Social Mediating: Using Telepractice for Clients With Autism


I think most of us agree that technology changes our social interactions. The daily flurry of “tweets,” “likes” and “snaps” can make us feel more engaged with our world than ever. At the same time, we probably feel isolated sitting next to a person who has their face buried in a smartphone.

So what does a highly technological exchange like telepractice mean for individuals with autism spectrum disorder (ASD) who typically require social interaction guidance and have restricted behaviors?

The core characteristics of ASD include “deficits in social communication and social interaction and the presence of restricted, repetitive behaviors.” As a result, people with ASD struggle with a variety of behaviors like joint attention, verbal and nonverbal communication, restricted interests and routines, and high sensitivity to sensory input. That’s a wide range of things to cover in treatment.

In addition, speech-language pathologists use many different treatment methods with these clients. The National Professional Development Center identified 27 evidence-based interventions for ASD. Some of these approaches require physical assistance. Others focus on a client’s environment. Treatment might also target subtle skills such as interpreting a partner’s eye gaze and tone of voice.

The remote nature of telepractice versus the “hands-on” nature of some tools means that SLPs must evaluate each client’s needs, treatments already in use, and ways to modify treatments for telepractice, and look at options better suited for telepractice. Be aware and ready for potential obstacles—how to address eye contact when you’re using a webcam, for instance, or if the equipment accurately conveys subtle changes in body language and tone of voice—ahead of time.

However, there are also advantages.  Telepractice interaction may be less overwhelming to a client with ASD, for example, or using technology may hold his interest more so than an in-person session.

April is Autism Awareness Month and our entire April issue focuses on related issues.

Obviously, autism and its treatments require flexibility. Fortunately, telepractice offers just that. Researchers at the University of Pittsburgh outlined various technologies and clinical applications for telerehabilitation. These include more-direct “teletherapy,” to less-direct “teleconsultation,” “telecoaching,” and “teleplay.”

You can use some techniques—like social narratives, technology-aided instruction and video modeling—through telepractice without many extra steps. Interventions including peer-mediated instruction, parent-implemented intervention and pivotal response training already require indirect approaches, so modifying them for telelpractice won’t take much more effort than applying them for a specific client in face-to-face sessions.

Emerging research in telepractice treatment for ASD clients already shows success in both direct and indirect interactions. One case study gives positive results for two clients with ASD. One subject received services through “active consult,” in which a student clinician was coached  and monitored by a remote supervising clinician using Bluetooth technology. The other client received telepractice services and responded more favorably to those than he did to onsite intervention.

Another study compared traditional onsite intervention to a hybrid model of direct onsite and indirect telecoaching services. They found that gains made through traditional therapy could be maintained as well or better in a model that also incorporated telepractice.

We still have a lot to learn about how to use telepractice to serve clients with ASD. However, developing evidence reinforces something we know from other settings: We are most successful when we analyze and individualize our services to fit a specific client.


Nate Cornish, MS, CCC-SLP, is a bilingual (English/Spanish) clinician and clinical director for VocoVision and Bilingual Therapies.  He is the professional development manager for ASHA Special Interest Group 18, Telepractice; a member of ASHA’s Multicultural Issues Board; and a past president and vice president of ASHA’s Hispanic Caucus. Cornish provides clinical support to monolingual and bilingual telepractitioners around the country. He also organizes and presents at various continuing education events, including an annual symposium on bilingualism.

Of Language Barriers, Culture Gaps and e-Bridges


It certainly isn’t news that our country is becoming increasingly diverse. What may surprise us is that some of the biggest growth is happening in non-border, less-urbanized states. California, Texas and Florida continue to have the most residents who were born in another country. However, Alabama, Arkansas, Delaware, North Carolina and Tennessee all saw more than a 70% increase in foreign-born residents between 2000 and 2012.

This means that ASHA members probably find themselves with more and more English-language learners on their caseloads. These audiologists and SLPs likely also live in areas where there may not be many resources for serving ELL students. Our Code of Ethics states that we should provide culturally and linguistically appropriate services. ASHA also acknowledges that the ideal situation for ELL clients is to work with a bilingual service provider with specific language and clinical skills.

Telepractice offers an elegant solution for connecting colleagues with these competencies to our clients that need them.

The versatility of telepractice makes it useful in different settings. A school district might use several Spanish-speaking telepractitioners to manage its entire ELL caseload. A rural health clinic may create a limited agreement with a bilingual audiologist for follow-up care of a patient who communicates in a less-commonly spoken language.

