PERSPECTIVES SIG 18

Clinical Focus

Ethical Considerations
for Client-Centered Telepractice
Ellen R. Cohna and Jana Casonb

Purpose: This article addresses the ethical conduct of client- Conclusions: The hypothetical scenarios presented in this
centered telepractice, with the following purposes: to define article employed examples from telespeech; however, the
ethical communication, to describe state licensure requirements guiding ethical principles are similarly relevant to tele-audiology
for practicing clinicians, and to provide examples of lawful service delivery. The driving force for telepractice is to improve
and unlawful telepractice. the quality of life of clients with communication disorders.

elepractice is “the use of telecommunications tech-

T
1. practice in a lawful manner,
nology to deliver speech therapy and audiology 2. employ ethical communication, and
services to a client who is in a different physical lo-
cation than the practitioner” (Cason & Cohn, 2014, p. 4). 3. uphold the well-being of the client.
The current article describes how key features of telepractice Hypothetical scenarios follow, each supported by
can best be delivered in an ethical manner. The client- brief commentary. While the scenarios employ telespeech
centered descriptor in this article’s title underscores the examples, the guiding ethical principles are similarly rele-
premise that a driving force for the use of telepractice should vant to tele-audiology service delivery.
be to improve the quality of life of clients with communi-
cation disorders.
The American Speech-Language-Hearing Associa- Practice in a Lawful Manner
tion’s (ASHA) Code of Ethics (COE; ASHA, 2016) is as The ASHA (2016) COE commands lawful practice
applicable to the conduct of telepractice as it is to clinical in Principle of Ethics IV, Rule R: “Individuals shall comply
services delivered in-person. Denton (2003) published one with local, state, and federal laws and regulations applicable
of the earliest descriptions of the moral and legal obliga- to professional practice, research ethics, and the responsible
tions of telepractice: that work remains highly relevant. conduct of research” (p. 8). The ASHA COE Principle of
More recent work has drawn even more fully on the link- Ethics I, Rule N, links the requirement for lawful practice
age of specific principles of ethics and rules of ethics to ad- to telepractice by permitting telepractice when it is not solely
dress tele-ethical imperatives (Cohn, 2012). reliant upon correspondence and is “consistent with profes-
Why author yet another article on tele-ethics when sional standards and state and federal regulations” (p. 5).
our profession has already codified four principles of ethics What is meant by lawful practice? The ASHA (2016)
and 55 rules of ethics that can inform telepractice? So as COE defines crime as “any felony; or any misdemeanor
not to tediously relate how telepractice relates to each of
the 59 ethical imperatives in the COE, this work will ap-
proach the ethical conduct of telepractice by focusing on Disclosures
Financial: Ellen R. Cohn is employed as Professor, Department of Communication
three overarching (and sometimes overlapping) principles Science and Disorders, School of Health and Rehabilitation Sciences, University of
that can be guided by best practice and common sense: Pittsburgh, Pittsburgh, PA. She receives book royalties from “Telerehabilitation”
(Springer, United Kingdom) and honoraria or reimbursement for expenses related
to presentations about telepractice. Book royalties are also anticipated for Tele-AAC
a
Department of Communication Science and Disorders, School of (Plural, 2020. Available from https://www.pluralpublishing.com/publications/tele-aac-
augmentative-and-alternative-communication-through-telepractice). Jana Cason is
Health and Rehabilitation Sciences, University of Pittsburgh, PA
b employed as Professor, Auerbach School of Occupational Therapy, Spalding
Auerbach School of Occupational Therapy, Spalding University,
University, Louisville, KY. She receives honoraria or reimbursement for expenses
Louisville, KY related to presentations about telepractice.
Correspondence to Ellen R. Cohn: [email protected] Nonfinancial: Ellen R. Cohn is Editor of the International Journal of Telerehabilitation,
Editor: Geralyn Schulz prior director of the American Telemedicine Association, and past coordinator of the
ASHA Special Interest Group on Telepractice. Jana Cason is Senior Associate Editor
Received April 17, 2019 of the International Journal of Telerehabilitation. She is past chair of the American
Accepted May 11, 2019 Telemedicine Association’s Telerehabilitation Special Interest Group and the American
https://doi.org/10.1044/2019_PERS-SIG18-2019-0001 Occupational Therapy Association’s Technology Special Interest Section.

