurring. However, only those families who have a high level of technological proficiency with access to technology and broadband services have access to the services. Thus, clinical efficacy with those who are not familiar with technology and who may not have the resources to pay for technology may be different. Some practitioners who work with children are not convinced that telemental health is the best way to work with them. Similar to those working with adults, clinicians may have concerns about the therapeutic alliance and engagement with child clients. The safety of the client during telemental health sessions is particularly important when practitioners determine whether to use telemental health (Luxton et al., 2014). A particular concern is what to do if the client becomes distressed or has a medical emergency during the session. Clinicians and clients should develop a written safety plan that includes procedures for contacting emergency services where the client is located and alternative methods of contact in case the telemental health technology becomes disabled. It may be helpful to identify someone locally, such as a family member or friend, whom the clinician can contact in case of an emergency. Similarly, the advancement of mobile applications also raises patient safety and privacy concerns (Agboola & Kvedar, 2016). Telemental health practices have evolved from basic technology, such as telephone communications, to more complex smartphone-based applications. Some developers of these technologies lack medical training and do not involve clinicians in the development and implementation processes. Many of these mobile applications are marketed directly to consumers without the need for clinical assessment prior to their use. Agboola and Kvedar (2016)
offer recommendations to improve the safety of telemental health applications for consumer use. ● Incorporate patient safety into all phases of telemental health applications. ● Integrate safety testing as part of the usability and efficacy trials. ● Update and use the most recent data security and encryption systems to protect privacy. ● Encourage regulatory and professional bodies in the development of operational protocols, standards, and guidelines. ● Disclose possible risks of telemental health use in the consent process prior to treatment. ● Create systems for documenting telemental health services as part of the client record. ● Develop alternative systems of care for clients who do not have adequate technology or literacy skills. Clients who have a history of negative, excessive, or adverse reactions to treatment, such as severe panic attacks, impulsivity, or repeated attempts at self-harm or harm to others, may not be appropriate for remote telemental health services (Daniel & Sulmasy, 2015; Luxton et al., 2014). The lack of in-person contact can carry potential risks, such as misdiagnosis, inappropriate prescribing, loss of therapeutic touch, nonverbal miscommunication, potential medical errors, and loss of continuity of care (Agboola & Kvedar, 2016; Daniel & Sulmasy, 2015). However, research up until this point suggests that implementation of telemental health is often effective compared to no treatment when timely in- person services are not available. Clinicians who use telemental health services must be able to determine when it is appropriate to use remote technologies and when face-to-face encounters are needed. If a patient complains of physical discomfort, such as chest pain, the practitioner must understand that an in-person physical examination is necessary. One study of 32 cases found that telephone communication was a root cause of catastrophic medical outcomes and malpractice settlements amounting to more than $12 million (Agboola & Kvedar, 2016). Before beginning telemental health services, practitioners should first review the client’s history, potential risks, available technologies, and comfort with using technology. If individuals are not appropriate for telemental health services, clinicians should provide or refer clients to alternative options, such as face-to-face sessions. Telemental health services offer convenience to the patient, but they also present challenges in the continuity of care and the patient–practitioner relationship (Daniel & Sulmasy, 2015). For example, if telemental health services are used for single crisis incidents or consultations, members of the regular healthcare team may not have knowledge of the telemental health visits, prescriptions that may have been written, or recommendations for follow-up. One avenue for practitioners is to offer integrated healthcare options that include telemental health consultations and visits in addition to face-to-face availability. Telemental health visits can be offered during after-hours times to increase convenience and client access. Practitioners reinforce the importance of ongoing relationships with their clients by offering the convenience of different modalities and tools for treatment.
CHALLENGES
In one study of telemental health programs in the U.S., Lauckner and Whitten (2016) interviewed 33 telemental health program administrators, 27 of whom were still operating. Among those whose telemental health programs were discontinued, the administrators revealed several
reasons that particular telemental health programs were discontinued. ● They were not intended to be a long-term project. ● The agency ran out of funding. ● The needs of the on-site clinic changed.
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