evolved more quickly than standards to guide or regulate the practice (NASW, 2017b). Using the axiom of “start where the client is,” a practitioner might justify engaging with adolescents via their preferred medium of electronic communication (Reamer, 2013). However, some ethical vignettes illustrate the ethical risk and emphasize the need for informed consent related to confidentiality and access limitations that using technology may pose. Texting has become more frequent in clinical practice. Despite the risk to client privacy and confidentiality, some clients - especially adolescents - prefer this mode of communication. Therefore, serving adolescent populations may involve texting, an issue that providers previously - say, 10 years ago - would have have likely considered an unlikely practice. Informed consent should address this risk. Should texts be included in the health record? The short answer is yes. Whether to include the exact text or a summary of the text discussion is at the discretion of the provider, but there should be some record of text communication (NASW, 2017b). Next, the expansion of electronic health records or electronic medical records is well underway in healthcare generally, and behavioral care specifically (Arauz-Boudreau et al., 2019). The majority of agencies are moving toward electronic record keeping. The burgeoning field and profession of health informatics encompasses the development and monitoring of electronic health applications (Nelson & Staggers, 2018). Private practitioners usually are not required to use electronic record keeping, but many are choosing to do so via various platforms and software packages. Financial record keeping related to the private practitioner’s experience becomes as important as clinical record keeping. Edgcomb (2022) summarized the digital advance into healthcare documentation, primarily child mental health in broad strokes as “adapting the EHR as a tool for health delivery provides an important avenue to support measurement-based care, improve communication between providers, patients, and families, and mitigate clinician burnout and fatigue. However, the promise of bridging these fields must be tempered with an understanding of the feasibility within the context of workforce shortages, need for protection of health information, potential for biases, and challenges ahead” (p. 11). Accuracy in billing records is a risk management safeguard against client complaints. It is recommended that such records include the date as well as the type and duration of services provided, with associated charges and dates of receipt of payment or third-party reimbursement. Complications arise when modifications are made to fee arrangements, such as sliding scales or other considerations regarding ability to pay. Documentation is particularly important to avoid misunderstandings or the appearance of preferential treatment. However, new technologies can also usher in the threat of potential cyberliability - a new concern for behavioral health providers. The most salient risk in electronic record keeping is computer security and subsequent breach of client confidentiality when records are stored on agency servers or personal computers. Malpractice insurers list several ways in which technology breaches can put practitioners at risk, including losing a laptop or flash drive with stored client information, faxing or emailing information to the wrong recipient, or falling victim to cyberhacks on a data management system. Even if a data storage service loses the information, the practitioner can be held directly liable (NASW Assurance Services, 2018). In addition, using distance counseling platforms presents potential conflicts of interests. Clients may assume that practitioners endorse the advertisers and sponsors on the video counseling sites (Reamer, 2013). Electronic recording poses multiple risks. In her book on social work documentation, Liz O’Rourke (2010) paints a grim picture:
“The power of databases to enable information about us to be shared by others in ways over which we have no control raises the spectre of Foucault’s Panopticon . . . the all-seeing Panopticon was a means to observe, control and discipline behavior . . . The social work record may be seen as part of the Superpanopticon, which is scrutinizing the service user, but at the same time it may also be a means to scrutinize the practitioner” (p. 31). Indeed, applying the metaphor of a panopticon (a building, usually a prison, designed in such a way that people can be observed at any time without their knowledge) to electronic documentation emphasizes that both the client and therapist need to consider that the information contained in a record may be viewed at any time by unknown parties. This awareness should serve to regulate what the therapist records about a client. Although extreme in nature, this metaphor does illustrate the importance of the caution practitioners need to apply when creating client records. The assumed scrutiny speaks to the need for proactive risk management protocols in record keeping and documentation. Both paper-based and electronic records are subject to breaches if access is easy (Bradshaw et al., 2014). Thus, the focus should be on securing records, either physically or through technology such as encryption. Although Reamer (2013) also speaks about the ethical risks of electronic documentation, he advises providers to document electronically in the same way as they would make a paper record because encrypted electronic records are actually more secure than traditional charts. He does caution that any clinical encounters via electronic media (email, text, social networking, or telephone) should be charted in the case record. Behavioral health practitioners working for organizations rely on compliance and information technology professionals to provide secure computer network security systems. With respect to private practitioners, of course software programs and platforms must be HIPAA compliant, and records should be encrypted. In addition, practitioners are advised to ensure that their liability coverage includes digital documentation protection. Liability and billing insurers may also have recommended programs for private practitioners to use for electronic record keeping. Despite the extensive reach of HIPAA regulations, standardized measures to monitor electronic records and dissemination of confidential information have yet to be developed (Bradshaw, 2014). The duty of quality assurance (QA) programs is focused on service implementation and outcomes, with less focus on managing the quality of records. Internet Cognitive-Behavioral Therapy Innovative behavioral programming has been created and studied to investigate the effectiveness of asynchronous delivery of mental health services that aim to ameliorate symptoms of substance abuse, depression, anxiety, insomnia, and health anxiety. Online tools of this kind alter the documentation and treatment landscape and reflect the growing movement within healthcare to integrate technology in the service of patient needs, without inadvertently sacrificing ethical and clinical requirements (Axelsson et al., 2020; Richards et al., 2020; Sharif- Sidi et al., 2021). According to Sharif-Sidi and colleagues (2021), one such program sought to create greater access to behavioral care, thus overcoming identified obstacles such as stigma and cost. Researchers utilized a brief therapy format comparing online Internet cognitive-behavioral therapy (ICBT) to face-to-face cognitive-behavioral therapy (CBT) delivery, discovering that the two methods of clinical delivery measured approximately the same in terms of effectiveness. The authors emphasized the effectiveness of ICBT but cautioned that long-term studies are needed to understand if ICBT functions best as a bridge to other face-to-face treatment modalities or as a viable long-term treatment option.
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