704 Perspectives of the ASHA Special Interest Groups • Vol. 4 • 704–711 • August 2019 • Copyright © 2019 American Speech-Language-Hearing Association

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 SIG 18 Telepractice

involving dishonesty, physical harm to the person or prop- initiated despite repeated parental request. One day,
erty of another, or a threat of physical harm to the person Gregg was punched in the face during school recess and
or property of another” (p. 3). Fraud is defined as “any suffered facial fractures that required emergency recon-
act, expression, omission, or concealment—the intent of structive surgery. Facial fractures and loss of teeth are
which is either actual or constructive—calculated to de- painful injuries that are expensive to repair. The family
ceive others to their disadvantage” (ASHA, 2016, p. 3). The had a high medical insurance deductible and no dental
ASHA COE Principle of Ethics III, Rule D, states “Indi- insurance. Moreover, Gregg has suffered psychological
viduals shall not defraud through intent, ignorance, or neg- trauma and will require private counseling. His parents
ligence or engage in any scheme to defraud in connection thus retained a malpractice attorney who sued the new
with obtaining payment, reimbursement, or grants and school district. While Gregg’s parents were grateful to
contracts for services provided, research conducted, or prod- Ms. Jones, their attorney implored them to sue her as
ucts dispensed” (p. 7). The ASHA COE Principle of Ethics well, because professionals carry malpractice insurance.
IV, Rule E, further underscores the expectation for integrity: The lawsuit contended that Gregg’s continued stuttering
“Individuals shall not engage in dishonesty, negligence, factored into bullying and the physical attack. To bolster
fraud, deceit, or misrepresentation” (p. 8). his case, the attorney also filed a grievance with the
Ohio professional licensing board and communicated
Scenario: Does Ms. Jones Really Need Another about the unlawful practice without a state license to the
State License? Pennsylvania licensing board. Ultimately, ASHA’s Board
of Ethics was informed.
Ms. Jones, MS, CCC-SLP, has worked as an in-
The malpractice insurance company declined to cover
person, school-based speech-language pathologist (SLP) in
legal expenses or damages for Ms. Jones because she had
Pennsylvania for over 20 years. For the past 5 years, she
established and maintained this telepractice-based client
has also engaged in telepractice, evenings and weekends
relationship while practicing without a professional state
during the school year and nearly full time in the summer.
license as required by law. Adding to Ms. Jones’s trou-
Her pediatric private telepractice accepts patients from
bles is that she also failed to become familiar with the
Pennsylvania, New Jersey, and New York, and as required
different legal forms of private practice that might have
by state regulations, she holds current licenses to practice
shielded her personal assets from liability. As a “sole pro-
in each of those states.
prietor,” she had unlimited liability as “the liabilities as-
During the current school year, she has treated 10-year-
sociated with the business are the personal liabilities of
old Gregg due to his severe fluency disorder. Gregg has
the owner” (ASHA, 2019b, para. 1). She might have con-
responded well to desensitization techniques and is increas-
sulted an attorney or accountant before beginning her
ing his comfort with both his disfluency and peer responses
private practice to consider establishing a “Limited Liabil-
to his speech. He has also decreased his disfluency by use
ity Company.” Now, she could risk losing her personal
of easy-onset speech. Gregg’s parents were pleased with his
assets, including a newly purchased condo.
progress and were complimentary of the therapy provided
by Ms. Jones.
Commentary
Three weeks before the end of the school year, Gregg’s
family learned they must relocate to Ohio. They wished for This unfortunate scenario demonstrates that unlawful
Gregg to continue to make improvements in his speech and telepractice (i.e., practice without a state license), especially
not regress over the summer. The family requested that within a private practice conducted by an unprotected sole
Ms. Jones continue therapy with Gregg over the summer proprietor, can have devastating consequences, particularly
via telepractice and offered to pay her out of pocket. when expected coverage by malpractice insurance may be
The problem: Ms. Jones did not hold an Ohio state rendered null and void. Ms. Jones might have noticed that
license. Since she already expended the time and expense ASHA concludes Ohio has telepractice-related licensure
to obtain and renew three other state licenses, she won- laws and regulations and provides links to licensure re-
dered if she really needed to obtain Ohio licensure before quirements (ASHA, 2019a, 2019f). She might have exam-
she works with Gregg over the summer. ined Ohio’s telepractice law at the time of this writing,
Ms. Jones decided that it was in the best interest of detailed in the Appendix. General advice that pertains to
her client to engage in telepractice over the summer months all states is also posted by ASHA (2019f ) as follows:
without obtaining the new license. Applying for a new • Obtain a license from the state in which you reside
license would cause her effort, a delay in commencing and from the state in which the patient/client resides.
therapy, and expense, and after all, she was licensed in
• If a state has not established regulations on teleprac-
three other states; shouldn’t that be sufficient?
tice, then contact the licensure board for further
Fast forward 2 months to the following October.
guidance and ask for written verification.
Gregg has made a poor transition to his new school and
has been relentlessly bullied on account of his speech. He • It is the responsibility of the clinician to review the
has not yet established a supportive peer network. Planned, regulations on the state licensure board website in
school-based speech therapy services have not yet been their entirety and regularly check for updates or

