EPISODE 03

[INTRODUCTION]

[00:00:12] ANNOUNCER: Welcome to Season One. All Things Ethics, a podcast series presented by SpeechTherapyPD.com. The SLP Learning Series explores various topics of Speech-Language Pathology. Each season dives deeper into a topic with a different host, and guest who are leaders in the field. Some topics include stuttering, AAC, sports concussion, Teletherapy, ethics, and more. Each episode has an accompanying audio course on SpeechTherapyPD.com and is available for 0.1 ASHA CEU. Now come along with us as we look closer into the many topics of Speech-Language Pathology.

[INTERVIEW]

[00:01:04] EDM: Welcome to Ethics is Essential. Today we will be discussing the Ethics of Telepractice. Telepractice is one of the newer innovations in clinical practice for communication disorders professionals, and it has become an approach to provision of clinical services in schools, hospitals, rehabilitation, and long-term care facilities, as well as an international practice. Telepractice can be effective in providing language therapy for a child during the school day, or aphasia therapy, or voice therapy for an adult. There are also opportunities to supervise a student or clinical fellowÕs therapy with a client, as well as the capability to meet with or counsel a clinical fellow or consult with another clinician via Telepractice. 

It is a potent and productive approach to the remediation of communication disorders. Telepractice brings telecommunications technology to the service delivery of remediation of communication disorders by Speech-Language Pathologists and audiologists. It links the clinician and the client over distance while allowing for assessment, interaction, and consultation. Over 10 years ago, the Mayo Clinic judged Telepractice therapy for speech-language services to be reliable, beneficial, and acceptable. Studies have consistently found intervention by Telepractice as effective as in-person therapies. 

There have also been therapies and studies. I'm sorry, studies found Telepractice to be even more effective than in-person therapy. Several studies have verified client and clinician satisfaction with Telepractice. Telepractice can be very successful, but there are many things to consider in contemplating or developing and conducting a Telepractice program. A suitable Telepractice platform must be selected. There are state licenses that must be acquired and certified clinicians who engage in Telepractice must follow ASHAÕs Code of Ethics. That's what our discussion is about today, Ethics in Telepractice. 

Let me introduce you to our guest for this podcast. Melissa Jakubowitz is the President and Founder of eLiveNow, which provides Telepractice services and training to clinicians in universities. She's a Board-Certified Specialist in Child Language, with extensive administrative experience, running a multi-office private practice and leading a Telepractice company's clinical department. Miss Jakubowitz has presented on a variety of issues, including private practice, language disorders in school, aged children, and Telepractice. She has also taught a graduate course in Telepractice so that her students had Telepractice skills as part of their professional arsenal upon graduation. 

She has extensive experience working directly with school-aged children in various settings, in addition to leadership positions in both work settings, and professional associations. She has served ASHA and related organizations. She was president of the California Speech-Language and Hearing Association and the California Speech-Language Pathologists and Audiologists in Private Practice Association. She has served on ASHAÕs Board of Ethics, where she served as chairman of the Education Subcommittee. She's also the recipient of honors of the California Speech-Language and Hearing Association and she is a fellow of ASHA.

Melissa, welcome to All Things Ethics. I'm pleased to have you here with me today to discuss Ethics in Telepractice. This is still a relatively new area of practice for some of our listeners. I'm sure they're anxious to hear about some of the issues that can arise as a result of not being aware of the ethical requirements that accompany Telepractice. You have years of experience in this area and have even taught students how to develop and conduct Telepractices. I'm very interested to hear you share your knowledge and experience with us. Let's get right to the scenarios and questions that you've provided for us. Your responses will provide a wealth of information for our listeners. Let's begin with a scenario that will illustrate several points about Telepractice for our listeners.

Alex Smith is a Speech-Language Pathologist with 15 years of experience in the schools. He lives in Ohio, and he decided to work for a company that provides services via Telepractice. He was hired by company A to work at a school in Oregon. He obtained an Oregon license and was placed in a school in Corvallis, Oregon. Alex loves this new job and his students have responded well to Telepractice services, and they're making progress. About four months into this new experience, he decided to take a two-week vacation in Hawaii. His students were still in school, so Alex felt he could continue to work with his students and enjoy his vacation. He didn't think it would make a difference for him to provide services from Hawaii. He would not need another license since he was only vacationing in Hawaii. He didn't tell his company about his vacation. 

