2020 Essay Contest - Honorable Mention: Telepractice: Current and Future Issues by Ben Zook
Within the past few weeks, the COVID-19 outbreak has confined many of us to our homes and made us wonder how those of us in helping professions can continue to help individuals who need our services remotely. The obvious answer to this question is telepractice, but the clarity in this situation stops there and many questions remain. How do we ensure that services offered via telepractice are effective? The American Speech-Language-Hearing Association’s (ASHA) code of ethics states that telepractice “must be equivalent to the quality of services provided in person” (ASHA, n.d.). How do clinicians implementing telepractice adhere to legislative standards at both the state and national level and adhere to the standards of our professional organizations? And finally, how do we equip current and future clinicians with the tools and skills that will allow the above goals to be possible? The development of telepractice has potential to change our field for the better, but before that happens these questions must be addressed. The most unresolved issue in our field is the successful and ethical delivery of therapy services through telepractice.
The concept of telepractice itself is relatively new, and very little research exists on its efficacy in treating particular disorders related to speech, language, swallowing, and hearing. Definitions vary from state to state, with some saying telepractice includes all forms of communication with clients including email or text, while others define it as exclusively face-to-face videoconference therapy (Cornish-Raley & Lowman, 2020). Evidence-based treatments may be used remotely, but if the evidence supporting these methods came from in-person studies, it is unethical to assume that they are equally effective when presented to clients on a screen. For example, many treatment methods require tactile cues or auditory-perceptual observation that may be challenging to hear on an online video stream, especially if a poor Internet connection exists. To address uncertainty related to efficacy, we must significantly increase the evidence-base for both proven and novel treatments delivered exclusively via telepractice.
Another pressing issue is healthcare equity. The Pew Research Center stated that in 2019, 10% of Americans either didn’t have access to the internet or chose not to use it (Anderson et al., 2019). This means that 1 out of every 10 potential individuals that we may serve could not access telepractice services. The importance of this situation has been brought to light by the recent pandemic, as we have seen low participation in online classes from closed schools with large numbers of children living in poverty and without internet access (Goldstein, Popescu & Hannah-Jones, 2020). It is crucial to avoid already deepening economic disparities in access to healthcare, and if telepractice continues to become more prevalent, this disparity may become significantly more apparent. Before telepractice can ethically become the new normal, we must ensure that all of the people we serve can access our services.
National, state and organizational legislation and guidelines have been created to help ensure that every individual has equal access to the best possible services. One major challenge is ensuring that telepractice services meet the requirements of all three sources of authority. At the national level, can we guarantee telepractice services are equally effective as in-person therapy, meeting the requirements of the Every Students Succeed Act or Medicare guidelines? Will parents be able to access their child’s records in a safe and secure manner, as required by the Family Educational Rights and Privacy Act? In the United States, there is significant variation from state to state regarding legislation addressing telepractice. In Kentucky, an initial in-person meeting is required before telepractice can be offered, whereas in California or Texas clinical relationships may begin remotely (Cornish-Raley & Lowman, 2020). These issues are especially prominent as existing technology allows for us to provide services across state lines. COVID-19 has resulted in dramatic alterations to state legislation. Students in our Pennsylvania-based program were told that nearby New Jersey has relaxed its requirement that all therapy provided to New Jersey residents must be from clinicians licensed in the state of New Jersey. Pennsylvania has stated that as services shift to telepractice, we are no longer required to use secure, encrypted forms of online communication to provide therapy and share documentation. These temporary provisions are surely not long-term solutions, which is why developing guidelines and technologies to address these challenges is the most prominent issue in our field.
Clinicians must ensure that their services not only meet their national and state regulations, but also the requirements of their professional organization, such as ASHA’s requirement that telepractice services must be equally effective as in-person services. Those of us who are being asked to navigate these legal requirements need to receive guidance from their employers and governing bodies to ensure that they are following these requirements, so we can focus on the primary aspect of our job, which is helping others improve their health and communication.
Finally, if clinicians are expected to adhere to these legal requirements and provide equally effective services, what tools are being provided to us to ensure that this happens? There are many practical problems that come along with teletherapy. For those clients and patients who do have internet access, their connections may not be strong and reliable enough to allow us to provide effective therapy. Additionally, many individuals may be unfamiliar with the technologies that they are being asked to use. It then becomes the role of the therapist to teach and counsel clients on how to use these platforms, and for the educators in our field to do the same for students and emerging professionals. If telepractice platforms are a tool that we must become familiar enough with to educate clients and use to provide therapy, then the ability to use them must be considered a new skill required for clinical competency. Ohio legislation states that clinical providers are only allowed to use technology “with which they are competent to use as part of their telepractice services.” (Cornish-Raley & Lowman, 2020). How do we define and assess clinical competency in this skill area, now that so many of us are providing therapy through telepractice? Initial solutions should include extensive and free telepractice education provided by governing bodies like ASHA, and the availability of dedicated technical support personnel to ensure that the technology works adequately to allow us to provide therapy.
As I was finishing edits for this paper, I learned by email that my first teletherapy session would begin the following week, and I began scrambling to plan sessions that are as effective as my sessions were in the clinic, as ASHA mandates. The uncertainty that my classmates and I are feeling as we begin teletherapy highlights the immediate need for addressing this issue. Challenging times do tend to result in breakthroughs in the development of new tools and technologies that allow us to help others in ways that seemed impossible before. Telepractice has the potential to allow people who either are unable to leave their home or choose not to leave their home to receive services. It will allow us to integrate technology into therapy in ways we never did before; I have already found fun online games I plan to screen-share in my upcoming session. But before telepractice can become the new normal, we need to ensure that clinicians receive consistent support from our governing bodies that help us follow federal guidelines, navigate unique state regulations, and access technologies that allow us to provide services that are as effective online as they are in person. Looking towards the future, there must be a significant increase in research related to the efficacy of therapy delivered via telepractice. If these steps can be followed, we will be able to help more people and in more ways than we had ever imagined possible.
- American Speech-Language-Hearing Association (ASHA). Telepractice. (n.d.).
- Anderson, M., Perrin, A., Jiang, J., & Kumar, M. (2019). 10% of Americans don't use the internet. Who are they?
- Cornish-Raley, N., & Lowman, J. (2020) Preparing To Offer Quality Services Through Telepractice: An Introduction.
- Goldstein, D., Popescu, A., & Hannah-Jones, N. (2020). As School Moves Online, Many Students Stay Logged Out.