HIPAA Compliance for Mental Health Clinicians

Note: This blog post is not a substitute for legal advice. It’s just a blog post.

You’ve decided that you want to start using technology in your practice, whether it’s using an EHR, offering teletherapy, or even emailing with clients. Great! Your clients will thank you for it! But first, you need to be familiar with HIPAA, the Federal Law which establishes national standards for electronic health care transactions and identifiers for providers, health insurance plans, and employers.


What is a Business Associate Agreement (BAA)?

The BAA is an assurance from a service provider (business associate) that they will safeguard your clients’ data in the same ways you as a clinician (covered entity) are required to. It also clarifies and limits how service providers use and disclose protected health information (PHI). Finally, it highlights the appropriate safeguards necessary to prevent unauthorized use or disclosure of PHI. If a company will not sign a BAA with your organization or practice, then you should not trust them with your clients’ PHI.

Why do I need a BAA?

Because HIPAA says so. Every covered entity must have a written agreement with each of its business associates, or else it is not compliant with HIPAA regulations. Your “business associates” are all the various service providers who interact (“create, receive, maintain, or transmit”) with your clients’ data: email, video, records, texts, etc.

Yeah but what will really happen if I’m not compliant? I’m just a small practice.

It’s not worth the risk, and your organization’s size doesn’t matter. The federal government has the latitude to impose both civil monetary fines and criminal punishments upon individuals and organizations that violate HIPAA. Under the current omnibus HIPAA rules, each violation can incur a penalty of up to $50,000, with repeat violations of the same provision costing as much as $1.5 million per year. In the first seven months of 2016 alone, HHS recorded close to $15 million in HIPAA violation settlement payments.

I don’t have a BAA with Google and use Gmail. Is it enough to simply ask my clients to not email me sensitive information?

Probably not. Even a simple emailed appointment reminder can be considered ePHI. In order to be in compliance, you’ll want to use a provider with whom you can sign a BAA, such as by using G Suite (Google). It’s important to note that in the case of G Suite, your data will be encrypted on Google’s servers, but may not be fully encrypted while in transit. Given that, it’s advisable to document that your clients have provided informed consent to communicate via email.

There are services that are designed to provide fully-encrypted email solutions to providers. Some examples are Hushmail, or Protonmail. Remember you NEED A BAA between yourself and the company to be compliant! Simply signing up for a service from a provider who claims to be HIPAA compliant is not enough.

Can’t I just use FaceTime or Skype for teletherapy? My client says they’re OK with it.

No. Your service provider must sign a BAA with you to be compliant. To the best of my knowledge, Apple currently does not sign BAAs with FaceTime users. Microsoft (who owns Skype) will enter BAAs, but not for Skype. What about Google Hangouts? No. Google will sign BAAs for email (see above re: G Suite), but not for Hangouts. It’s not enough for your client to be OK with using one of these services, and therapists would be well-advised to remember that just because a client says they’re not worried about the privacy of their data today doesn’t mean they won’t sue you in the future.

Can I use something like SurveyMonkey or Google Forms to administer assessments?

Yes, if you sign a BAA with either SurveyMonkey or G Suite (Google) to do this. 

So do I have to sign a whole bunch of BAAs to be HIPAA compliant?!?

Yes, if you are using multiple different types of services. Alternatively you could opt for the simplicity of having a provider that offers a number of services in one platform. Pacifica offers HIPAA-compliant teletherapy, assessments, and access to a large library of CBT- and mindfulness- based therapeutic content. Learn more here.

7 Tips for Incorporating Technology Tools into Conventional Therapy Practice

Individuals seeking health care are increasingly interested in using technology to help manage their symptoms and obtain treatment. A poll by The Pew Research Center reported that in 2012, 72 percent of Internet users reported seeking health information online (PRC, 2013) and of the 64 percent of people who own a smartphone (PRC, 2015), 62 percent reported having used it to acquire some type of health-related information (PRC, 2015).  These trends in general health present a great opportunity for improvements to existing care-delivery models in mental health too.