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SIG 18 Telepractice

changes (Subheading ASHA Guidance: Telepractice which they seek to engage in telepractice. Questions about
State Licensure). the requirements for international telepractice frequently
appear on ASHA’s Special Interest Group on Telepractice
It is important for readers to recognize that state laws
(SIG 18) listserv. In response, SIG 18 members often offer
and licensure requirements can change very rapidly for some
narratives (many demonstrating the need for perseverance
states and that a professional organization’s website postings
and patience) on how they obtained permission to practice
might lag behind such changes. Clinicians must therefore
in a specific non-U.S. country.
exercise vigilance.
The ASHA website contains information concerning
At the time of this writing, a state professional license
multilateral reciprocity agreements and topics on interna-
is required for practice in almost every U.S. state (An excep-
tional practice (ASHA, 2019c, 2019e). However, there is as
tion: The state licensure requirements for clinicians working
of yet no compendium of links to country-based regula-
within the Veterans Health Administration system and the
tions for telepractice.
Department of Defense offer greater reciprocity under spe-
The proposition to conduct “voice improvement”
cific conditions). What could happen if an SLP or audiolo-
without a license is controversial, with strong opinions on
gist engages in telepractice without holding a license in a
both sides. Many of the techniques used to accomplish
state that requires a license? Complaints could be registered
behavioral change and improvements in voice were likely
with the professional licensure boards of all states with
acquired during graduate school courses and clinical prac-
which the practitioner is associated, with potential negative
tice. It can, therefore, be difficult to separate the “coach”
impacts on future professional livelihood. Note that the
from the “therapist.” Be wary of reframing the manage-
ASHA (2016) COE Principle of Ethics IV, Rule T, requires
ment of a disorder to avoid obtaining licensure. If such a
the following:
question needs to be asked at all, be especially cautious.
Individuals who have been publicly sanctioned or Putting on the SLP hat, consider whether an otolaryngology
denied a license or a professional credential by any consult is warranted to rule out pathology. Also consider
professional association, professional licensing that if the activity is not billed or labeled as speech therapy,
authority or board, or other professional regulatory malpractice insurance may not defend against a lawsuit
body shall self-report by notifying ASHA Standards and/or subsequent damages.
and Ethics (see Terminology for mailing address) in
writing within 30 days of the final action or disposition.
Individuals shall also provide a certified copy of the Scenario: Says One Clinician to Another:
final action, sanction, or disposition to ASHA Standards “Let’s Compare Prices”
and Ethics within 30 days of self-reporting. (p. 9)
Two urban university speech clinics are situated
Articles by Brannon, Cohn, and Cason (2012); Cason within a 20-mile radius. Their directors meet monthly for
and Brannon (2011); and Cason and Cohn (2014) describe lunch. Most recently, they decided to compare and set sim-
barriers to state license reciprocity and possible solutions. ilar prices for telepractice. They also agree that one clinic
While an agreement between U.S. states to accept the will only accept children and adults with fluency disorders
licenses of other states has been variously proposed, with for telepractice; the other clinic will not treat those popula-
current efforts underway, such reciprocity is not yet tions but will accept all other disorders for telepractice.
operational.

