Strategic Goals

Strategic questions, such as the potential for specific technology-based approaches to promote partnerships with primary healthcare providers or other key community partners, will shape the direction of planning and elucidate a central role for administrators in establishing the overall goals for any given technology intervention. The adoption of technology for staff supervision or training can assist your organization in reaching strategic goals related to staff recruitment or retention, and it can also help address process improvement challenges. Issues of positioning in the market, competitive advantage, improvements to customer service, and adding value for purchasers also drive the establishment of clear goals.

Planning Team

To foster successful planning, involve stakeholders with a range of skills and perspectives and focus on improvements in clinical care and business processes. Your planning team must make many decisions about the clinical goals of the TAC your agency provides; the content of TAC intervention that will be most responsive to the needs of the population your agency serves; the particular technologies that best complement TAC goals; and the technological, clinical, and administrative infrastructures required for implementation. Exhibit 2.1-1 outlines roles and responsibilities of various stakeholders in the technology adoption process.

Exhibit 2.1-1

Responsibilities of Stakeholders in the Technology Adoption Process.

Population-Specific Considerations

Most of the same considerations regarding cultural responsiveness and appropriateness that apply to in-person interventions also apply to technology-based interventions. In addition to the issues that you already typically consider, it is important to think about the suitability of various technological approaches to the strengths and needs of your intended service population. For example, you should avoid text-based approaches in situations where the target population has limited English proficiency or limited literacy skills, and you should establish clear protocols to assess literacy rather than relying on professionals to assess this skill without formal support. Interventions that include transmission of images may be sensitive for certain cultural and ethnic groups, and digital applications intended to serve older adults must have options for large text sizes and follow elder-friendly digital design principles. Certain groups, such as African Americans, Latinos, and young adults, are more likely than older Whites to use mobile devices as their primary source of Internet access, whereas people over the age of 65 and those with lower incomes are least likely to own a smartphone (Smith, 2010; Smith, Rainie, & Zickuhr, 2011).

Certain populations may significantly benefit from the use of technology to deliver services. For example, technology offers opportunities to improve treatment services for individuals who are hearing impaired by overcoming some challenges in communicating with hearing individuals, expanding the mechanisms for Deaf people to communicate with each other, and offering enhanced access to culturally specific treatment and support (Pollard, Dean, O'Hearn, & Haynes, 2009). It is also important to consider how much technical support your agency will need to implement a particular technological approach based on the problems and needs of the populations to be served. This will drive your decisions about which aspects of the intervention to automate and which aspects counselors should direct (Andersson, Carlbring, Berger, Almlöv, & Cuijpers, 2009). Thus, it is crucial to conduct a review of the strengths and needs of the population to be served and to include former and potential clients in the planning and implementation process. Doing so will help you match TAC to their needs and ensure greater usefulness to the group being served (Forducey, Glueckauf, Bergquist, Maheu, & Yutsis, 2012).

Factors Influencing Successful Adoption of New Practices

Implementing new practice patterns or technologies can be challenging for organizations. However, research in the area of implementation offers some useful lessons. Individuals tend to adopt an innovation when they believe there is a need for the innovation, see the benefit in the new practice, and have the skills and confidence to implement the innovation (Meyer, Clarke, Troke, & Friedman, 2012). You can support clinicians by identifying how technology can be used to solve problems that are relevant to the key stakeholders. You should also consider providing training and support for, and involving clinicians in, service planning processes (Meyer et al., 2012). When adopting new technologies, the level of support from top management and the degree of assistance and support available to service providers are critical. (Jeyaraj, Rottman, & Lacity, 2006; Meyer et al., 2012). For example, ensuring ease of access to the equipment, having adequate support for operating the technology, and providing sufficient time for clinicians to learn the technology can promote the successful adoption of new practices. Clinicians and supervisors on the planning team must think carefully about how the introduction of TAC will change the flow of work for staff members (McGinty et al, 2006); they must also consider how to ensure that efficiencies are gained, or at least maintained, as the agency introduces TAC to the workflow. Successful implementation requires a well-developed business plan and identification of challenges before creating a mechanism to measure success (Meyer et al., 2012).

The Network for the Improvement of Addiction Treatment (NIATx, 2013), a division of the University of Wisconsin's Center for Health Enhancement Systems Studies, developed an effective process improvement system. NIATx identifies five principles for effective implementation of change:

• Focus on an important problem to be solved by implementing the change.
• Identify a change leader.
• Look to other organizations for ideas.
• Pilot the change on a small scale and make adaptations prior to large-scale implementation.
• Understand and involve clients in the change process.