Telepractice can be used for more than intervention. We can assess patients—even formally—through telepractice. Formal assessment via telepractice is getting easier because many well-known tests are now digitized. Even when a certified professional is not available through telepractice, an onsite team can use technology to connect with interpreters and cultural brokers to help provide appropriate services.

Telepractice licensing, however, remains a hurdle for taking advantage of remote services or becoming a telepractitioner. Most states don’t currently have regulations on telepractice for our professions. ASHA and local associations, however, advocate for states to formulate and adapt guidelines permitting telepractice.

In the meantime, associations advise telepractitioners to verify requirements and policies, as well as hold all appropriate credentials, both in the state where we reside and where the client receives services. This applies also to special credentialing for bilingual telepractitioners.

ASHA doesn’t certify bilingual service providers, but it provides guidelines for those who represent themselves as such. For example, we are ethically-bound to ensure that we speak or sign another language with native or near-native proficiency, and possess various clinical competencies.

To my knowledge, only Illinois and New York have a type of credential for bilingual practitioners, and these are specific to professionals working in schools. However, because policy changes frequently (and is difficult to track), SLPs and audiologists should verify any bilingual-specific requirements in states where they might practice before providing services.

Telepractice holds a lot of promise for serving clients with diverse needs. Even when there is some red tape to figure out, using technology to build bridges to communities that may not have many resources is one of my most rewarding professional experiences!


Nate Cornish, M.S., CCC-SLP is a bilingual (English/Spanish) SLP and clinical director for VocoVision and Bilingual Therapies.  He is the professional development manager for SIG 18: Telepractice, a member of ASHA’s Multicultural Issues Board, and a past president and vice-president of the Hispanic Caucus.  Cornish provides clinical support to monolingual and bilingual telepractitioners around the country.  He also organizes and presents at various continuing education events, including an annual symposium on bilingualism.  Contact him at

Our Profession’s Biggest Open Secret


What’s the biggest open secret in our field? Each of us might have slightly different answers. Here’s mine: the reason so many students are blocked from receiving needed services is because their home states have not updated their Medicaid telepractice policies.

Children who qualify for Medicaid coverage, by definition, are from low-income families. My experience is that these children are disproportionately affected by the shortage of SLPs and could therefore benefit a great deal from access to treatments delivered via telepractice.

In addition, many schools, when faced with tight budgets, simply do not have the money to hire additional SLPs–telepractice or not–without Medicaid funds.

This places an unfair burden on the rural and urban schools that need telepractice the most. They struggle more than their affluent peers to find qualified SLPs. One reason is that those wealthier districts can pay substantially more for treatment delivered via telepractice if state Medicaid policies haven’t been updated to reimburse for online services.

This isn’t the most surprising part of the secret, however. That honor goes to how easily states can make the change. Consider this:

  • The federal government, which partners with each state on its Medicaid plan, has already approved billing for telepractice. That’s right, the Centers for Medicare & Medicaid Services already has an approved billing treatment for treatment delivered via telepractice.
  • All reimbursements for telepractice are paid for entirely by the federal government. This means that states don’t pay for additional reimbursements out of pocket. Let me repeat that one more time: allowing reimbursement for telepractice increases access to services without requiring additional funds from your state’s Medicaid program.
  • For all states that PresenceLearning has researched—aside from Indiana—allowing reimbursement for telepractice is as simple as publishing a clarifying policy memo. The memo should say that online services can be billed with the same codes as traditional sessions as long as a “GT” telepractice modifier is included for tracking purposes.

It is important to keep in mind that telepractice is just a different delivery method for services already approved by CMS and reimbursed by Medicaid in schools.  SLPs provide online services using the same approaches and materials they would use if they were physically at the school site. 

What can you do to help students get the treatment they need by motivating your state to write that memo?

  • Speak to stakeholders to build a consensus. Stakeholders include: ASHA, state licensing boards, special education directors, state departments of special education and directors of child health programs for your schools.
  • Consult state-level billing agents on the best way to document services to ensure program integrity.
  • Network with colleagues using telepractice to find out which states currently approve Medicaid funding for telepractice.