Commentary
Scenario: “Do I Need a Special License Clinicians from competing organizations routinely
to Use Telepractice to Treat a Client share what codes to use for billing, what insurance compa-
in a Non-U.S. Country?” nies are denying or paying, and best practices for therapy.
Such communication is normative at continuing education
This clinician holds CCC-SLP and two U.S. state events and is even posted on the listservs of special interest
licenses and wishes to engage in telepractice with a client groups. This generous sharing of information is a hall-
with a voice disorder who is relocating to a country in mark of a congenial local professional community and
Europe. (The client has never been a member of the U.S. poses no legal problems.
military.) The clinician wonders if he needs permission to It can therefore seem innocuous for competing
practice abroad. He is also hopeful he can avoid the need practitioners to generalize such collaborative practices to
for licensure and permission to practice within another setting fees and to ask one another “So what do you
country if he markets his services as “voice improvement,” charge?” or “How about we lower our prices for xyz?
since vocal coaches and voice teachers are not required to Then, we can capture all of the business from the hospi-
obtain a state license. tal outpatient clinic and put our competitor down the
street out of business.” Unless taught in graduate school
Commentary professional issue classes, many SLPs would not know
Clinicians seeking to engage in international practice that sharing information and collaborating to set prices,
must learn about and observe the laws of each country in termed price fixing, is illegal.

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 SIG 18 Telepractice

The Federal Trade Commission (FTC, 2019a) defines It is not the purview of this article to advise how to
price fixing as: avoid engaging in such fraudulent activity, except to un-
equivocally state that federal health care regulations also apply
An agreement (written, verbal, or inferred from
conduct) among competitors that raises, lowers, or to telepractice. Even seemingly innocent transgressions can
stabilizes prices or competitive terms. Generally, the be viewed as violations. Before a clinician accepts a client
antitrust laws require that each company establish who receives Medicare benefits, it is incumbent upon the
prices and other terms on its own, without agreeing clinician to learn how billing should proceed and if/when
with a competitor. When consumers make choices waived, discounted, or higher fees are prohibited by law.
about what products and services to buy, they expect
that the price has been determined freely on the Scenario: We Don’t Want to Travel
basis of supply and demand, not by an agreement to That Neighborhood—Let’s Use Telepractice
among competitors. When competitors agree to
restrict competition, the result is often higher prices. Employees in a home health agency have been “push-
Accordingly, price fixing is a major concern of ing back” about visiting clients who are impoverished,
government antitrust enforcement. (para. 1) refugees, HIV positive, and/or living in a neighborhood
with known gang activity. Sometimes a client resides at the
There are other illegal ways to restrict competition. fringes of the agency’s territory and requires a long com-
These include rigging bids, market division or customer mute to the home. The staff convinced the agency manage-
allocation (e.g., “I won’t send promotional mailings to ment to serve these clients via telepractice.
your region, if you promise not to mail yours to mine”),