The Substance Abuse and Mental Health Services Administration's (SAMHSA's) Strengthening Treatment Access and Retention State Initiative (STAR-SI) supported NIATx and others (Molfenter, Boyle, Holloway, & Zwick, 2015) in conducting case studies of the use of telemedicine in addiction treatment. In each case study, treatment providers identified factors impeding or facilitating the sustainability and use of TAC, which they were most interested in conducting via videoconferencing and mobile devices. Impediments included costs, lack of reimbursement, unease with technology, lack of models to follow, and concerns about confidentiality. Facilitating factors included local success stories about TAC, champions of TAC, and a strong need to increase access and improve services. One notable STAR-SI effort is the Recoveration program (https://www.recoveration.org), which provides information, support, and distance counseling to consumers (Molfenter et al., 2015).

Staff Recruitment and Training

Counselors who have strong in-person counseling skills will not necessarily be skilled in delivering TAC. Therefore, assessing the technological competence of the workforce and helping staff members develop a sense of self-efficacy with the technology will help increase the success of technology adoption (Andre, Ringdal, Loge, Rannestad, & Kaasa, 2008; Wisdom et al., 2010). As with any new practice, clinicians need to establish competence and develop self-efficacy with the intervention prior to engaging in service delivery (Andre et al., 2008; Maheu & Gordon, 2000; Midkiff & Wyatt, 2008).

To build competence and confidence, behavioral health service providers must have the opportunity to practice integrating services and technology prior to their first client interactions (Abbott et al., 2008; Wood et al., 2005). This might include hands-on practice with the technology before using it with a client, as well as supervised interactions with clients using the technology prior to independent activity. Providers must be comfortable enough with the technology to be able to answer clients' questions, talk about potential privacy and security risks, and troubleshoot technological problems with clients (Ragusea & VandeCreek, 2003). An alternative approach is to use technology that has built-in support and can assist with training clients.

Building competence in staff members should be an ongoing activity. The skills of clinicians and other staff members involved with the technology should be reassessed regularly, and you should have plans in place to institute additional training and support to help staff members who may struggle with the technology or experience new concerns as their competence with the technology advances. Professional associations, such as the American Psychological Association, have begun to develop specific guidelines for the ongoing evaluation of providers' skills and their effectiveness. Exhibit 2.1-2 outlines some of the technological competencies required to implement TAC in behavioral health services.

Exhibit 2.1-2

Technological Competencies Required of Clinical Staff.

Clinical Supervision of Technology-Based Care

The challenges that emerge in the recruitment and training of clinical supervisors to oversee the delivery of TAC are similar to those that arise in preparing clinicians to deliver traditional care (Mallen, Vogel, & Rochlen, 2005). Supervisors need to have advanced knowledge of the technology, experience in delivering TAC, well-developed strategies for building relationships using technology, an understanding of the common ethical concerns related to its use, and experience in identifying and averting crises among clients participating in TAC. Additional competencies are required when clinical supervisors use technology to deliver supervision and when they supervise clinicians who are conducting TAC.

Technology-Mediated Supervision

The use of technology increases the flexibility and accessibility of supervision and presents new avenues for clinicians in remote areas to seek support and expert advice (Abbass et al., 2011; Barnett, 2011; Byrne & Hartley, 2010; Kanz, 2001; Murphy & Mitchell, 1998; Wood et al., 2005). Additionally, using technology to deliver supervision can reduce the stress associated with travel and provide an opportunity for people working in similar specialties to share expertise despite distance (Marrow, Hollyoake, Hamer, & Kenrick, 2002). A variety of tools can be used to deliver supervision, including telephone conferencing, Web cams to record clinical sessions that are discussed in supervision later, email exchanges, online discussions or chats, store-and-forward technologies, and video conferencing. Some technologies are better suited than others to individual and organizational strengths, needs, and resources; therefore, supervisors should think critically about how technology may be most useful for the needs of the individual or group participating in supervision. It is also important to consider how the use of technology will improve care (Stamm, 1998). Use of email or Web-based supervision may improve access to and quality of care in rural areas or in cases where specialty knowledge is required, but it may detract from quality in areas where adequately trained supervisors are plentiful and in-person contact is accessible.

State licensing regulations may restrict or impose specific requirements on the delivery of supervision using technology. In some cases, it may be useful to supplement technology-mediated contacts with in-person supervision (Vaccaro & Lambie, 2007). These blended approaches that combine in-person contact, video conferencing, email, and asynchronous discussions provide flexibility in responding to the unique learning preferences of the supervisees and afford supervisors the ability to tailor their methods of communicating various types of information (Wood et al., 2005).