His supervisor decided to observe him on the second day of his stay in Hawaii. He realized that he was not in Ohio when he shared a view of the Pacific Ocean with his students, and his lesson incorporated information about the Hawaiian Islands. At the end of this session, Alex's supervisor asked him if he was licensed in Hawaii. Alex responded that he was not and that he didn't think it was necessary since he was only there for two weeks. Upon hearing this, Alex's supervisor told him that he could not continue providing services while he was in Hawaii unless he was licensed there. 

Since Alex had not gotten a license immediately, his supervisor told him that he would not be paid for the sessions, while he was in Hawaii, since he was not legally licensed to practice in that state. This made Alex angry since he would lose money, the money that he was counting on to pay for his vacation. He wanted his supervisor to just ignore the fact that he was in Hawaii, but she couldn't ignore it, because of her commitment to upholding ASHA's Code of Ethics. Melissa, what's your response to that?

[00:08:08] MJ: Well, thank you, Elise. I think this scenario illustrates several issues that are important in terms of ethical practices of Telepractice. First, it's important to know that one must obtain a license in the state where you're providing services, as well as the state where the client receives those services. The reason for this is that it's to protect the consumers. I think there's a great article that David Denton wrote, he's a former director of Ethics at ASHA. He wrote an article back in 2005 that was published in seminars in Speech and Language that talked about just this issue. 

In addition, there are several principles in the Code of Ethics that are related to this, Principle IV, Rule R, states, ÒIndividual shall comply with local, state and federal laws and regulations applicable to professional practices, research ethics, and the responsible conduct of research.Ó In addition rule and links the requirement for lawful practice to Telepractice by permitting Telepractice when it's not solely reliant upon correspondence and is consistent with professional standards, and state and federal regulations. In addition, this scenario illustrates that a supervisor is bound by Principle IV, Rule I, which states, ÒIndividuals shall not knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics.Ó 

Certainly, this scenario is a reminder that individuals participating in Telepractice should obtain a license from the state where services are provided, as well as where the client receives those services. In addition, it's incumbent on the telepractitioner to be aware of any laws in states where they are licensed to understand the regulations and laws and to continually update themselves around those regulations. I also think that initially, there was some confusion, because of some language that was on the ASHA website that since has been updated, where it stated that clinicians should be licensed in the state where they reside, as well as in the state where their client resides, not taking into consideration that we've got a very mobile society. So it's important to remember that you are licensed in the state where your client is receiving those services, and you are licensed in the state where you're providing services from.

[00:11:00] EDM: Interesting. Two licenses, if you're in one state, your client is in another, then that requires two licenses.

[00:11:08] MJ: Correct. Correct. The same thing goes if your client is mobile and moves to another state or goes on vacation in another state, you need to know that because you need to be licensed in the state where the client is receiving services from. The supervisor was probably again, that this situation may be handled differently by different companies, but I believe the supervisor was within her right to say, ÒI can't pay for the services, because you are not licensed in the state. We can't build the school districts for a service where you're not appropriately licensed.Ó

[00:11:55] EDM: Interesting. Melissa, for colleagues who may have clients in let's say, three or four different states, that means that they have to be licensed in each of those states as well as the state in which they live.

[00:12:13] MJ: Correct. Correct. There are many clinicians out there that have multiple licenses. It's not unheard of, especially in the early days of Telepractice, when I first started a number of years ago, because we didn't have full-time contracts, so we might have a therapist who wanted to work full time, but she was in California two days a week and in Kentucky two days a week. One day a week in Texas, and oh, she lives in North Dakota, so yeah, they could have multiple licenses.

[00:12:47] EDM: Interesting. All right. Well, that's great information for our listeners to have if they are currently conducting a Telepractice or they're anticipating developing a practice. Okay, so let me ask you a question. This may involve licenses, too. If you're a certified Speech-Language Pathologist living abroad, living outside of America, and you're doing Telepractice, or if you are in the United States and have clients overseas, do you have to have a license to practice?

[00:13:23] MJ: That is an excellent question and one that I hear frequently. It is a bit tricky because according to what ASHA has said, we should be licensed in those countries, either where we're living or where we're providing services to. The issue with that is it is sometimes very difficult to find out what the rules and regulations are around the SLP to find out what the rules and regulations are around SLP licensure in various countries. Now ASHA does have an agreement with a number of other Speech-Language and Hearing organizations in other countries. This agreement allows recognition of the ASHA sees by the organizations that licensed and certify Speech-Language Pathologists in other countries and it makes it a bit easier to get the appropriate credentials in that country, but it is really important to check. 