Mobile apps are a burgeoning area of health technology which have substantial opportunity to improve treatment, quality of life, and patient self-management and engagement. Numerous professional and non-professional groups have acknowledged the value of these tools, as they are often well-liked by users and have advantages over traditional in-person therapy. For many individuals, therapy is out of reach due to cost, access/provider availability, transportation, or stigma. Though not necessarily a replacement for traditional therapy, apps and other healthcare technologies can help these individuals overcome these barriers and begin to reduce their symptoms and better manage their mental health.

For others, apps can be a helpful adjunctive to regular treatment, allowing them to be more engaged and get more support between sessions. While in-person therapy offers a human relationship that isn’t always possible within an app, mental health clinicians have an opportunity to work WITH these tech tools to enhance their in-person work and take advantage of the benefits that come with the use of technology in their practices.

When beginning to introduce apps into your practice, there are some things to consider in order to be successful and ensure your clients accept and use the new technology.

1. Think about your goals–what will the app help you or your client to do? Don’t introduce technology just because you can. Have an idea of what you think the app or program can be good for, and explain that. Perhaps it’s mood tracking or building a mindfulness meditation practice. Make sure that whatever tool you are suggesting is clinically appropriate and indicated for that client.

2. Be familiar with the tools you’re suggesting. A surefire way to make your client doubtful of the technology is to lack understanding and knowledge of the app and how it works. The more comfortable you are with the app, the more they will be too. Download and use the app yourself. In addition to having more credibility with your clients, you may discover interesting or valuable ways to use the technology that perhaps aren’t immediately obvious otherwise.

3. Put yourself in your client’s shoes. When introducing the client to the app, don’t grab the client’s phone and do it for them. Instead, talk them through the process, allowing them to click through the different tools and describing what to use and when so that they feel a level of familiarity with the app before they leave your office. This is particularly important for apps that have minimal in-app guidance.

4. Problem solve using the app. When might a client want to use a given tool? Provide some suggestions for scenarios and think about any difficulties they might run into ahead of time.

5. Don’t overwhelm yourself or your clients. You might find it helpful to pick just one app at a time to keep it simple. If you start using a wide variety of products, it may be difficult to keep track of how the apps work, what they do, etc.

6. Be familiar with the app’s security and privacy policy. Your clients may have questions about their app usage data and what happens to it. It’s helpful if you have at least some knowledge of the app’s policies so that you can either explain those policies, or know where to direct your clients so that they can read the policies themselves.

7. Have a discussion about the use of the technology much like you would have at the beginning of therapy. What are the limits of confidentiality? Will your client expect that you will be reviewing their app usage? Should they use the app to communicate with you? It’s important for provider and client to have an open and frank conversation about what is and is not appropriate for app usage, and what the client’s expectations should be. Some clients may not fully understand how apps work, and it’s incumbent upon the provider to make sure their clients are informed before beginning to use an app or other tech tools.

Thinking about taking the leap of bringing your practice into the 21st century by starting to work with a mental health app? Consider Pacifica. Pacifica is a mobile application that empowers people to manage their stress, anxiety, and depression using cognitive behavioral therapy (CBT) and mindfulness techniques. The app currently has over 1.4 million registered users and has been highly-rated and well-received in the App Store and Google Play Store, reflecting its appealing design and engaging tools.

In addition to its iOS and Android consumer apps, Pacifica Labs also offers Pacifica for Clinicians, a dashboard tool designed to help mental health care providers leverage the app with their patients and improve treatment effectiveness. The HIPAA-compliant clinician-facing product allows providers to administer and score assessments, conduct teletherapy, and increase between-session engagement and therapeutic efficiency with assignments and education.