Clinical supervisors must communicate clearly and encourage supervisees to raise questions about the meaning of the communication, especially when using text-based communication (e.g., email) where visual cues are not available. Supervision benefits from use of a more structured format with clear guidelines, responsibilities, and expectations (Graf & Stebnicki, 2002). However, many of the same considerations that arise with using technology to deliver care are also present for technology-mediated clinical supervision. Clinical, legal, and technological training and support are essential for averting frustration and ensuring the effectiveness of supervision (Abbass et al., 2011; Maheu, McMenamin, & Pulier, 2013; Marrow et al., 2002; Vaccaro & Lambie, 2007). Because supervision relies on an exchange of clinical information across participants, supervisors and clinicians must be well versed in strategies that minimize risks to clients associated with data integrity, data security, privacy, and confidentiality.

As with any exchange of clinical information, your agency should have a policy to inform clients of the ways in which the supervision process will use and protect their data. Give clients a chance to consent to their information being shared (e.g., teleconferencing) and explain how the information will be used (Abbass et al., 2011; also see the Master Clinician Note on p. 52). Clinical supervisors delivering supervision via technology also need to be well versed in the state regulations dictating the delivery of technology-mediated supervision, and they must have an understanding of the risks when state regulations do not specifically address the use of technology. For a checklist of competencies for supervisors conducting supervision of TAC and using technology in supervision, see Exhibit 2.2-5 in Part 2, Chapter 2.

Continuous Monitoring and Evaluation

As an administrator, you can facilitate effective adoption of new interventions by putting a system in place to monitor and respond to implementation successes and challenges. Organizational cultures that support ongoing use of data to analyze problems and make needed corrections fare better in the adoption of new practices than those that do not typically rely on structured process improvement (Wisdom et al., 2010). Although continuous monitoring and evaluation can be viewed as an end stage of implementation, planning teams must grapple with the types of data necessary to conduct monitoring and evaluation activities during the initial phases of planning. Selection of data elements depends on the strategic goals of the project and the plans for sustainability; data elements should include both process and outcome measures. For example, process measures such as usage rates, dropout rates, staff perceptions of the challenges and successes of implementation, compliance with the key ingredients of the intervention, and demographic characteristics of the client population can provide helpful information to refine technology-based interventions. Outcomes—including changes in hospitalization rates, symptom changes, and cost effectiveness—can help stakeholders buy into the concept of TAC and promote its sustainability in practice. A system for refining or enhancing TAC is critical to ongoing success.

Disaster Planning

As essential community providers, many behavioral health organizations are required to have disaster plans. In addition to resources such as SAMHSA's Disaster Technical Assistance Center (http://www.samhsa.gov/DTAC/), organizations may consider the ways in which technology can assist in responding effectively to disasters. Technology has the potential to be useful in addressing certain challenges that commonly result from disasters, such as by allowing access to information about medications or health histories via the Internet and enabling communication via text messaging, cell phones, and reverse 911 calling to disseminate information and dispatch providers.

GO2AID

In a disaster, it's essential that behavioral health responders have the resources they need, when and where they need them. SAMHSA's GO2AID—Field Resources for Aiding Disaster Survivors application makes it easy to provide quality support. You can perform predeployment preparation, on-the-ground assistance, postdeployment resource delivery, and more, all at the touch of a button:

• Be focused. Spend less time worrying about logistics so you can focus on what really matters—the people in need.
• Be prepared. Rely on and access predownloaded resources on your phone in case of limited Internet connectivity.
• Be confident. Review key preparedness materials so you're confident about providing the best support possible.
• Share resources easily. Send information to colleagues and survivors via text message or email, or transfer to a computer for printing.

Source: SAMHSA, 2013c.

Technology can help ensure that professionals from outside the jurisdiction are properly licensed and credentialed during disasters. In more widespread disaster environments, state regulations for licensure and practice may be waived for providers coming from outside the disaster area; teleconferencing, long-distance telephone consults, and other technology-based services may be allowed by state regulators on a temporary basis. The use of telemedicine, a cornerstone of most current disaster service plans, can bring remotely located providers to the affected area without the logistical challenges of travel (Yellowlees, Burke, Marks, Hilty, & Shore, 2008). Some states offer reciprocity specifically for physicians and nurses practicing telehealth in disaster environments; however, others do not offer such reciprocity, creating challenges during disasters. The Emergency Medical Assistance Compact (EMAC) provides protections for medical personnel who provide care across state boundaries during natural disasters and other emergency situations. See the EMAC Web site for more information about the compact (http://www.emacweb.org).