Some countries say, if you're not providing services within our country, we don't care that you're living in our country and doing Telepractice outside of the states. You don't need to have a license to do that if you're providing services back to the US. Other countries don't even understand Telepractice or what it is about. So it is difficult, because Telepractice is so new, especially outside of the United States, except for maybe Australia where they've been doing it for quite some time. It's important to check in with the licenses and figure out what licenses and what credentials you need. 

[00:15:22] EDM: You know, that's interesting because I can imagine in some countries, it may even be difficult to know what agency or what authority you would check with in my travels. I'm sure yours is also. I've been to some places where there wouldn't necessarily be a way to know who or what office you should check with in order to find out whether or not you need a license for Telepractice. I think for these Ð for our colleagues who are doing international practice, that could be a real challenge, couldn't it?

[00:16:00] MJ: It definitely is I've talked to a number of clinicians who have attempted to get some information. Oftentimes, they'll say, I checked with this country and they said that we should, that they should be providing services or they should have a license and somebody else will say, ÒWell, I was told they didn't have to have a license.Ó It is a bit confusing. Okay, so again, as I was saying, you've got to check with the country. I think the best place to start is with ASHA. They do have some contact information for Speech-Language and hearing professional organizations in other countries and to start there to determine whether or not you may or may not need a license. Don't be surprised if they don't understand what you're doing, because Telepractice hasn't spread as quickly as it has here in the United States.

[00:17:00] EDM: Okay, good advice. Begin with ASHA, if you don't know. All right, I have a scenario for you that I think poses some questions about confidentiality issues in Telepractice. Let's say our colleague Sarah, just started working in Telepractice, this year after 10 years of experience in work in the public schools. She has been assigned to provide services to a school in North Dakota. She's appropriately licensed and credentialed in her home state of Alabama, as well as in North Dakota. Our company provides an online data-tracking client portal, where all therapy notes are housed. 

However, Sarah prefers to track data and client notes on paper throughout the day. Then enter them at the end of the day. So when she has a break during her workday, she does that. Typically she leaves the paper notes and file folders, labeled with each child's name on her desk in her home office. One day she has some of her Speech-Language Pathology friends, come over for a get-together. A couple of them are interested in seeing what Sarah's Telepractice setup looks like, so she takes them to her home office, where her friends can see her therapy notes sitting on the desk. 

One of her friends sees that she's working with a client with selective mutism and begins asking Sarah questions about this client, not just general questions, but very specific ones regarding what precipitated the selective mutism about the student's background and her progress. Is Sarah guilty of any ethical violations in this situation? 

[00:18:49] MJ: Well, Elise as in any setting, confidential information needs to be kept in a secure place, whether it's electronic or on paper. Since Sarah prefers to keep handwritten notes on top of the secure platform her employer provided she still needs to secure her files in a locked cabinet. Keeping client information out in full view of the public and sharing details about a specific client do violate the Code of Ethics including Principle I that states that, ÒWe shall honor our responsibility to hold paramount the welfare of persons we serve professionally.Ó Again, we're not holding the welfare of our clients paramount when our therapy notes are out there for anybody to see. 

Principle I, Rule O, states, ÒIndividual shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to record shall be allowed only when doing so if necessary to protect the welfare of the person or the community, is legally authorized or is otherwise required by law.Ó In this scenario, Sarah should not have shared any specific information about her client, even though her friend was an SLP. 

It is so important that we remember that if we are working from a home office, and frankly, agency most, many clinicians do work from a home office, when they're providing Telepractice services, we have to secure whatever records we have, even if they are data tracking, or just handwritten notes, those are still part of the client file. we really need to protect those so that nobody else has access to those and leaving them out on a desk where someone can see them is problematic. 

[00:20:56] EDM: I can imagine. I think it's very interesting that one of the things I hear you saying and that I know to be true, is that we have to maintain the same ethical requirements with Telepractice, as we do with in-person therapy sessions, because it's all under the aegis of ASHAs Code of Ethics. Any SLP, who is certified by ASHA, certainly, regardless of whether it's Telepractice, telecommunications or in-person practice, certainly has to be aware of the same requirements, especially, I'm sure in terms of confidentiality of records and client information.