How to Improve Therapy Session Attendance, Reduce No-Shows & Cancellations

No-shows and cancellations for therapy appointments are more than just annoying, they can be detrimental to you, your clients, and your practice. If a client cancels a session at the last minute, or if they simply don’t show up, you’re not able to bill for that session, and you’re stuck with a non billable hour in the middle of your day that could have been filled with another appointment. In addition to being frustrating, studies have shown that high rates of cancellations can lead to diminished clinician confidence and affect one’s ability to provide effective care. Poor session attendance rates also impact clients, as they don’t receive the full benefit of therapy and can go on to struggle with persistent symptoms.

For many clients suffering from depression or anxiety, trying to improve their session attendance can be something of a catch-22 situation. Attending sessions can be made more difficult due to symptoms of their anxiety or depression, but in order to see improvement in their symptoms, they need to attend therapy. Clients may miss their first appointment due to a perceived stigma, or because they’re having difficulty taking the first step toward seeking help. Therapy can be a difficult experience, and often clients feel worse before they feel better, which can also lead to cancellations or no-shows if the individual does not experience immediate symptom relief. Alternatively, if they start to feel better, they may quit early and still miss out on the full benefit of in-person counseling. Other issues that can lead to cancellations, no-shows, and low session attendance include logistical concerns such as transportation, disability, or difficulty finding childcare or getting time off from work.

There are many ways you can improve session attendance at your practice, a lot of which aren’t expensive or labor intensive:

  • Give clients as much freedom in scheduling as possible. Giving more options for scheduling can result in fewer cancellations or no-shows.
  • Confirm appointment dates and times immediately after making the appointment with a printed card, so misreading handwriting or making a typo in a phone calendar cannot occur.
  • Give adequate appointment reminders in the patient’s method of choice: phone calls, text messages, emails, or postcards in the mail.
  • Offer rewards for attending sessions by giving discounts on bills, or penalties for no-shows or late cancellations. Create a clear no-show policy and work with clients to troubleshoot when they are struggling with repeatedly no-showing. Consider discharging clients who repeatedly no-show or cancel.
  • If a client no-shows for an appointment, follow up to find out why and reschedule promptly. You may notice patterns that can help you improve attendance in the future.
  • Offer video therapy sessions to your clients. Teletherapy can be a great way to lower the barrier to entry for those seeking help, and has been shown to be just as effective as in-person treatment for a variety of conditions.

Of these, teletherapy may be the most major change to make, but it can also be the most impactful. To learn more about how to bring teletherapy to your practice, and why it’s becoming more and more popular, download our free tip sheet.

Download our free tipsheet

Lessons from HIMSS: How mental health tech can advance population health

Last week Dale and I had the opportunity to attend the Health Information and Management Systems Society (HIMSS) Conference in Orlando, Florida. Here are some thoughts and reflections I’ve had since then.

One view of the HIMSS conference
One view of the HIMSS conference

Technology and Progress in Mental Health

The 1990s were the “Decade of the Brain”. Though many advances and discoveries were made during this time, the experience for mental health patients today is still challenging. Finding providers (particularly those which are covered by insurance), understanding different models of care, and integrating mental and physical health can all be difficult. Despite the high rates of mental illness in our society, stigma is still a problem and a barrier for many people trying to seek treatment. Recently, pharmaceutical companies drastically reduced budgets to research medications for psychiatric conditions.

So what can we do? The first step should be working to improve mental health outcomes through measurement-based care and evidence-based practice using proven behavioral/psychosocial treatments. In order to do this, we can harness the power of the Internet and mobile apps and use technology to advance the state of this sector of health care.

While there are a number of connected-health tools available, few of them are geared towards people with mental health problems, and even fewer are achieving traction or widespread adoption. There could be several reasons for this, but employers and health insurers are increasingly looking for innovations in this space. Health care providers and insurers on a broader scale are beginning to realize that without solid mental health, patients struggle to manage their chronic health conditions and costs can increase dramatically. Employers, too, are motivated to help keep their workforce feeling mentally well. Depression, for example, is as costly as heart disease or AIDS in terms of lost productivity, costing over $43B annually in the U.S. and mental illness is a leading cause of absenteeism in the workplace.