group boycotts, and making other agreements among Commentary
competitors that restrict or depress competition (FTC, The ASHA (2016) COE Principle of Ethics I, Rule C
2019a). Placing our clients at a disadvantage by inhibit- is clear: “Individuals shall not discriminate in the delivery
ing competition is a crime, enforceable by the FTC. The of professional services or in the conduct of research and
FTC enforces over 70 consumer protection laws (FTC, 2019b). scholarly activities on the basis of race, ethnicity, sex, gender
The following question is often posed in listservs and identity/gender expression, sexual orientation, age, religion,
continuing education courses: “How should we charge for national origin, disability, culture, language, or dialect”
telepractice (vs. in-person practice)?” The conventional (p. 5). Federal health care law similarly prohibits discrimina-
wisdom is to charge the same, because telepractice is just tory practices in the delivery of health care (Johnson, 2018).
another type of service delivery. These authors have never
heard advice rendered to charge less. Most reject charging
more. However, Karen Golding-Kushner, a private prac- Employ Ethical Communication
titioner who specializes in treating clients with cleft palate
Ethical communication is integral to the conduct of
and craniofacial conditions, makes the case that, in some
all clinical practice, and telepractice is no exception. Ethi-
instances, it can be appropriate to charge more for services
cally constructed communication is clearly understood,
based on higher expenses for the clinician, such as equip-
timely, truthful, lawful, and complete. It offers the client
ment and user fees, and so forth. When and if the charges
(and as appropriate, their family) all of the information
are higher than for in-person practice, Golding-Kushner
they need to make an informed choice. Such communica-
insists that families should know of that (and why) before
tion relates to the initiation and termination of telepractice
therapy commences (personal communication, June 7, 2012).
and everything in between. The following scenarios and
even more questions illustrate potential infractions in ethi-
cal communication. They address the circumstance when a
Scenario: Do Federal Health Care Regulations
telepractice provider and/or the conditions of telepractice
Apply to Telepractice? are unknowable.
A university-based director of a speech and hearing
clinic is seeking adult clients for student practicum. They Scenario: A Lack of Transparency and Worse
decide to market services to potential Medicare recipients.
The plan is to waive co-pays and selectively discount prices After completing a long online intake form and pro-
for that population. viding bank account information for payment, the Yost
family signed a contract with a telepractice company to
pay upfront for 20 telepractice sessions, without knowing
Commentary the session length or the cost per session. They were sadly
Medicaid fraud, Medicare fraud, and other viola- surprised when they learned of the amount deducted from
tions of federal health care regulations (often referred to their checking account. The Yost family later realized that
as health care fraud schemes) are serious transgressions other, unrelated electronic withdrawals from their checking
that can result in criminal prosecution, monetary fines, account had been made by the company.
and even years in prison. ASHA (2019d) provides exten- Following the first telepractice session, the clinician
sive guidance on Medicare audits and program integrity. was unable to initiate a second therapy session, because