When considering how technology can be used in a disaster, think about how internal organizational communication as well as communication with other critical providers or responders might be affected. For example, having charged cell phones programmed with critical contacts may be vital to effective communication. This may include a plan to communicate with pharmacies to ensure that clients or disaster victims have access to needed medications. In addition to using technology to assist in disaster response, you and your implementation team must plan for technology failures in the event of disasters as reliance on technology to conduct business increases. This includes backup power sources, access to electronic health records (EHRs), systems of communication with other providers and local authorities, and access to provider credentialing records.

Data Security

HIPAA dictates the privacy and security safeguards required for the protection of protected health information (PHI). The security aspects of these rules, which address how health data are accessed, transmitted, and stored (U.S. Department of Health and Human Services [HHS], 2006; HHS, Office of the Secretary, 2013), must be considered when implementing TAC. HIPAA also addresses who is authorized to access data and how access restrictions are implemented. Organizations must establish a password management system that controls access to client data on devices owned and controlled by the organization, as well as remote devices or devices accessed from remote locations. In addition, organizations are advised to have policies that address lost and stolen passwords, automatic session logouts for unattended work stations, and virus protection on all computer equipment and other devices that store PHI (HHS, 2006).

Staff training effectively addresses many security risks, so dissemination of these policies is critical. Training should include information about risks associated with password sharing, saving logins and passwords in unsecured locations, and forgetting to log off.

HIPAA requires policies that prohibit the transmission of PHI via unsecured email and provide for email encryption. In addition, policies about remote access to PHI via networks and Web-based email are necessary (HHS, 2006). Data storage security as defined by HIPAA includes encryption of stored data and backups and policies about storage of PHI on devices that are outside the physical control of the organization, such as laptops, universal serial bus (flash) drives, and personal digital assistant devices (HHS, 2006). Policies must address the handling of security violations, equipment repair, and disposal of technologies no longer in use, and procedures must be put in place to train staff members on policies initially and on an ongoing basis.

These are just a few privacy and security issues to consider. The Office of the National Coordinator for Health Information Technology provides more comprehensive guidance and resources on compliance with HIPAA when implementing health information technology solutions (http://www.healthit.gov/providers-professionals/ehr-privacy-security/resources).

Video and Web Conferencing

The video conferencing systems telehealth and telemental health programs typically use take a hub-and-spoke approach to delivery, meaning that clients travel to a local health or behavioral health center to access services that are not available in their community. This model has the advantage of averting some of the technological, privacy, and security complications associated with clients accessing services in their homes. The implementation planning process should inform assessment of the technological infrastructure necessary to deliver TAC. If video conferencing will be central to the intervention, issues of bandwidth, image resolution, display size, and audio quality on both sides of the exchange are central to its effectiveness. Issues of bandwidth are particularly important for video conferencing. If using public Internet for video conferencing, it is important to consider fluctuations in Internet use and the impact of that use on speed. For instance, high Internet use times on the public network may limit available bandwidth and slow the transmission to an unacceptable level.

Internet connectivity and bandwidth must be sufficient at both ends of the transmission. Bandwidth and encryption are as important for the client participating from home as for the primary transmission site. In addition, data security and storage are essential to consider and are related to unique risks when transmitting client images using video conferencing. Various videophone and video conferencing technologies are available and offer a range of solutions to these challenges. Audio Web conferencing can be used to conduct group discussions over the Internet. A number of vendors sell access to products useful for Web conferencing. Audio technologies are typically more familiar to providers and generally pose few challenges. However, mobile phone use for Web conferencing raises some privacy and security concerns. See the “Telephone/Audio Conferencing” section for additional information.

For providers, ease of use of the technology is important. Some approaches using video and Web conferencing require technology experts to operate and troubleshoot the equipment but still demand at least some technical skill from clinicians. Other models rely on clinicians to perform their own troubleshooting, requiring more advanced technical skills.

The physical location of counselors and clients while they participate in audio/video conferencing has implications for privacy. The American Telemedicine Association (2009b) addresses physical location requirements, including visual and audio privacy, room lighting, backdrops, and ergonomic considerations. Organizations should consider adopting policies that require individuals to introduce themselves upon entering the room during a session and that encourage discussing the privacy of clients' locations with clients at the beginning of each session. Planning teams need to grapple with these issues in advance of TAC delivery and have plans for monitoring and adjusting their approach to troubleshooting technology issues as implementation proceeds.

