Running head: PRIVACY IN MENTAL HEALTH 1

Privacy in Telehealth: A Look at Telehealth Visits

In the Mental Health Field
Eduardo Santoyo
COH 611
National University

March 26, 2016

PRIVACY IN MENTAL HEALTH 2

Table of Contents

1) Introduction 3
2) Purpose of Study 3

3) Research Question 3
4) Definition of Terms 4
5) Review of Literature 5
6) Methods 7
7) Participants & Sampling 7
8) Instruments 8
9) Research Design 9
10) Procedures 9
11) Assumptions 10
12) Limitations 11
13) References 12
14) Appendix A Informed Consent 16
15) Appendix B Sample Questionnaire 18
PRIVACY IN MENTAL HEALTH 3

Introduction
Telehealth visits are becoming widely used in different mental health settings in various

countries. The goal for most of these countries is to address access to patients who are not able

to meet their mental health needs for various reasons. For instance, transportation is a barrier for

the homebound in which the option of the telehealth program would be suitable in meeting this

populations mental health needs (Levy & Strachan, 2012). Another barrier that telehealth

attempts to address would be access to those patients with variable work schedules such as

patients that travel, or those that cannot attend their sessions in person at a health care facility

due to time constraints (Choi, Kunik, & Wilson, 2013).

Purpose of the Study
The purpose of this study is to see how telehealth is operating in the mental health field

with respect to maintaining patient privacy. We will be looking at legal, ethical, technological

issues, as well as trust, confidentiality, and location in our research study. Each of these topics

has an impact on patient privacy. This study is being conducted because the rise in telehealth

visits are being incorporated into organizations, who are trying to address issues with access to

appointments with mental health providers. As technology has become an option in alleviating

the healthcare needs of patients, who are gaining medical coverage, this has in turn affected those

who look for mental health services. Telehealth is being addressed in this research study because

privacy is a high priority, when it comes to mental health services. The different issues that

pertain to privacy need to be investigated in order to meet the standard of care for patients

receiving mental health services through telehealth.

Research Question
The goal of this research will be to address issues pertaining to privacy in the mental

health field with the use of the telehealth program. This study asks the question: Is telehealth

complying with privacy standards in the mental health field? This question leads us to ask

further questions pertaining to privacy.

PRIVACY IN MENTAL HEALTH 4

1. Is safety of the patient seeking mental health services being addressed through

telehealth services?
2. Are providers utilizing the telehealth program meeting the standard of care for

patients receiving mental health services, such as informed consent,

confidentiality, and HIPAA regulations?

3. What technological and environmental barriers are patients encountering

during their sessions?

4. Are patients developing a trusting relationship with their mental health

provider through the telehealth sessions?

Definition of Terms
Telehealth- a collection of means or methods for enhancing health care, public health, and health

education delivery and support using telecommunication technologies (Center for Connected

Health Policy, 2016)

HIPAA (Health Insurance Portability and Accountability Act)- reduces health care fraud and

abuse; mandates an industry-wide standard for health care information on electronic billing; and

requires the protection and confidential handling of protected health information (dhcs.ca.gov,

2015)

Review of Literature
A literature review was conducted in order to gather information in regards to privacy,

focusing on factors such as confidentiality, HIPAA, environment/location, technology, and trust.

The articles that were retrieved provided insight into each topic and expanded on those factors as

having an impact on all those participating in mental health telehealth sessions.

Confidentiality
When looking at confidentiality, it is a crucial component that explains how a mental

health professional would keep information that pertains to the patient private. A common issue

found when using the telehealth program is assuring the patients confidentiality. For instance,
PRIVACY IN MENTAL HEALTH 5

the utilization of email and online chat rooms puts patients in a vulnerable position, as it is

possible for others to access their confidential information (Bischoff, 2004). It is also imperative

for providers to assure patients confidentiality, as multiple parties in a patients network share

information with one another, which can affect patients decision to continue receiving services

through the telehealth program (Lee & Harachi, 2015). By having multiple parties share

information, it can pose a security risk, as confidential information may be easily accessible to

unauthorized individuals (Wood, Miller, & Hargrove, 2005).