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SIG 18 Telepractice

the company had failed to pay for the Internet service. The determine if they wish to accept the risks of potential privacy
Yost family could not locate a way to successfully directly and security inherent in the delivery of service via telepractice.
contact the clinician or the telepractice company, because Without this information, clients and their family will not
none of the “contact us” information (e.g., phone, e-mail) know whom to hold accountable if there are breaches of
was operational. The clinician did not receive her salary. privacy and security.
Not even the consumer protection division of the state at-
torney general’s office could locate the company.
Uphold the Well-Being of the Client
Commentary Scenario: Where Is My Client Located?
Clients and clinicians deserve to have access to the During a telepractice session, a 76-year-old patient
following information to make an informed decision about suffered a seizure. Unknown to the clinician, the client
initiating services or to file a complaint, grievance, or legal was not at home and instead was visiting family in a dif-
action: ferent community. The family members were at work. The
• the name, training, and certification and licensure clinician did not obtain the relative’s address and, there-
status of the practitioner; fore, could not contact family members or emergency
services.
• if applicable, the name and location of the company,
and if they are a subsidiary of one or more other Commentary
companies, their names and locations; Clinicians have an ethical responsibility to keep their
• the cost of diagnostic and therapy sessions—this in- clients safe. This might require a trained e-helper, care-
formation should be readily available to clients and/ giver, clinician, or family member on the client side. The
or their family before an agreement is made to com- clinician should ask the location of the client before every
mence the therapeutic relationship. session begins. If a client suffers a medical emergency dur-
ing the session, the clinician must know how to quickly
A clinician who provides services as an employee of
connect to the local emergency service. Do not depend
a telepractice company should be wary of a lack of corporate
upon calling 911 if telepractice is occurring between two
transparency. While it is likely that most of the currently
distant locales. Know the telephone numbers of the emer-
prominent telepractice companies provide services in an
gency services that are local to the client, as a condition of
honorable fashion, clinicians need to be alert to unethical
beginning a session.
business practices, so as to first and foremost protect the
When is a session over? A session is concluded
interests of their clients, as well as themselves.
when the client leaves the room or turns off the technology.
Watch the screen even after a session concludes to be cer-
Scenario: Why Is a Video of My Child Posted tain the client remains safe and there is no need to call for
on a Website That Is Popular With Pedophiles? help.
Commentary
The telepractitioner used a videoconference service Scenario: The Technology Failed. Is There
provider that was free and unencrypted, though the com- a Back-Up Plan?
pany made numerous fallacious claims that they were Commentary
“HIPAA compliant.” The sale of pediatric videos to illicit Short-term technology failures are inevitable and
websites unfortunately constitutes a source of income for must be planned for and communicated about. Telepracti-
the videoconference service provider. When conducting tioners should supply clients with a back-up communica-
telepractice, free connectivity can result in unfortunate tion plan (e.g., a phone number). The ASHA (2016)
costs. COE Principle of Ethics II, Rule H, underscores the ethical
The clinician failed to secure a business associate responsibility to effectively manage technology: “Individ-
agreement (BAA) with the videoconference software pro- uals shall ensure that all technology and instrumentation
vider. The BAA requires the business associate—in this used to provide services or to conduct research and schol-
case, the videoconference software provider—to protect arly activities are in proper working order and are properly
personal health information in compliance with HIPAA calibrated” (p. 7).
guidelines.
The Internet and videoconferencing providers, as
well as the clinical service provider, must uphold privacy Scenario: Promote the Highest Quality Service
and security in a manner that is consistent with HIPAA Julie is 6 years old and was born without an observable
regulations. As a matter of ethical communication, clients cleft lip or palate. She is severely hypernasal, with speech
should be told whether or not a BAA is in force (Watzlaf, that is characterized by numerous articulation errors that
Moeini, & Firouzan, 2010; Watzlaf, Moeini, Matusow, & contribute to moderate unintelligibility of speech. Julie
Firouzan, 2011; Watzlaf & Ondich, 2012). Clients should has a history of otitis media since birth, often as frequent
be provided with the complete information they need to as three times per year. Despite the reported ear infections