Telephone/Audio Conferencing

Delivering treatment services via telephone is likely to be the most accessible, inexpensive means for providing TAC in organizations that lack existing technology infrastructures. Teleconferencing, or connecting multiple users into an audio discussion, can facilitate group discussions for treatment or supervision purposes. Various teleconferencing vendors with a range of contract terms are available. Although use of the telephone can be highly accessible, organizations should be aware that without additional protections, mobile phone transmissions are not secure. Voice communication over mobile phones must be encrypted to minimize the risk of third-party interception; when mobile devices transmit data, they should be treated like other remote devices (e.g., laptops) in terms of security.

Email

When protocols are specific and based in scientific evidence for the population, email can be an effective, accessible, and inexpensive way to conduct outreach with high-risk individuals (Luxton, June, & Kim, 2011) and to sustain contact with clients between scheduled in-person sessions (Alemi et al., 2007; Barak, Hen, Boniel-Nissim, & Shapira, 2008). There is a small body of evidence suggesting that the use of email to deliver primary clinical content may be effective (Luxton et al., 2011; Te Poel, Bolman, Reubsaet, & de Vries, 2009). Because email is not a secure form of communication unless it is encrypted, organizations and providers must implement safeguards to ensure privacy of communications. These precautions include having policies to prevent unintentional disclosure to someone other than the client, such as confirming an email address, and fully exploring risks related to someone other than the client having access to his or her email account. Furthermore, all email exchanges of treatment-related information must use email encryption to meet HIPAA Security Rule requirements (HHS, 2006). Various single-user and organizational solutions for email encryption are available and are generally quite affordable. The National Institute of Standards and Technology Guidelines on Electronic Mail Security provide detailed information on email security and encryption (http://csrc.nist.gov/publications/nistpubs/800-45-version2/SP800-45v2.pdf).

Another option for email is the use of secure, Web-based messaging systems. Several large online behavioral health service providers exist and often include proprietary systems for communicating with clients that may allow for the sending of encrypted email and the storage of text communication with clients. Because emails may be subpoenaed, you should develop policies for your behavioral health program on the storage of these communications. Research suggests that before implementing email or instant messaging interventions (or any technological intervention), behavioral health service providers and program administrators should carefully consider the needs and characteristics of the clients who are likely to benefit from the intervention. Consider implementing structured clinical protocols and procedures to cover the full range of ethical and legal issues discussed in this Treatment Improvement Protocol (TIP) and heed current research as you consider incorporating email into your program's delivery of behavioral health services.

Text Messaging

Text messaging can effectively provide brief interventions or resources to clients on their mobile phones. Text messaging-based interventions may include reminders for medications and appointments or regularly scheduled educational or preventative text messages. In some cases, these reminders may be managed through an EHR. Text messages are easy to send if the client has a mobile phone and a text messaging plan. However, clients may be charged per character or per message for text messaging, so it is important to seek consent to communicate by text message and to ensure that clients understand the security and privacy limitations of data transmission and storage via mobile phone. (For more information on informed consent, see Part 1, Chapter 1.)

Unencrypted text messages should not include PHI. Although there are some secure text messaging services, standard text messages may not be secure. They may be stored on a subscriber identity module card, which identifies the user to the cell phone network, and they can be easily visible to others. Encryption software downloads messages to computers and secures the mobile phone or device if it is lost, eliminating some—but not all—of the privacy and security risks inherent to this mode of communication.

Counselors should carefully evaluate the type of information they need to send to or receive from clients before using text messaging; if the information's inadvertent release could have serious consequences, text messaging is generally inadvisable. Consider establishing a means for counselors delivering TAC to verify their clients' identity before sending/receiving texts. Clients, too, may wish to consider using a screen lock and/or time-out feature to keep information from remaining viewable on their mobile devices to unauthorized viewers. Asking clients to confirm receipt of text messages and establishing measures such as auditing and remote wiping can protect sensitive information to a degree, but providers should generally avoid using text messaging for communication when privacy and security are of significant concern.

Web-Based Text Communication

Real-time instant messaging can serve as an alternative to asynchronous email or text message exchanges. Providers and clients can download chat programs, which are often free, quickly and easily from vendors; these programs require only a computer with an Internet connection. However, issues of data security and storage exist. Real-time chats and instant messaging features are widespread and can broaden access to social support, but the privacy and confidentiality risks inherent to this mode of communication are extensive. Your agency's TAC policies should remind clients that messages sent through chat programs and the chat or messaging features on social networking sites such as Twitter, Facebook, or LinkedIn are not secure and that posts to such sites are not confidential. TAC policies should also discourage providers from interacting with clients via social networking sites and urge them to remind their clients that communications posted on such sites are public.