HIPAA
HIPAA provides protection for the patient from fraud and abuse, as well as sets the

standards for health providers in protecting and handling of protected health information. With

the telehealth program, a key issue that patients face is whether they are receiving the

information necessary to obtain mental health services. A key part of complying with HIPAA

standards is reviewing informed consent, which should include the uses and disclosures of health

information including health care operations (Wood, Miller, & Hargrove, 2005). This should

also include confidentiality requirements pertaining to electronic communications, including

time frame for responding to e-mails or text messages sent by patients (Reamer, 2013). Luxton,

Pruitt, and Osenbach (2014) stressed the importance of following state law and local security

requirements through the usage of telehealth and should be addressed during the informed

consent process.
Environment
The environment also plays a part with privacy in the mental health and telehealth

relationship. Wilson and Wells (2009) describe environmental conditions that can disrupt the

therapeutic process between a patient and therapist, which include: home interruptions and

distractions that come from different sources such as family members, friends, or pets. As a

result to this issue, it is important to remove environmental constraints in order to allow the flow
PRIVACY IN MENTAL HEALTH 6

of treatment (McGinty, Saeed, Simmons, & Yildirim, 2006). Patients receiving mental health

services through the telehealth program, may encounter discomfort sharing personal detailed

information with their provider, when around in public settings which can affect the treatment

process (Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010).

Technology
Technology consists of various factors that deal with the actual issues that can arise from

using equipment. Barriers associated with the telehealth program include technological issues.

Technical equipment problems, such as audio or visual signals with little audio delay, unplugged

or moved machinery, can affect the flow of treatment and relationship with the mental health

provider (Tuerk, et al., 2010). Another barrier associated with the use of technology is patient

and provider competency in utilizing technological equipment. It is imperative to take into

account the user-friendliness of such equipment when participating in the telehealth program

(Cartwright, Hirani, Rixon, Beynon, Doll, Bower, Bardsley, Steventon, Knapp, Henderson,

Rogers, Sanders, Fitzpatrick, Barlow, & Newman, 2013). Patients have reported feelings of

frustration when faced with technical difficulties due to possible local set up, regional

infrastructure, or user competency (Levy & Strachan, 2013).

Trust
Trust is important when it comes to the relationship between the mental health provider

and the patient. Trust is a key component for mental health professionals assisting patients with

their emotional health. The telehealth program encounters difficulties in strengthening trust with

patients seeking mental health services. Mental health professionals have reported lower

therapeutic alliance when using a telehealth program (Richardson, Frueh, Grubaugh, Egede, &

Elhai, 2009). It is important to consider whether the telehealth program would be an appropriate

tool when treating patients with high-risk factors, such as posttraumatic stress disorder (PTSD).

For instance, with veterans receiving telehealth mental health services diagnosed with PTSD,
PRIVACY IN MENTAL HEALTH 7

may encounter barriers during their treatment when receiving imaginal exposure therapy (Tuerk,

et al., 2010). This type of therapy requires the client to imagine any images or thoughts that

would cause fear in the client. These patients may become hyper-vigilant and unwilling to

cooperate with the exposure therapy because of the severity of their symptoms which affects the

rapport-building process. When initially meeting patients through a telehealth program to

receive mental health services, providers conduct an assessment to determine appropriate

treatment for patients. Patients receiving mental health services through the telehealth program

need to feel comfortable and safe to disclose personal information related to the assessment in

order to comply with treatment (Luxton, et al., 2014).

Methods
Participants & Sampling
The recruitment of participants for the research project will include patients who have

taken part in telehealth sessions in a mental health setting. The populations that the research

project aims to investigate are male/female, low- to middle-income households with access to

telehealth devices (cell phones, tablets, laptops, personal computers). This research study aims

to use random sampling in order to obtain wide range of subjects. By obtaining a wider range of

subjects, it would help to reduce bias and provide a representation for this study. In order to

obtain a desirable sample size, we would have to attempt to reach out to approximately 350

subjects, with the possibility of getting a sixty percent response to initial questionnaires. From

those responses, this study would exclude those individuals who do not meet the criteria of the

population that is being studied for this research ending with approximately 180 participants.

The study will need approval from the Institutional Review Board (IRB) at National University

in order to properly protect the participants in the study due to data collection and interaction that

will take place during the study. An informed consent has been created in order to obtain consent
PRIVACY IN MENTAL HEALTH 8

from all participants in the study that will be mailed out to the potential participants (Appendix

A). The researchers will allow three weeks to return in order to move forward with the study

within a timely manner and start collecting data.