There are eight states that reimburse for telepractice services. They include: Colorado, Maine, Minnesota, North Dakota, New Mexico, Ohio, Oregon and Virginia. In addition, reimbursement for telepractice services are pending in California and Michigan.[Note from ASHA editors: This list was published in July 2013, so it may have changed. Our December issue focused on telepractice and has a slightly different list of states offering reimbursement.] 

Contact state speech and hearing associations or state-level Medicaid directors to find out how you can assist in getting Medicaid reimbursement for telepractice services. Let’s work together to ensure students who need our services receive them and schools receive the appropriate funding from Medicaid.

Melissa Jakubowitz M.A. CCC-SLP, vice president of clinical services at PresenceLearning, is an SLP with more than 20 years of clinical and managerial experience, Melissa is a Board Recognized Specialist in Child Language. She is a past-president of the California Speech-Language-Hearing Association and is also active in ASHA, serving as a Legislative Counselor for 12 years. Melissa began her career working in the public schools and can be reached at

On the Road Again: ASHA Convention and Telepractice


I admit it. I am an ASHA convention regular attendee. I am the SLP you see year after year collecting large yellow tote bags, company pens and my new favorite—nail files. This year, I even lined up to have my professional photo taken for my LinkedIn profile. I take in all that the ASHA convention offers, and my schedule allows, year after year.

One reason why the ASHA convention is so important to me is that I rarely stay in one place very long. I am the spouse of an active duty military officer. Therefore, I move a lot. With each move (eight so far), I’ve attended ASHA with a new job title: Department of Defense school SLP, hospital SLP, staff SLP, Lead SLP… This year, I attended ASHA as an SLP that works via telepractice. I deliver services and perform assessments via an online, custom built platform. I’m several states away from my students but I am licensed in the state where they reside and the state in which I reside. Using my home computer(s), a headset, webcam and high-speed internet connection with plenty of bandwidth, I treat, assess and collaborate with other SLPs, school staff and parents daily.

At this year’s convention, I encountered some surprising conversations regarding telepractice. I was met with responses ranging from: “Telepractice. I’m not so sure how I feel about that,” to “Yes, I’ve been looking into doing that. How does it work?” When embarking on a career in telepractice as a service delivery model, I was skeptical too. Was it ethical, effective and authorized? After researching ASHA’s rules and state bylaws, I put my feet in the water. That was four years ago.

During the ASHA convention, I was pleased to attend an increasing number of sessions focused on telepractice. However, these sessions highlighted the work and research still to be done to prove the effectiveness of telepractice as a service delivery model (especially with regards to culturally and linguistically diverse populations).

I still wonder, does an increase in sessions and visibility at the ASHA convention translate to increased acceptance/adoption by SLPs on the ground?

Telepractice is established and has been used in the medical field for more than 40 years. The American Telemedicine Association states that “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a variety of applications including two-way videos, smart phones, tablets, wireless tools and other forms of technology.” According to ATA, “the use of telemedicine has spread rapidly and is now becoming integrated into the ongoing operations of hospitals, specialty departments, home health agencies and private physician offices as well as consumers’ homes and workplaces.”

I am looking forward to next year’s ASHA convention in Denver. I am already wondering about the sessions, networking opportunities and of course the pens and highlighters. Most of all, I’m looking forward to attending ASHA again as a SLP working via telepractice and the discussions that will surely follow.

Lesley Edwards-Gaither , MA, CCC-SLP, is a Speech-Language Pathologist in the Washington D.C. area.  She is a Lead SLP with PresenceLearning and an affiliate of Special Interest Group 18, Telepractice. She can be reached at


Beyond Skype for Online Therapy: Protecting Student Privacy



The trend for kids online is sharing more, not less. Today’s kids consciously and unconsciously share so many aspects of their life using Facebook, Skype or even newer tech tools like Snapchat. But, as educators, we hold ourselves to a much higher legal and professional standard for protecting the information of these very same students. We’ve all heard about the laws—FERPA, HIPAA, COPPA— that set the standards for privacy of student records and personally identifiable information, but what do the laws mean in the context of delivering speech-language therapy online?

HIPAA: Protecting Individually Identifiable Health Information

Created by the Department of Health and Human Services in 1996, The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects patient medical records. HIPAA specifically protects “individually identifiable health information,” which includes:

  • the individual’s name, address, birth date and Social Security number.
  • the individual’s past, present or future physical or mental health or condition.
  • the provision of health care to the individual.
  • the past, present or future payment for the provision of health care to the individual.