Avoiding the use of social networking sites can become particularly challenging when disgruntled clients post ratings or comments about their experience with your behavioral health program or your agency's personnel. You and your TAC implementation team should carefully consider establishing policies to guide agency responses to consumer ratings and comments that are posted on the agency's own Web site as well as on other public forums.

Self-Directed Therapeutic Tools

Self-directed therapeutic Web sites and applications are typically hosted by third-party vendors. Organizations will typically purchase a usage license for a group of clients; the clients then receive a unique user ID and password. The content of self-directed therapeutic tools is developed by the vendor and often restricts the client's ability to enter personal information.

Many self-directed therapeutic tools target prevention and treatment of mental and substance use disorders. For example, college campuses often purchase licenses so that their students can access substance use or mental health risk factor reduction programs delivered over the Internet. Another example is a secure Web site that provides self-directed education and secure messaging with a care manager for clients enrolled in outpatient mental health services (Hunkeler et al., 2012). In addition, many mobile applications have been developed that lead the user through a process of screening, education, and support. Applications vary in terms of data security and the amount of personal information entered.

Self-directed behavioral health applications frequently include Web-based messaging systems that send emails to clients prompting them to log in to a password-protected Web site. Before incorporating digital self-directed therapeutic tools into your agency's behavioral health program or recommending their use to your clients, your TAC implementation team should investigate how such applications address password protection, automatic logouts, firewalls, audit trails, encryption, and authentication. They should know what data the tool collects; how it stores and protects those data; and the extent to which it may share the data, including any third-party access to the data. Online therapy service providers may serve as an alternative for secure communication with clients. These services help manage privacy and security concerns by providing encrypted chat stream identifiers and storing text communication with clients, but you must carefully examine the reputations of such services before choosing one.

Self-directed therapeutic tools can be attractive to clients and providers because they require little investment in infrastructure other than access to the Internet, allow clients to work at their own pace, and are accessible (assuming an Internet connection) whenever and wherever the user wishes. Although some of these tools allow for clients to share information with their behavioral health service providers, they generally operate outside of the formal treatment process.

Organizational Web Sites

Organizational Web sites can provide information about behavioral health service systems in a way that can motivate people to seek services (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2004). More active approaches that include discussion groups, built-in chat or email features, and other opportunities for digital interaction with staff members are more likely to engage people into service delivery. That said, organizational liability increases as the organization's Web sites become more active. Although the design and maintenance of professional Web sites are beyond the scope of this document, administrators and TAC implementation teams are urged to consider the risks and opportunities associated with embedding email and discussion group features into Web sites. These more active approaches to Web site design pose challenges and raise concerns similar to those for stand-alone approaches to email and discussion groups.

Cost Categories

Costs associated with various technology-mediated interventions vary widely. In addition to identifying the specific expenses related to the type of intervention selected, agencies have the option of leasing, contracting, or buying equipment and services. Your organization's strategic goals, existing technology infrastructure, and cost considerations dictate which options you select. In planning to implement TAC, you will benefit from careful investigation of the following cost categories.

Infrastructure development cost considerations include:

• Equipment, including computers and servers, mobile devices (for both client and staff use), video conferencing equipment, and telephones.
• Cabling and other communications lines, building reconfiguration, equipment, and cooling systems.
• Internet service provider fees.
• Software, including encryption systems, virus protection, applications, storage, and security systems.
• Expert consultation in technology.
• Content development (e.g. clinical materials, protocols, procedures).
• Initial staff training, including staff time, expert trainer time, and content development.
• Legal and accounting consultation (e.g., sufficient and explicit insurance coverage).
• Development and/or revision of forms, such as informed consents and privacy disclosures.

Ongoing costs considerations include:

• Equipment maintenance, insurance, and replacement costs.
• Ongoing Internet service provider fees.
• Annual licensing or hosting fees.
• Software renewal licensing fees.
• Expert consultation and/or troubleshooting services.
• Ongoing staff training for new staff recruits and refresher training for existing staff members.
• Content refinement and updating of client materials.
• Legal and accounting consultation.
• Inclusion of extra client data and client privacy/consent management information.