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 SIG 18 Telepractice

and the strong association between clefting and otitis me-

dia, the telepractitioner has no knowledge of Julie’s cur- The Texas Instruments Ethics Quick Test
rent hearing status. Due to difficulties accomplishing Is the action legal?
intraoral inspection via the videoconferencing platform Does it comply with our values?
in use, the clinician cannot fully visualize the submucous If you do it, will you feel bad?
How will it look in the newspaper?
cleft palate or the dental structure and relationships. The
clinician has not had a course in cleft palate nor any other If you know it’s wrong, don’t do it!
If you’re not sure, ask.
experience with the condition. He also is not aware that Keep asking until you get an answer.
muscle exercises, icing, blowing activities, or the “milk- Note. The Texas Instruments Ethics Quick Test is available from
shake cure” cannot improve the function of a structurally http://www.ti.com/corp/docs/company/citizen/ethics/quicktest.shtml
compromised velopharyngeal valve; he continues these
activities without progress. Though there is a nearby cleft To this, we pose additional questions:
palate–craniofacial team that is recognized by the American
Cleft Palate–Craniofacial Association, the clinician wishes
to please his telepractice company employers by handling Telepractice Ethics Quick Test
• Is there evidence (research or experiential) that telepractice
the case himself. He therefore does not refer Julie to the might be equally effective as in-person practice for your client?
team for evaluation and possible visualization of the velo- • Might your client be better served by a hybrid (in-person plus
pharyngeal valve nor call the team for advice. telepractice) approach to treatment?
• Is your knowledge of telepractice delivery (e.g., client safety,
privacy, technology, telepresence) sufficient to render services in
Commentary this manner?
When a client presents with a condition that requires • Is your knowledge about a client’s disorder sufficient to practice
interprofessional management and/or that the clinician is “at the top of your license,” or would it best serve the client to
not familiar with, client-centered practice dictates that a refer the client to another clinician or a specialized team?
referral should made. This principle is fittingly codified
as the first rule (Principle I, Rule A-B) of the ASHA COE:
“Individuals shall provide all clinical services and scientific Telepractice Temptations
activities competently. Individuals shall use every resource, The authors of this article are optimistic that readers
including referral and/or interprofessional collaboration when already possess an “ethical compass within.” Knowing
appropriate, to ensure that quality service is provided” (p. 4). when to ask the right questions of themselves and others
and when to consult the ASHA COE is paramount.
The thought of engaging in telepractice can initially seem
Parting Thoughts
exciting. It can be tempting to earn extra income by using a
This article has attempted to demystify the appli- free videoconferencing system; to work anywhere in the world;
cation of selected ethical practices to the conduct of to work from one’s bedroom in pajamas; and to treat clients at
telepractice. For additional information, ASHA main- any location—any time of the day or night. However, if this
tains a website that is replete with content about ethics, all seems too good to be true, it probably is. In order to en-
titled Ethics Resources (https://www.asha.org/practice/ gage in telepractice in an ethical and effective manner, clini-
ethics). The website houses several sections (i.e., ASHA cians must seek a new body of knowledge, acquire hands-on
COE, Board of Ethics Complaint Adjudication, Ethics experience, and are advised to relate to an experienced mentor.
Guidance, In the Spotlight, Sanctions and Violation
History, Student Ethics Essay Award, and Ethics Educa-
tion), and most sections contain several links to specific References
information. American Speech-Language-Hearing Association. (2016). Code of
The section of “Ethics Resources” entitled Ethics ethics [Ethics]. Retrieved from https://www.asha.org/uploaded-
Guidance provides a link to “State Code of Ethics” avail- Files/ET2016-00342.pdf
able at https://www.asha.org/Practice/ethics/State-Codes- American Speech-Language-Hearing Association. (2019a). ASHA state-
of-Ethics/. The state regulations contained therein are by-state. Retrieved from http://www.asha.org/advocacy/state/
American Speech-Language-Hearing Association. (2019b). Business
important to review because some states maintain their entities. Retrieved from https://www.asha.org/practice/
own COE, which may differ from the ASHA COE. BusinessEntities/
Telepractitioners are therefore urged to visit the State American Speech-Language-Hearing Association. (2019c). Inter-
Codes of Ethics of the states that are relevant to their national programs. Retrieved from https://www.asha.org/
telepractice. members/international/
Educational and health care professionals are not American Speech-Language-Hearing Association. (2019d). Medi-
care audits and program integrity. Retrieved from https://www.
alone in striving to “do the right thing.” Texas Instru- asha.org/Practice/reimbursement/medicare/Medicare-Audits-
ments, Inc. (2019), for example, provides all employees and-Program-Integrity/
with a business card size mini-pamphlet with four simple American Speech-Language-Hearing Association. (2019e). Mutual
questions and three simple actions, along with a hotline recognition agreement (MRA). Retrieved from https://www.
number: asha.org/Certification/MultilateralMRA/

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SIG 18 Telepractice

American Speech-Language-Hearing Association. (2019f ). Ohio Federal Trade Commission. (2019b). Price fixing. Retrieved from
telepractice requirements for audiologists and speech-language https://www.ftc.gov/tips-advice/competition-guidance/guide-
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Brannon, J., Cohn, E. R., & Cason, J. (2012). Making the case for Washington, DC: American Health Lawyers Association.
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org/10.5195/ijt.2012.6091 Texas Instrument, Inc. (2019). Corporate social responsibility: The
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Appendix ( p. 1 of 2)
Telehealth Communication (Ohio Admin. Code 4753-2-01; Ohio Laws and Rules Chapter 4753-2)

