Should Telehealth Knowledge Become an Expected Competency for Board Certification Candidates?

The American Board of Professional Psychology (ABPP) holds a mission of serving the public by promoting the provision of quality psychological services through the examination and certification of professional psychologists engaging in specialty practices (ABPP, 2023). This philosophy holds true for each of the currently identified specialty boards. Evaluations for ABPP certification typically includes core constructs of the psychologist’s knowledge of, and demonstration of, advanced level mastery related to: evidence-informed knowledge and methods of providing assessment, intervention, consultation, research, supervision, teaching, administrative, and advocacy services; interpersonal relationships; dedication towards diversity/multicultural considerations; adherence to ethical standards and legal policies; and general professionalism. Assessment procedures to clarify competencies include the credential review, professional statement, practice samples (e.g., written and/or video), written examination, and/or oral examination as varying by board and career stage (i.e., initial versus senior option).

Historically, candidate evaluations have focused on reviewing the psychologist’s traditional in-person activities. However, the field of psychology has demonstrated rapid evolution in response to the Coronavirus 2019 (COVID-19) pandemic. While the COVID-19 pandemic is associated with a wide range of challenges, one of the few positives that emerged was the mainstreaming of telehealth, or the integration of telecommunication technologies (e.g., videoconferencing, telephone, email, text, messaging programs) with clinical services. Despite once being seen as the exception to traditional in-person psychological strategies, telehealth has not only become commonplace in healthcare, but an expectation for many providers and patients. Resultantly, more and more psychologists seeking board certification are employing the technologies in their day-to-day activities (e.g., clinical services, supervision), and submitting materials (e.g., professional statements, practice samples) illustrating their use in patient care. As telehealth has been hypothesized to remain a mainstay in our healthcare delivery system (Mishkind et al., 2021), the question arises as to whether the ABPP specialty boards should consider more formally defining an evaluation of telehealth competencies as part of the board certification examination processes, whether written or oral.

Despite increased usage, research has highlighted highly variable preparation among psychologists using telehealth (Baier & Danzo, 2021; Glueckauf et al., 2018; Perle, 2022; Sammons et al., 2020). To address this concern, literature, field experts, and guiding organizations have suggested that development of telehealth competence requires both didactic and hands-on training, whether coming from self-education of the literature, consultation, direct training and supervision, continuing education, or a combination of approaches (Edirippulige & Armfield, 2017; Perle, 2021). Those studying telehealth have suggested that being masterful at the clinical skills for in-person care, while also adept at technology, does not necessarily adequately prepare a psychologist for the many “what if” scenarios that arise when utilizing telehealth. This can unfortunately create challenges and affect outcomes for both the provider and patient. Nevertheless, adequate preparation and training can equip psychologists with knowledge to prevent and address such challenges as they arise. As summarized by McCord and colleagues (2021) and Perle (2021), adequate knowledge of telehealth technologies has been suggested as requiring multiple core competencies, including, but not limited to: (a) research on efficacy and effectiveness for various mental health conditions and patient characteristics, (b) differences between in-person and telehealth encounters, (c) care considerations and adaptations (e.g., history taking, assessment, intervention, rapport), (d) ethical considerations (e.g., informed consent), (e) legal factors (e.g., cross-state, cross-province, cross-territory, cross-country practices), (f) safety planning, (g) data security, (h) technology troubleshooting strategies, (i) logistics of practice (e.g., documentation), (j) implications of diversity, equity, and inclusion, (k) adaptations for special populations (e.g., older adults, children, disabled, military), and (l) the use of supplemental tools (e.g., apps). Simply put, a psychologist should strive for comprehensive telehealth competence to ensure an ethical, legal, safe, and evidence-informed practice, while seeking to prevent and mitigate challenges and risks.