[00:21:45] MJ: Yeah, absolutely, Elise. We're functioning as a Speech-Language Pathologists or audiologists when we are providing Telepractice services. So it is important that we uphold and maintain our Code of Ethics. I think, one of the things that there is also confusion about is emails. If you're emailing a client or a client's family, what is appropriate and not appropriate to put in that email? Should you put information about the client and the client's progress in an email? Is your email secure? Now there are some secure email systems out there that meet HIPAA standards and would be considered HIPAA compliant, but it's important that you make sure that whatever email system you're using, it is secure, I would suggest not putting client information in an email or in a text even.

I would use emails and text to confirm appointments, to schedule phone calls, but if you're going to talk about client information and data with someone you do it on the phone or in person, if that's possible, or even through your video conferencing platform, rather than writing it in an email. We hear all the time about emails being hacked. If that happens, then you've exposed your clientÕs personal medical information, if your email does get hacked. So these things are extremely important when you're setting up a Telepractice that you keep this in mind as you're choosing your email system and your platform that you are compliant with because we don't want to expose our clients and as part of our Code of Ethics. We need to keep that information from the public view.

[00:23:57] EDM: You know, the point that you're making about email is so important because email is such a big part of our lives in terms of our personal life as well as our professional life. That might be something that you might not even think of automatically in terms of what it is that I can share about a client via email as supposed to what I certainly cannot. So thank you for that reminder about email, because that really is important. 

[00:24:29] MJ: Right.

[MESSAGE]

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[INTERVIEW CONTINUED]

[00:24:54] EDM: Let's let our listeners have you respond to a scenario about clientsÕ safety in Telepractice. Susan has been doing Telepractice for two years, she sees Dave, an adult client with vocal nodules, whom she's been working with for six months. Today during their online session, Dave mentioned that he's not feeling well. Shortly thereafter, he appears to faint and he appears to be having a seizure. Since Susan lives in Delaware, and Dave is in Florida, she can't call 911, because she will not be connected to emergency service near Dave. Once Dave recovers, his wife complains that Susan did not do anything to help her husband, during his medical emergency. Did Susan have a responsibility in this situation?

[00:25:47] MJ: Absolutely. SLPs have an ethical responsibility to keep their clients safe. When we are physically in the same space with our client, it's very easy to do that, because we can pick up the phone and dial 911, but with Susan, who lives in Delaware, and Dave is in Florida, Susan dials 911 in Delaware, she's going to be connected to the Delaware emergency services in her state and they can't help Dave in Florida. Clinicians should always ask the client where they are located during each session because we know our clients can be mobile. We also need to ensure that the clinician has the emergency contact numbers for them, not just family member's contact information, but the direct dial phone number for emergency response professionals, including fire police and ambulance, in addition to the family contact members. 

It's also important to be aware of any medical issues that a client will have, so that if for instance, somebody has a seizure disorder, then you want to be aware of that and aware of any signs that things that may happen before the client actually has a seizure. We must keep our clients safe, and not only do we keep their records safe, but we have to keep them personally safe as well. Now, in Telepractice, in particular, we're working with kids, primarily, but also some adults as well. We have a facilitator or an E-helper with our clients. 

It's important that having that person there can really help if there is an emergency, and can help if a client gets ill just like Dave did, but we need to think about those things. I have to admit, early on when I first started in Telepractice, I hadn't thought about that, but I talked to a colleague of mine who had been doing that and she happened to mention getting emergency contact information. She talked about it in a presentation that she did. I talked to her afterward. I was glad that she did, because it's not something that you think about. You assume that your client is going to be healthy and available and there. You also need that information, not only if there's an emergency with your client, but what if somebody should if Dave was in his home and somebody broke into his house, or his house caught on fire? There are all kinds of not-so-good things that can happen, and we do need to be prepared for them, even if we're 100 miles or 1000 miles away from our clients. 

[00:29:01] EDM: Gosh, that is, I can imagine that is something that's quite compelling to have clients, have a medical emergency via Telepractice, but what I hear you saying very clearly is that we have to be prepared for that, and have the information that we need in order to be able to assist that client in even from over a distance.

[00:29:27] MJ: Yeah, absolutely. That is always a scary thing to think about. I've been in situations where these emergencies have happened and being prepared really helps you to deal with it in a calm manner. Sometimes even if, let's say Dave's wife had been there and David had a seizure and he never had a seizure before. His wife might not in the frame of mind to be able to call 911. She wants to help her husband and may be so distraught that she's not able to make that phone call, so the clinician needs to be able to do that for her.