Instruments
The data will be collected from the entire sample population questionnaires and will later

be analyzed to gather information such as demographics, and data in regards to the privacy

(Appendix B). The questionnaire aims to collect information covering demographics and

privacy (including technology, trust, confidentiality, HIPAA, and location). Some of the

questions for the privacy component of the questionnaire are open-ended, allowing the

participant to expand on answers. The closed-ended questions use a Likert-scale in order to

obtain information. The validity and reliability of the study tools have not yet been established,

so there will be a pilot test that will be need to be done. In order to obtain tools that are valid and

reliable, the researchers will need to conduct a pilot test on a sample of 50 participants.
A similar questionnaire will be developed in order to obtain and analyze data about how

providers and staff are maintain privacy using telehealth tools in mental health services. Same

procedures will be followed in creating and validating these research tools before being put to

use in the field with participants. A sample group of mental health staff and providers of 25

participants will help in validating and showing the reliability of the questionnaire.
Research Design
The research design for this mixed methods study will be the use of survey methods,

using a cross-sectional, self-reported questionnaire, which includes a open-ended questions in

order to collect qualitative data. The goal is to gain information about how organizations are

upholding privacy regulations during telehealth visits in mental health sessions, so it is important

to approach patients who are using telehealth services as well as the providers. The goal of the

different questionnaires is to examine the perspective of each group in regards to privacy. How

the patient participants are perceiving their privacy as being upheld and respected by providers,
PRIVACY IN MENTAL HEALTH 9

their perspective as what they are doing to uphold regulations while services are provided for the

patients through telehealth methods. There could be some issues in regards to the validity and

reliability of the design, but the process of gaining validity and reliability with the questionnaire

tools might help to establish validity of the research design.

Procedures
Once the questionnaire is finalized, it will go through a pilot test in order to test the

validity of the instrument being administered to the participants. A basic questionnaire will be

mailed out in order to obtain demographic information from patient participants and provider

participants. After the desired population is acquired, the questionnaires that have now been

proven to be validated and reliable will be sent to the participants. The questionnaires will be

mailed and e-mailed out in order to give participants an opportunity to either mail or e-mail back

their responses. Patients and providers will be made aware that depending on how they respond

(mail or e-mail), they will then be asked to respond to any follow-up questions or inquire in that

method. That is to say, if a participant initially responds by returning the responses via e-mail,

all follow-up information will be done solely through e-mail correspondence. Once all data is

obtained, all participants will be assigned a number, so as to avoid attaching any direct personal

information. Patients will be given a number starting with the letter A, and providers will be

assigned a number starting with the letter P in order to differentiate between patients and

provider participants. All responses will be kept under lock and key so as to protect participant

identity. All work will be encrypted so as to protect the participants as well. Participants will

have a week to return all questionnaires back to the researchers in order to provide analysis in a

timely manner.
Analysis of the data will include a descriptive statistical analysis for quantitative data and

qualitative responses will be analyzed to see if any identifiable trends and common threads
PRIVACY IN MENTAL HEALTH 10

emerged from the collection of data.

Assumptions
Assumptions can be made and have an effect when the analyses of the data are to occur

during collection in this mixed methods study. One assumption would be the participants are

answering all the questions honestly. Assuming that patients are answering dishonestly on the

questionnaires, it can affect the outcome of the study and the end the whole outcome of the

research study.
Limitations
The limitations that can be speculated to present themselves because of this research may

negatively affect the results need to be addressed so future research can avoid such issues.

Having limitations in things such as sampling (e.g., not having a sufficient number of

participants for the study) is one example of a limitation. Due to the type of instruments and

procedures used to collect data, it may turn away subjects from participating in the research. The

stigma that mental health has is another factor that would hinder individuals from coming

forward and be willing participants in our study. Another issue would be focusing on a group

population who may not be familiar with the technology that is involved with telehealth visits

(computer, cell phones, tablets), some of the older population may not be able to use telehealth to

its full capabilities. Last issue would be the telehealth procedures not being used by all major

health organizations especially for mental health sessions. This would limit the number of

sources that would be able to present subjects to test our questions with regards to privacy in

telehealth visits in the mental health field.