(A) Definitions
(1) Asynchronous” means recorded therapy sessions submitted for later review.
(2) Board” means the Ohio board of speech-language pathology and audiology.
(3) Facilitator” means the individual at the client site who facilitates the telehealth service delivery at the direction of the
audiologist or speech-language pathologist. For purposes of fulfilling their role, as defined under this chapter, an individual
may serve as a facilitator, at the direction of the audiologist or speech-language pathologist, without becoming licensed as
an aide under Section 4753.072 of the Ohio Revised Code.
(4) “Patient” means a consumer of telehealth services.
(5) “Provider” means an audiologist or speech-language pathologist who provides telehealth services.
(6) “Service delivery model” means the method of providing telehealth services.
(7) “Site” means the client/patient location for receiving telehealth services.
(8) “Stored clinical data” means video clips, sound/audio files, photo images, electronic records, and written records that
may be available for transmission via telehealth communications.
(9) “Synchronous” means therapy sessions occurring via telepractice applications using real-time, encrypted videoconferencing.
(10) “Telehealth” means the use of telecommunications and information technologies for the exchange of information from
one site to another for the provision of audiology or speech-language pathology services to an individual from a provider
through hardwire or Internet connection.
(11) “Telepractice” means the practice of telehealth.
(B) Service delivery models
(1) Telehealth may be delivered in a variety of ways, including, but not limited to, those models listed in this paragraph.
(2) Store-and-forward model/electronic transmission is an asynchronous electronic transmission of stored clinical data from
one location to another usually by the Internet via e-mail and fax.
(3) Synchronous clinician interactive model is a real-time interaction between the provider and the patient that may occur via
encrypted audio and video transmission over telecommunication links, including, but not limited to, videoconferencing.
(4) Live versus stored data refer to the actual data transmitted during the telepractice. Both live, real-time and stored clinical
data may be included during the telepractice.

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 SIG 18 Telepractice

Appendix ( p. 2 of 2)
Telehealth Communication (Ohio Admin. Code 4753-2-01)
(C) Guidelines for the use of telehealth
(1) A provider shall be accountable for any ethical and scope of practice requirements when providing telehealth services.
(2) The scope, nature, and quality of services provided via telepractice are the same as that provided during in-person sessions
by the provider.
(3) The quality of electronic transmissions shall be appropriate for the provision of telehealth services as if those services were
provided in person.
(4) A provider shall only utilize technology with which they are competent to use as part of their telepractice services.
(5) Equipment used for telehealth services shall be maintained in appropriate operational status to provide appropriate quality
of services.
(6) Equipment used at the site at which the patient is present shall be in appropriate working condition and deemed appropriate
by the provider.
(7) The provider shall be responsible for assessing the client’s candidacy for telehealth, including behavioral, physical, and
cognitive abilities to participate in services provided via telecommunications.
(8) A provider shall be aware of the patient’s level of comfort with the technology being used as part of the telehealth services
and only accept for treatment via telecommunications patients who can reasonably be expected to benefit from a service
delivery model under section in paragraph B of this rule and continue with such treatment when there is reasonable expectation
of further benefit.
(9) As pertaining to liability and malpractice issues, a provider shall be held to the same standards of practice as if the telepractice
services were provided in person.
(10) A provider shall be sensitive to cultural and linguistic variables that affect the identification, assessment, treatment, and
management of the clients.
(11) Telehealth providers shall comply with all laws, rules, and regulations governing the maintenance of client records, including
client confidentiality requirements, regardless of the state where the records of any client within this state are maintained.
(12) Notification of telehealth services should be provided to the client, the guardian, the caregiver, and the multidisciplinary
team, if appropriate. The notification shall include, but not be limited to, the right to refuse telehealth services, options for
service delivery, and instructions on filing and resolving complaints.
(D) Limitations of telehealth services
A provider of telehealth services shall inform the patient as to the limitations of providing these services, including, but not
limited to, the following:
(1) The inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person
service delivery.
(2) The quality of transmitted data may affect the quality of services provided by the provider.
(E) Requirements of personnel providing telehealth services
(1) A provider telehealth services who practices in the state shall be licensed by the board.
(2) A provider of telehealth services shall be competent in both the type of services provided and the methodology and
equipment used to provide the service.
(3) A provider of telehealth services who resides out of state and who provides services to Ohio residents shall be licensed by
the board. (Ohio Admin. Code 4753-2-01)
1. Professional experience shall entail the direct involvement of the supervisor in any and all ways, which may include
telepractice that will permit the supervisor to monitor, improve, provide feedback, and evaluate the applicant’s performance
in professional employment.
2. When onsite supervision occurs via telepractice applications, supervision shall occur using real-time, synchronous,
encrypted videoconferencing and shall meet the supervision requirements as specified in this rule.
3. Asynchronous, recorded therapy sessions submitted for later review shall not meet the requirements for onsite supervision
but may suffice as “Other Supervisory Activity” as outlined in the supervision log.

Cohn & Cason: Telepractice Ethics 711

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