[00:30:12] EDM: Another very good point, very good. Okay, let's switch gears a little bit. I want to talk about what about selecting a video conferencing platform for your Telepractice? Are there special requirements that can become ethical issues if you ignore them? What is it that someone who's starting out, let's say with a private practice, who wants to do Telepractice? What do they need to know about selecting the platform?

[00:30:43] MJ: Well, certainly we've touched on the confidentiality issue. When Telepractice first came about was when Skype was first introduced to us. It was the first video conferencing platform. If you have ever used Skype, you know that it was not great quality, there was a lot of pixelation and a lag between the audio and video feed. If we were to do Telepractice with Skype as it was back then, it was not equivalent to in-person therapy. Our code does say that if we do Telepractice, it does need to be the equivalent of in-person therapy. That's certainly something to consider as you're looking at a platform. You want high-quality platforms and most platforms that are out there today are high quality. They have a much better audio video feed than they do. 

There are even now some platforms that are specific to SLPs. They're built by SLPs for SLPs. Not only have the video conferencing piece but have data tracking systems and materials and all kinds of other bells and whistles built into those systems. It's important when looking at a video conferencing platform that you ensure that it is encrypted to the standards that are set out in the HIPAA laws. It's important too, that you're able to obtain what's called the Business Associate Agreement or BAA, this helps protect both you and the video conferencing platform and lays out who was responsible for what portions of maintaining the confidentiality of their server and who has access to those servers. 

Again, in choosing a platform, we have to make sure that the quality is what it would be in person. We have to make sure that we're ensuring our clientsÕ security, and that we get that business associate agreement as well. Now, there are a number of platforms out there who state that they meet the standards for HIPAA, but they will not issue a BAA for you. I would be a little bit leery of folks that ask about, that won't give you that BAA, because that gives you the assurance that they're doing what they need to do in terms of the HIPAA compliance. 

When choosing the platform, ensure that you have that, and that you obtained that BAA. Video conferencing platforms are great. I hear a lot of folks say, ÒWhy can't I use a free one? They say that they're HIPAA compliant.Ó Well, I personally and I wouldn't recommend that you use a free platform. I don't think that those free platforms are protected in the same way that a platform is that will offer and will give you that BAA. They're more costly, but it's important that you've got that business associate agreement to protect yourself and to protect your clients. 

Certainly when you're talking to clients about using Telepractice you do have to inform them of the risks. Someone could potentially hack into it. It doesn't happen very often, it happens rarely, but they need to know the risks just like you inform, if you're with your doctor, and you're going to have a certain medical procedure, they inform you of the risks that you may encounter if you go through a particular procedure. You need to inform your client of the risks of using Telepractice, there is a small potential that somebody could hack into a session.

[00:35:27] EDM: Interesting. Well one of the risks, I think, is failure. We're talking about technology. Sometimes it fails. What does the clinician do, if all of a sudden the picture signal goes out or the audio goes out?

[00:35:48] MJ: Absolutely. Again, this is all about being prepared before you go into Telepractice. If the audio goes out or the video goes out, then you need to know how to troubleshoot that or you have to have access, immediate access to tech support to help them out. Then if you can't get the audio or the video back up and running fairly quickly, then you're going to have to reschedule that client session. If you are working in schools, I think that might be a little bit easier to do, but if you're working with a private client, you can't bill an insurance company for a failed session in addition to another session to make it up. You have to be very careful and have some policies and procedures around how you're going to handle those kinds of sessions. 

That's again, why you need to make sure that your computers are up to date, that you have high-speed internet, and that things are going to go smoothly as far as you can tell. You have to make sure that your clientÕs internet speeds are up to date. You have to make sure that you've got enough bandwidth. These are all things that you need to set up in order to ensure that the quality is going to be good. What are you going to do if something happens? There could be a tornado that comes through and affects your clientÕs internet or I'm in California we have earthquakes, unfortunately. Sometimes that cuts off the power. If I have no power, and I don't have any auxiliary power, I've got to figure out a way to meet my clientÕs needs. It's important that you have policies and procedures in place on how you're going to handle disruptions to the video conferencing.