Often, a false dichotomy between in-person and telehealth practice is assumed. Knowledge of the appropriate use of technologies in clinical care remains necessary even for psychologists not seeing patients virtually, as many situations can arise when familiarity with telehealth can be of great importance. For example, there is the potential for psychologists not employing telehealth technologies to still be required to refer for telehealth services, requiring the ability to inform patients of how such services differ from in-person care, as well as how to prepare for the services (e.g., find a confidential location). There is also the potential for psychologists not employing telehealth technologies to receive new patients that have already received telehealth-based care, requiring the psychologist to be aware of how telehealth differs from in-person services they seek to provide. Additionally, crises can arise between sessions prompting a patient to contact their provider by phone or email; thereby necessitating a psychologist’s understanding of how to preventatively inform clients about expectations, as well as how to remotely (and preventatively) manage safety needs. Finally, there is the potential for psychologists not employing telehealth technologies to supervise trainees or other healthcare professionals who are utilizing telehealth themselves, requiring knowledge of telehealth competencies to ensure proper supervision of not only the clinical components, but the technological.

Revisiting the mission of ABPP certification that aims to serve the public by promoting the provision of quality services via evaluation, combined with consideration of the role of specialized education and competencies required to properly employ telehealth in clinical services, ABPP boards can consider one of several options to evaluate telehealth practices (and mHealth, or the use of mobile applications in healthcare services; Rowland et al., 2020). The first two options would retain the 17 currently identified specialty boards and embed evaluation of telehealth competencies: 1) a sub-category of general practices (i.e., built into general ethics, assessment, and intervention discussions), or, perhaps more appropriately as based upon the complexity of telehealth-based practice, 2) a standalone set of competencies over-and-above traditional in-person practices. A third option, and a much more sizable undertaking, would be to create a full 18th specialty board that focuses more exclusively on telehealth-related practices as differentiated from in-person services. Finally, a fourth option that is aligned with option three is to create “sub-boards” of the preexisting 17 boards to essentially serve the same function as option three. Options three or four would serve to substantiate the multitude of differences between in-person and telehealth activities, as well as the likely need for more time per evaluation to critically evaluate the additional clinical components. Either option could also result in a telehealth-specific certification that indicates a psychologist’s awareness of the relevant telehealth-related competencies, while also showcasing evidence-informed flexibility as varied by patient presentation, setting, and technology. Due to the focus on telehealth-related practices, options three or four can be viewed as not needing a review of all prerequisite information about general training, but could focus on clarifying how psychologists prepared for use with telehealth, ethical and legal considerations, knowledge of the research base for the use of the selected technology and patient presentation, pros and cons of the use of the technology for the specific patient in question, and education they sought to ensure competence in their use of the technologies. Evaluation could include written, multimedia (e.g., video), and/or oral examination processes.

Despite the potential benefits for the evaluation of a candidate’s telehealth knowledge, implementation of such suggestions is not without limitations. First and foremost, the ability for committees to critically evaluate a candidate’s use of telehealth requires committee members themselves have adequate knowledge of the use of telehealth in general practice, as well as the candidate’s specific methods of implementation of the technologies. This is seen as essential to not only guide questioning, but ensure the candidate’s alignment with contemporary research. Additionally, modification of specialty board evaluation processes can be challenging and time-consuming. More specifically, it is recognized that options 3 and 4 would be a more sizable undertaking for ABPP and its specialty boards given the implications of such changes on board bylaws; likely requiring revision, approval voting, and iterative implementation of such changes.

Regardless of the option selected to more formally integrate telehealth knowledge into examination processes, questions will have to be tailored to the candidate’s practice. Examples of questions to guide a reviewer’s evaluation of telehealth that could be amended or expanded upon by the evaluation committee can be found in Table 1.

As both ethical and legal (i.e., licensure) requirements suggest the ensuring of up-to-date competency in all aspects of psychological practice, directly evaluating telehealth-related factors as part of the board certification process can be viewed as aligning with the ABPP mission, and can be beneficial to both the candidate and those patients being served by the psychologist. It is therefore proposed that boards consider formally evaluating a psychologist’s telehealth-focused training, research knowledge, and both preparatory and maintenance activities as an evaluation target to determine their overall competency and mastery of their practices.