Reimbursement for Technology-Mediated Care

Medicaid and Medicare reimbursement guidelines for telemedicine have been developed and are available through the Centers for Medicare and Medicaid Services (CMS). Currently, Medicare authorizes reimbursements for telehealth services delivered by designated professionals in underserved areas or as demonstration projects (HHS, CMS, 2012, 2013). Some state plans dictate Medicaid reimbursement for telehealth. Some private payers also reimburse for video conferencing, and others are piloting video, text, and telephone interventions (Maheu et al., 2004). Although these and other reimbursement structures for TAC under other private and public health insurance plans are emerging, depending on state licensing and reimbursement policies, providers may have the ability to recapture their costs in other ways. For example, the use of technology-mediated interventions may be incorporated as a value-added service that assists providers in meeting other contractual obligations, such as improving care coordination or reducing rehospitalization; the costs may thus be recovered in other service areas.

Gilman and Stensland (2013), of the Medicare Payment Advisory Commission, analyzed 100 percent of telehealth Medicare claims for 2009 (the most recent available data). They reported roughly 38,000 telehealth visits in 2009. Of the providers who delivered 10 or more Medicare-covered telehealth services, 44 percent were psychiatrists, 3 percent were clinical psychologists, and 2 percent were licensed social workers (although the nonpsychiatric providers could be underestimated, as services are sometimes billed under the name of a physician). The authors noted that there were only 26,000 Medicare telehealth visits in 2006, but they considered the increase to 38,000 in 2009 to be “modest,” with only 185 mental health professionals providing 10 or more telemental health visits. Although Medicare recognizes the potential of TAC and has made changes by increasing reimbursement and decreasing regulatory burden between 2006 and 2009, the barriers to implementation described throughout this TIP may continue to restrain reimbursement of telemental health services provided to clients who are covered by Medicare or Medicaid.

Data Management

The issues of data management, quality, and security as dictated under HIPAA are discussed earlier in this TIP. As for how much of the content in digital or audio exchanges between clinicians and clients should be stored, you must consider whether to retain every email communication or transcripts of every chat, and if so, whether to contain such information within client records. Although storing more information about clinical interactions may improve continuity of care, it also creates storage space challenges, and the information may be subject to subpoena. The sheer volume of information text-based communications generate, as well as added challenges associated with video storage, suggest the need for clear administrative policies about retaining and storing information.

In addition to data management and security, issues of data quality can arise when clinicians or clients make data entry errors (e.g., misreporting a weight that a physician then relies on for medication dosage, understating or overstating symptoms). The use of crosschecking software and other internal procedures to ensure data quality can minimize these risks.

EHRs

A comprehensive look at EHRs is beyond the scope of this publication, but EHRs do often include integrated tools that are relevant to direct service delivery. For example, EHR systems can generate reminder phone calls and text messages. EHRs that let providers share access to a client's clinical record are helpful when coordinating care. Sharing clinical information among providers and their supervisors can enhance care and promote technology-mediated supervision. (See also http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs)

Client Access to Organizationally Owned Devices

In addition to addressing PHI-related data security issues when providing computers and other Internet-enabled devices for client use, you must decide whether to control client access to Web sites that distribute pornography or provide downloading software that gives access to illegal or unhealthy activities. These can be particularly thorny issues for your agency's TAC implementation team to weigh.

Informed Consent

In addition to the usual elements of an informed consent to participate in services, a number of considerations emerge when delivering care through technology. As with all informed consent, the consenting process must ensure that clients fully understand the risks and benefits associated with participation in the intervention. Technology introduces a new level of complexity and jargon that may be unfamiliar to some clients. Thus, TAC implementation teams must be diligent about ensuring that clients are fully informed of risks and benefits in language that they can understand. This includes a full disclosure of the risk of losing real-time control of personal data through systems that intrude into clients' homes or personal environments for the purpose of monitoring health and wellness, in addition to privacy and confidentiality risks.

Advising clients of the risks and benefits of participating in TAC should be an ongoing process. Clinicians must be well versed in these risks to identify when risk potential changes, to detect client ambivalence, and to initiate discussions of new risks or concerns. Informed consent processes should address the limitations of the technology-based intervention and the alternative interventions available (Barnett, 2011). Although documentation of these discussions and agreements is essential, ensuring that the client fully understands and agrees to the risks and benefits is paramount (Maheu, McMenamin, & Pulier, 2013).

Consider how your agency will secure written informed consent from clients who will primarily engage in services remotely. Clients can provide electronic signatures or select a box on a Web page to acknowledge reading and understanding the information; however, there are concerns in ensuring that clients fully understand and agree to risks and benefits in this manner. Some programs use the low-tech option of having the client sign and fax the form to the provider (Midkiff & Wyatt, 2008); others require telephone or in-person intake sessions to ensure that clients are fully informed. Informed consent should include information about the roles and credentials of each staff member who will participate in a client's care.