[00:37:54] EDM: The points that you make about band Ð making sure that you have proper bandwidth, making sure that your computers are up to date. It's really important because in relation to our Code of Ethics, it really does underscore the fact that the clinician is responsible for managing the technology and the Code of Ethics Principle Section II, Rule Eight. Yeah, Rule H says that, ÒIndividuals shall ensure that all technology and instrumentation used to provide services or to conduct research and scholarly activities are in proper working order and are properly calibrated.Ó We really, too, as clinicians have responsibility for the equipment, but also, obviously, for having backup plans if there's a failure of some sort. 

[00:38:51] MJ: Yeah, absolutely.

[00:38:51] EDM: Great information.

[00:38:53] MJ: Yeah, and those backup plans could be as simple if you've only got a few minutes left in the session, that maybe you finish the session over the phone. If you've got a lot more and you have to decide at, what point do you end the session when you can't get it back up and running? So again, just having those policies and procedures and again, sticking to the Code of Ethics and making sure that everything's in proper working order.

[00:39:22] EDM: Sure. Makes a lot of sense.

[MESSAGE]

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[INTERVIEW CONTINUED]

[00:39:55] EDM: Now, let me ask you about the fact that there may be folks who are really interested in doing Telepractice, are thinking about how they might get started, and what it would entail, but let me ask you about this, do Speech-Language Pathologist who uses Telepractice requires special training?

[00:40:17] MJ: There is nothing in writing that says that requires us to have training except if you look at a couple of our Code of Ethics, Principle I, Rule A, states that, ÒWe shall provide all clinical services and scientific activities competently.Ó Number one. Then Principle I, Rule B, states that, ÒWe shall use every resource, including referral, etc. to ensure quality services is provided.Ó Then Principle II, Rule A, states that ÒIndividuals who hold the CCC shall engage in only those aspects of the profession, within the scope of their professional practice and competence.Ó

I think these rules really lead us to the fact that clinicians new to Telepractice should engage in some form of training and learning regarding the provision of Telepractice services. Many clinicians feel that this is really easy. I know how to do this. It's going to be a piece of cake and get in there, and don't know how to troubleshoot when something goes wrong. Don't know what to do when their client isn't engaged, don't know how to walk their client through actually getting on to their platform. I think our Code of Ethics really points us to getting some training and expanding our knowledge about Telepractice, before we jump into it. I think if we think about, I've been in this profession a long time, and back in the, I think it was in the late 80s, maybe early 90s, when we added dysphasia to our scope of practice. People weren't just going out and doing it, they really needed to have some training in order to do it. 

I think for a lot of those pioneers, including myself, we dove into it, figured out what it was we needed to know and did it, but we're at a point where Telepractice has been going on for quite a few years now. We do have some information, and we do have research behind it. We need to look at and find out what we need to know, it certainly looks easy. I have to admit, when I first got into it, I thought oh, this is going to be fairly easy and realized very quickly that it wasn't, because there were all kinds of things that we needed to know. All the issues that we've talked about today, Elise, have played into that and we need to have that knowledge before we dive into it. 

I think you'll be a much better clinician if you get some training. I think many Telepractice companies do offer training. I don't know if it's enough. Unfortunately, we don't have anything in research yet that looks at clinician qualities and whether clinicians are better if they get some training, and if they get some training, what is that training that they need? IÕve been doing this long enough that I have a sense of it, but that is my clinical judgment. It's based on my prior knowledge, and I certainly work on training SLPs, but it's important that SLP seek out that knowledge. We have a nice body of research on providing Telepractice services. I'd love to see some more research on how much training clinicians affect their ability to provide quality services. 

[00:44:27] EDM: Wow, that's interesting. If anyone has never done Telepractice, if they have observed Telepractice sessions, I think it becomes very clear that there really does need to be some special knowledge and experience in order to do it effectively. Especially with children who may be fidgeting, who may be distracted, you can't reach out and touch their hand to steal them. You have to have some strategies for getting that student, that child re-engaged and focused using telecommunication. That, I think can certainly be a challenge for folks who haven't contemplated some of the things that go along with Telepractice and may not be as prepared, as they might need to be in order to be effective over the medium of Telepractice. 

[00:45:28] MJ: Yeah, absolutely. What you're saying reminds me of the fact that when we're working with kids, obviously we're not able to touch them. For some clinicians, that's really tough, because oftentimes, we're in their mouths or we're giving them physical cues and we're not able to use that over Telepractice. Many clinicians have never worked with an assistant or an instructional aide or a paraprofessional. Frequently, we do have an adult on the child's side, because they do need somebody to redirect them, that's another specialized aspect of Telepractice. You have to know how to work with that person, and what that person can and cannot do. What are the state's rules and regulations around that individual that are helping you? Are they an SLP assistants? Are they a paraprofessional? Are they instructional aids? There are rules and regulations about that. It's important, again, that we keep all of that in mind.