PRIVACY IN MENTAL HEALTH 11

References
A framework for defining telehealth. (2016). Center for Connected Health Policy: The National

Telehealth Policy Resource Center. Retrieved from http://cchpca.org/sites/default/files/

uploader/Telehealth%20Definintion%20Framework%20for%20TRCs_0.pdf

Bischoff, R. J. (2004). Considerations in the use of telecommunications as a primary treatment

medium: The application of behavioral telehealth to marriage and family therapy.

American Journal Of Family Therapy, 32(3), 173-187. doi: 10.1080/01926180490437376

Cartwright, M., Hirani, S. P., Rixon, L., Beynon, M., Doll, H., Bower, P., Bardsley, M.,

Steventon, A., Knapp, M., Henderson, C., Rogers, A., Sanders, C., Fitzpatrick, R.,

Barlow, J., & Newman, S. P. (2013). Effect of telehealth on quality of life and

psychological outcomes over 12 months (whole systems demonstrator telehealth

questionnaire study): Nested study of patient reported outcomes in a pragmatic, cluster

randomised controlled trial. BMJ, 346(f653). doi: 10.1136/bmj.f653.

Choi, N. E., Marti, C. N., Bruce, M. L., Hegel, M. T., Wilson, N. L., & Kunik, M. E. (2014). Six-

month postintervention depression and disability outcomes of in-home telehealth

problem-solving therapy for depressed, low-income homebound older adults. Depression

& Anxiety, 31(8), 653-661. doi: 10.1002/da.22242

Choi, N.G., Kunik, M.E., & Wilson, N. (2013). Mental Health Service Use Among Depressed,

Low-Income Homebound Middle-Aged and Older Adults. Journal of Aging and Health,

25(4), 638-655. doi: 10.1177/0898264313484059

Health Insurance Portability and Accountability Act (2015, March). California Department of

Health Care Services. Retrieved from http://www.dhcs.ca.gov/formsandpubs/

laws/hipaa/Pages/1.00WhatisHIPAA.aspx
PRIVACY IN MENTAL HEALTH 12

Lee, J. Y., & Harathi, S. (2015) Using mhealth in social work practice with low-income Hispanic

patients. Health & Social Work, 41(1), 60-63. doi: 10.1093/hsw/hlv078

Levy, S., & Strachan, N. (2013). Child and adolescent mental health service providers'

perceptions of using telehealth. Mental Health Practice, 17(1), 28-32. Retrieved from

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Luxton, D. D., Pruitt, L. D., & Osenbach, J. E. (2014). Best practices for remote psychological

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45(1), 27-35. doi:10.1037/a0034547

McGinty, K.L., Saeed, S.A., Simmons, S.C., & Yildirim, Y. (2006). Telepsychiatry and e-mental

health services: Potential for improving access to mental health care. Psychiatric

Quarterly, 77(4). 335-342. doi: 10.1007/s11126-9019-6

Pruitt, L. D., Luxton, D. D., & Shore, P. (2014). Additional clinical benefits of home-based

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Richardson, L. K., Frueh, B. C., Grubaugh, A. L. ; Egede, Leonard ; Elhai, Jon D. (2009).

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Science and Practice, 16(3), 323-338. doi: 10.1111/j.1468-2850.2009.01170.x.

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doi:10.1037/0735-7028.31.2.184
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Swinton, J. J., Robinson, W. D., & Bischoff, R. J. (2009). Telehealth and rural depression:

Physician and patient perspectives. Families, Systems, & Health, 27(2), 172-182.

doi:10.1037/a0016014

Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., & Aciero, R. (2010) A pilot study of

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Appendix A - Informed Consent

Informed Consent- Telehealth Study for Mental Health

Please read the following information. (If an interpreter is present, please listen to the
following information)

Introduction: Dear potential participant, you are being invited to participate in a research study
for the telehealth program that is geared towards mental health, which focuses on the programs
effectiveness in maintaining privacy for patients receiving mental health services. As you are
aware, privacy is crucial in the mental health field.

Telehealth is program that consists of visits, where electronic devices are used for two-way
interaction between a patient and therapist, through the use of cell phones, tablets, or PDAs (also
known as mHealth). It also consists of collecting patient information that is electronically
transmitted from one location to another, for patient care. Telehealth is a growing practice in the
health care industry. The Institutional Review Board at National University in La Jolla, CA has
approved this study for the purpose of gathering further information on the effectiveness of the
telehealth program.