One of the biggest things that investors, providers, and health insurers are looking for is engagement: Getting folks interested and involved in managing their mental health. Apps like Pacifica can help people do just that, either on their own through guided self-help tools, or by connecting to an in-person provider and enhancing their between-session work. Rather than offering an alternative to an in-person provider, Pacifica’s goal is to work in concert with clinicians to improve outcomes and help users achieve longer-term behavior change and wellness.

HIMSS Lessons: The State of the Field

We attended HIMSS to announce our recent funding round and new product launch as well as a big update to the existing Pacifica app. Additionally, I participated in a panel discussion about women in mental health tech. It was clear from our experience in that conversation and the conference more broadly that while there has been a lot of innovation in this area, the field still has a long way to go.

At the conference, we attended a talk that included the CEO of Omada Health, which has developed an electronic diabetes prevention program. Their method is based on a well-validated, in-person program that they adapted to work virtually. They use objective outcomes to measure progress and bill for reimbursement. While this is slightly more challenging when applied to mental health, Pacifica follows the same basic principle of creating engaging, interactive tools based on empirically-supported best practices.

The Health IT Chicks panel participants at the HIMSS conference
The Health IT Chicks panel participants at the HIMSS conference

We left the HIMSS conference feeling exhausted but also excited about the opportunities that lay ahead as we continue to innovate and work to improve mental health care. The use of objective measures has been called for by the Kennedy Forum for years and will continue to be important as mental health care providers adapt to changes to reimbursement models and the introduction of value-based care. Everyone seems to agree that health care costs need to come down, and the use of objective measures to improve treatment monitoring and adjustment is a good first step. As we move forward, attention to issues of privacy and information security will continue to be important, as will integration into existing electronic health records. These are all challenges, but exciting ones, which hold the promise of improving health care for all.

Introducing Pacifica: Daily Tools for Stress & Anxiety Based on CBT

Available today, both the Pacifica iOS app and the Pacifica Android app offer daily tools to help those with stress and anxiety. Based on Cognitive Behavioral Therapy (CBT), a well-researched technique for helping people understand the relationship between their thoughts, feelings, and behaviors, Pacifica is comprised of quick, immersive tools that are designed to fit into our daily lives.

“Pacifica puts powerful therapy tools into the hands of consumers and guides them through Cognitive Behavioral Therapy in a thoughtful way. It is a beautiful, user-friendly app that will hopefully make a big difference in the lives of many people,” said Christine Moberg, Ph.D., a Postdoctoral Fellow at Stanford University School of Medicine. “It represents an important step forward for psychotherapy. By creating a tool that can be used outside of the clinic, we enable people struggling with anxiety, stress, and depression to work toward making improvements in their mental health. While there will always be a place for traditional therapy, barriers such as stigma, cost, and logistical considerations often get in the way of individuals getting the treatment they need.”

“We found that the current apps out there are simple mappings from typical workbook-based pen and paper exercises to a mobile device,” stated Pacifica Labs Co-Founder and CEO Dale Beermann. “However, workbooks themselves don’t fit into our normal routines. We knew we could do better.” The new app provides guided relaxation exercises, spoken thought journals, and daily goals, each designed around specific parts of the CBT cycle. In addition, mood and health trackers help people understand how their symptoms are affected by certain known triggers.

“I’ve personally dealt with anxiety most of my life and CBT was the way out of the woods for me,” said Pacifica Labs Co-founder and Designer Chris Goettel. “The challenge then in designing Pacifica was distilling these tools into an engaging and empathetic experience. I know first hand how debilitating and isolating anxiety can be. Pacifica is an extended hand to anyone suffering.”

Get Pacifica today on iOS or Android.