[00:46:34] EDM: Excellent points. Let's talk about clinical supervision via Telepractice. It can be done through Telepractice, but are there ethical issues that can arise that are more likely to occur in supervision by Telepractice, than with in-person supervision?

[00:46:53] MJ: Yeah, there are. Again, we've talked about some of the issues just around technology. I would not suggest using a video conferencing platform for supervision that doesn't meet HIPAA standards. Again, even though the supervisor is observing, again, the supervisor should be in a quiet room and there shouldn't be any distractions. Their people shouldn't be able to come in and out of the supervisor's office while they're observing an ongoing session. I also know that the ASHA CAA Council, or excuse me, CFCC. The Council for Clinical Certification is working on some guidelines for supervision via Telepractice. It gets very complicated because supervision can be done in a number of ways. 

Again, we want our students to be trained in Telepractice, and should a student Ð there are questions around if a graduate student is receiving training at Telepractice, should the supervisor be physically there with the graduate clinician, or can they do that remotely? Is it appropriate for a supervisor of a clinical fellow to supervise 100% remotely? These are all things that CFCC is working on and promulgating some rules and regulations. Again, as a total, our Code of Ethics definitely talks about supervision and we need to do it appropriately. Again, our Code of Ethics does apply to what we are doing. We do need to follow the code, whether we're supervising via Telepractice or whether we're doing it in person.

[00:49:19] EDM: Interesting. I once was visiting a program at a university and there was a clinical supervisor who was doing some supervision via Telepractice. It was quite something at one point, her phone rang, she answered the phone, she had a short conversation with the person on the other end. A couple of students knocked on her door and came in and asked a couple of questions, all of this while she is supposedly observing a student who is engaged in clinical practice. I was thinking, if she was working up close and personal or in person with a student that could never be allowed. Obviously, it's questionable whether or not you're devoting full time and attention to the student and the interaction that's going on in the clinical session, if you have all of these distractions and interruptions. I think you make some really good points about the importance of attention, then stillness and quietness, and focus with Telepractice supervision.

[00:50:29] MJ: Yeah, absolutely. Just like we would in a Telepractice session, we need to ensure on our client side that we maintain their confidentiality by making sure that they're in a room where they're not going to get interrupted. In school settings, it sometimes is a little bit more difficult, and it's always a dilemma, and I see conversations about this all the time about the SLP at a school site is sharing a room with the resource specialist or learning disability specialist. They're in a room together. Maybe there's just a small divider, but they've got kids coming and going. 

Are we maintaining the confidentiality of our clients, if they walk Ð if those students with learning disabilities walk into the room and see three kids that they had no idea we're getting speech therapy, now they know they're getting speech therapy because they're sitting with a speech therapist? Are we violating our clientÕs confidentiality? The same thing with a supervisor, we need to maintain the confidentiality of the clinician and the clinicianÕs clients and have the phone ring and have other people walk into your office and have conversations while you're supervising, is that appropriate? Are we violating again, confidentiality?

[00:52:02] EDM: Excellent points, really, really good. So as Speech-Language Pathologists, we all have our tools and the things that we work with, our materials and our tests and other things. I have a question. Do clinicians have to get permission from the publisher to use their tests or materials in a video conferencing situation? Are there copyright issues that we have to be concerned about?

[00:52:32] MJ: Well, I'm not a copyright expert, but my understanding of it is that if you own materials, you can share them with your clients by screen sharing them or using a document-sharing camera. It's a bit different with test and with mending of them depending on how you use them. You may need to get permission from a publisher. It would be a good practice to check in with publishers of test to determine whether or not you need explicit permission. This is all part of being an ethical practitioner and not using materials and tests in an unethical manner. 

The same thing goes for online materials. There are a number of websites where you can purchase materials or download materials, and it's not appropriate for you to share those materials with other folks. I just read an interesting blog post recently about copyright issues. When we purchase materials, there are a terms of understanding. If you actually read those terms of understanding, rather than just clicking that you agree. You will see that you're agreeing not to share those materials with anybody else. That's essentially what a copyright is all about.

[00:53:55] EDM: Okay. So be careful. Don't hesitate to ask if you're not sure. 