This includes direct service providers, support staff, and supervisors (Maheu et al., 2004).

It can be difficult to verify identity remotely (e.g., when engaging with clients primarily over the Internet or telephone), so some programs require validation of identity, such as photo identification or a signature declaration of identity (Midkiff & Wyatt, 2008). Another way that programs address verification of identity and age is to require an initial in-person or telephone interview prior to the inception of remote care (Abbott et al., 2008; Midkiff & Wyatt, 2008). In remote areas, video conferencing may provide an alternative to in-person sessions. Biometric authentication devices such as iris scan, voice print, and thumbprint readers may provide cost-effective alternatives for organizations. Agencies should also establish policies for verification of guardian consent (Maheu et al., 2004).

The process of obtaining informed consent from clients should include their provision of emergency contact information and their receipt of a disclosure of the procedures their counselor and/or other agency staff will use, should the counselor determine that the client may endanger himself or herself or others (Mallen, Vogel, & Rochlen, 2005). Verify clients' emergency contact information at the time of intake to ensure that your agency has valid information about the client to use in the event of an emergency or for mandatory abuse reporting. The informed consent process should also clearly indicate who the client should contact in the event of a crisis or emergency and should define the response time clients can expect. You may also wish to advise clients not to use email to communicate about emergencies (Maheu et al., 2004).

Informed consents should outline how and where the client's data are being transmitted and the risks and benefits associated with transmission. This includes seeking explicit consent to transmit the image of a person, such as through video conferencing. Informed consent should address risks of being overheard during audio transmissions and of text-based communications being intercepted by third parties. The informed consent process should also clarify how information will be transmitted and stored for clinical supervision.

In addition to explaining risks, give clients information about what they can do to protect themselves from privacy breaches. Advice may include not sharing passwords or email accounts with family members, logging off Web sites after each session (especially for clients in group living situations), and using virus protection software. Introducing clients to the Internet or mobile technology creates potential for benefits and risks that extend beyond TAC itself, so providers have an obligation to help clients become informed consumers of technology in general. Responsible providers give their clients information on topics such as viruses, malware, and spyware risks and protection; vetting Internet resources; the risks of sharing personal information on social media; the risks associated with sharing software, such as music files; the importance of passwords; and password management. Information available to clients should be understandable, accessible, and—for very vulnerable populations—delivered in various ways.

Explain how fees for technology-based interventions are charged and how payments for TAC are made (Barnett, 2011; Maheu et al., 2004). This may require explaining insurance reimbursement and limitations of reimbursement, which types of interactions are billed, and the logistics of payment. If clients wish to use credit cards, issues can arise regarding recurring payments, the name listed on the invoice, and where receipts may be sent. Depending on the type of technology used and the intervention's intensity, advise clients about how technology failures will be handled, including backup plans for clinical intervention and plans for handling technological problems (Mallen, Vogel, Rochlen, & Day, 2005).

Scope of Practice, Boundaries of Competence, and Credentialing

In any setting, a behavioral health service agency plays a role in ensuring that its counselors, supervisors, and other clinical staff provide services within their scope of practice and competence; this is often accomplished through formal credentialing and privileging procedures. Remote service delivery not only presents challenges in ensuring that providers are licensed to deliver a particular type of service in a specific jurisdiction, but also demands that counselors develop new TAC-specific competencies. Organizational TAC competencies differ from those required for agencies providing traditional in-person services. For example, program implementers need to be sensitive to such issues as naming of moderated forums and ensuring that the scope and role of the staff members responsible for moderating it are clear (Midkiff & Wyatt, 2008). Another example would be a client's potential inability to distinguish easily between a licensed professional's email and that of a support person who is responsible for logistical arrangements; you may wish to establish a policy requiring staff members to use full signatures that clarify who is sending the message, the role the sender plays, and alternative contact information for reaching the sender, such as a phone number (Maheu et al., 2004).

It is important for behavioral health organizations providing TAC to adopt policies and practices that ensure coordination of care among the various staff members who will communicate with a given client. You may wish to consider providing clients with an acknowledgment that explains the limits of any technology-based service that will be provided and the terms of participation, either as a part of the informed consent process or separately. You must also establish a process for identifying situations in which the use of technology may be counterproductive or dangerous and enact policies for handling these situations, including when and how services should be discontinued (Murphy, MacFadden, & Mitchell, 2008).