Purpose of Study: The purpose of this study is to see how telehealth is operating in the mental
health field with respect to maintaining patient privacy. We will be looking at legal, ethical,
technological issues, as well as trust, confidentiality, and location in our research study.

Risks and discomforts to you if you take part of this study: While participating in this study,
you might become aware that privacy is an issue in mental health consultations, which may
occur depending on the participants perception. You may feel hesitant to share your true
feelings about telehealth methods. You may also feel nervous, or anxious, if this is your first
time participating in a research study. The likelihood of nervousness, or anxiety occurring may
vary from participant to participant.

The benefits to you of taking part in this study: There are no direct benefits to you in taking
part of this research study. The results of this study will give us knowledge to change the way
telehealth operates in respect to patient care.
PRIVACY IN MENTAL HEALTH 15

Specific things you should understand about confidentiality: All of the information that will
be collected for the study will be kept confidential with regards to personal information and
identity. The information that is gathered from the groups will be reported. All participants will
be given a number at the beginning of the study and that number will be used on all forms that
include data. All information that is collected will be kept in a secure location and destroyed
once the study is completed.

What to do if you decide you want to withdraw from the study: Your participation in this
research study is entirely voluntary. You may choose not to take part, or you may withdraw from
the study at any time. If you decide to withdraw before the end of the study, all your information
will be destroyed and you will not be asked to provide any other information at that time.

If you have any questions regarding your rights as a participant in this research study, please
contact: Linda T. Macomber, Lead Faculty for Health Informatics Program at National
University, La Jolla, CA, 92037.

Thank you for your consideration to participate in the research study.

Investigator:
Eduardo Santoyo
Graduate Student
Department of Health Sciences
National University
11255 N. Torrey Pines Rd
La Jolla, CA 92037

I have read and give my consent to participate in the research project titled Telehealth Study for
Mental Health. The researchers have discussed their research project with me and I have
completely read the description of the project. I was also given the chance to ask any questions
about the study and was given answers to my satisfaction. I understand that I will be given a
copy of this consent form to keep for my own records.

______________________ ___________________________ ____________

Participant Signature Participants Printed Name Date
PRIVACY IN MENTAL HEALTH 16

Appendix B - Sample Questionnaire

Welcome to My Survey on Telehealth for Mental Health

Introduction: I plan to gather information on a research study for the telehealth program that is
geared towards mental health, which focuses on the program's effectiveness in maintaining
patient privacy.

The purpose of this study is to see how telehealth is operating in the mental health field with
respect to maintaining patient privacy. We will be looking at legal, ethical, technological issues,
as well as trust, confidentiality, and location in our research study.

Thank you for participating in our survey. Your feedback is important.

Demographics

In this section, we will gather some basic information from you.

1) Are you male or female?

Male
Female
2) What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
3) What is the highest level of school you have completed or the highest degree you have

received?
Less than high school degree
High school degree or equivalent (e.g, GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
4) Are you White, Black or African-American, American Indian or Alaskan native, Asian,

Native Hawaiian or other Pacific Islander, Latina/Latino, or some other race? (Check all

that apply)
White
PRIVACY IN MENTAL HEALTH 17

Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Latina/Latino (Mexican, Central American, South American, Dominican, Costa Rican,

Cuban)
Middle Eastern
European
Multiple Races
Other
Unknown
Some other race (Please Specify) __________________________________________
5) What is your approximate average household income?
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
$200,000 and up

Privacy

In the following questions, we will be discussing issues related to privacy practices in the mental

health field.

6) Did you understand the informed consent section related to HIPAA and confidentiality

provided to you by your therapist at the start of treatment?

No, I did not understand
Yes, I understood
No consent was presented to me
7) How comfortable did you feel participating in telehealth therapy?
Not comfortable at all
Somewhat comfortable
Comfortable
Very comfortable
Extremely comfortable
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8) In a couple of sentences, can you describe how safe you felt in receiving telehealth

therapy?

9) Were you able to develop a trusting relationship with your therapist through the use of the

telehealth program?

Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree

10) What kind of barriers did you encounter during your telehealth therapy sessions? (Check

all that apply)

Technology issues (i.e. computer not working, connectivity, etc.)

Environment (i.e. loud noises, automobiles passing by, space)
Distractions (i.e. around people, around a television)
No barriers encounters
Other (please specify)

Thank You

Thank you for participating in our survey. We value your input to improve telehealth services for

mental health.