[00:54:02] MJ: Absolutely. Yeah, absolutely. 

[00:54:05] EDM: Melissa, are there certain situations or communication disorders that are not particularly suitable for a really effective Telepractice?

[00:54:16] MJ: That is an excellent question, Elise. We have a fair amount of research, working with a variety of people with a variety of speech and language disorders that shows that it is effective. I wouldn't say that there are specific disorders that are absolutely inappropriate. I think that you really need to determine that on a case-by-case basis. You need to look at the client's cognitive skills, their behaviors, their physical and sensory issues, you need to look at where their speech and language skills are, and how are they going to interact with you on a video conferencing platform. 

I've had conversations with many parents who said, ÒI'm not so sure my child is going to be able to attend, they've got ADHD or they've got some behavior issues.Ó What we usually try and do is to either do a quick therapy session or just a quick session with a child, that's not necessarily therapeutic, but looking to see whether the child can function in a video conferencing environment. I've seen some kids whom you would have made the assumption right off the bat that, ÒNope, they're not going to be appropriate.Ó And you try them and they are so engaged, and they're so they're with you. It's great. 

I've seen it often used with middle and high schoolers who have burnt down and Speech Therapy or Language Therapy. They've been in therapy for many, many years. They really don't want to go and the last thing they want is the SLP to walk into their classroom and say, ÒHey, time for speech, let's go.Ó Teletherapy allows them an opportunity. They have permission to leave the classroom. I'm going to work on the computer. The teacher knows where they're going, but nobody else does and they go and have their session. They like it. Number one, it's more engaging for them, because it's in a medium that they are familiar with and used to, and they liked the interactivity of many of the things that we use in a therapeutic environment. 

They love it and they re-engaged in therapy, and then they end up meeting their goals because now they're re-engaged and we get them out of therapy, whereas if they had stayed in therapy and an in-person setting they would continue to refuse to attend. I've seen some Ð I've worked with kids with, who use AAC devices. There are ways to set that up so that it can be really successful. Again, it's got to be done on a case-by-case basis. It's just like when we decide, for instance, if we're working with a student who has an articulation disorder or phonological disorder. We decide whether we're going to put them in five-minute therapy every day or we decide that we're going to use picture cards with them, and we decide the mode of service delivery.

As clinicians and we make those decisions on a case-by-case basis. We can't say that every child who has an art problem is going to succeed in speech therapy. We have to work with him first a little bit to determine if what we're doing is going to succeed. Then if we decide that this client is not a good candidate, we need to be able to decide that fairly quickly. If they're not, we need to be able to refer them to in-person therapy and our Code of Ethics implores us to do that when we cannot treat a client, we need to be able to refer them to somebody who can.

[00:58:28] EDM: You know, I really like your idea of trying it, not making a decision without having any information about how the child will react to the Telepractice environment, but that is just great advice. If you're not sure, try it and see how the child relates to that type of environment. Thanks. Okay, one last thing that I want to ask you about. That is what should a clinician do when their employer demands that they continue to treat clients that they don't believe are appropriate for Telepractice services?

[00:59:10] MJ: Well, at least unethical employer demands not only to happen in Telepractice, but also happen in person settings. Essentially, you want to do the same thing you would do in an in-person setting. We are required to practice in an ethical manner in our Code of Ethics, ethics lays out how we do that. When an individual clinician feels that the demands of a job are violating the Code of Ethics and their own ethical practice they have a few choices. They can continue doing what the employer tells them to and potentially put themselves in a position of being accused of violating the Code of Ethics. 

They can have a conversation with their employer share the Code of Ethics along with research that supports their point of view and try and solve the dilemma or they can leave their job. Of course, none of these are easy decisions, as we all want to be ethical, but we have a duty to refer patients, which is Principle I, Rule B, to ensure quality services provided. We have a duty not to defraud insurance companies or clients or our employers. Often just having a calm conversation with an employer is the best way to handle these situations.

[01:00:26] EDM: Okay, thank you so much, great advice, on several different issues related to Telepractice. I want to thank you so much, Melissa, for being with me today. You have provided us with a lot of information and ideas and a lot to think about. I think especially for our colleagues who may be contemplating developing Telepractice, you have really given some information that should help them be successful in terms of not only developing the practice, but also having a very ethical practice, because ethics is essential. Thanks so much. 

[01:01:07] MJ: You're welcome.

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SLPL 03		Transcript

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