HIPAA gives patients a variety of rights regarding individually identifiable health information. With consent, HIPAA permits the disclosure of health information needed for patient care, such as speech therapy.

FERPA: Protecting Education Records

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects student education records. FERPA gives parents certain rights with respect to their children’s education records until they turn 18 or transfer to a school higher than the high school level, thus making them “eligible students.” The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. Under FERPA, parents or eligible students have the right to:

  • Inspect and review the student’s education records.
  • Request a school to correct records they believe to be inaccurate or misleading.
  • Prevent a school from releasing information from the student’s education record without written permission (with some exceptions).

COPPA: Protecting Children’s Personal Information

The Federal Trade Commission instituted COPPA (Children’s Online Privacy Protection Act) in April, 2000 to protect children’s personal information on websites and applications that target children under the age of 13. Under the legislation, websites and apps that collect this information must notify parents directly and get their approval prior to the collection, use or disclosure of a child’s personal information. The FTC describes personal information as:

  • A child’s name, contact information (address, phone number or email address.
  • A child’s physical whereabouts.
  • Photos, videos and audio recordings of the child.
  • A child’s “persistent identifiers,” like IP addresses, that can be used to track a child’s activities over time and across different websites and online services.

Recommendations for Online Therapy

Clinicians and educators often focus on the capabilities of individual pieces of technology, and, indeed, a secure therapy platform is highly recommended both to ensure the privacy of sessions as well as student data. However, it is the information, and the sharing of that information by the adults responsible for the care of each child, that these laws focus on. So educators need to focus on a systems approach that considers the end-to-end process of handling and securing student data.

While clinicians are trained in student identity protection, non-disclosure methods and the maintenance of student record confidentiality, it is ultimately the school’s responsibility to ensure agreements they have in place with online therapy service providers support them in protecting student privacy. So what are the practical considerations in this end-to-end approach to protecting the privacy of students receiving online therapy?

  1. Ask what type of security is in place. Solutions with bank-level security offer the strongest protection of data. This includes 256-bit encryption using TLS 1.0, restricted physical access to the servers on which data is stored, and 24/7 on-site security personnel.
  2. Use a secure platform for therapy. Secure platforms use an invite-only, encrypted, secure connection. In this model, only the online clinician and the student assigned to that particular appointment time are permitted to enter the password-protected “therapy room.” Parents may also view a session with a prior written request.
  3. Use a secure server to store data. Make sure all student files containing individually identifiable health information and education records are stored on a secure server using industry-leading security.
  4. Restrict access. Only online clinicians, authorized school administrators and parents should have access to this password-protected information, thus further protecting student privacy.

This “big picture” thinking will let educators take advantage of new online delivery models for therapy services AND stay compliant with privacy laws. And leave Snapchat to the students.

Melissa Jakubowitz, MA, CCC-SLP, is the Vice President of SLP Clinical Services at PresenceLearning. She is a Board Recognized Specialist in Child Language with more than with more than 20 years of clinical and managerial experience. She is the past-president of the California Speech-Language-Hearing Association and is active in ASHA, serving as a Legislative Counselor for 12 years.

Coaching Parents to Foster Their Child’s Expressive Language Skills


I recently had the opportunity to provide tele-speech-language services to a toddler with autism spectrum disorder. I knew it would be difficult to have him sit in front of a computer for long periods, so I decided that I would employ a “parent coaching” approach, empowering his parents to more effectively help their son.

I started by having the parents videotape their daily interactions with him, which revealed that they were aware of their son’s difficulties and in-tune with his communication needs. However, even though this little boy appeared quite bright, it was difficult to distinguish when he was answering a question from what he had learned, or if it was a rote response. The parents had specific goals they wanted their son to achieve, so how was I going to help them?

I provided the boy’s parents with information about expressive language development and explained that their expectations appeared to be beyond this child’s current capabilities (determined by the boy’s age, as well as his disability). Next I took the language and vocabulary skills the parents wanted their son to learn—such as labeling an apple—and broke them out into smaller steps. These are the types of activities I suggest parents use to help a child grasp a language concept:

  • Present the child with several apples, preferably of different colors.
  • Talk about the outside of the apples: color, shape, size, smell, taste and texture.
  • Cut open the apples (“What do you see?”) , and eat some of each, talking about how it sounds and tastes as you bite into each piece.
  • Cut an apple in half horizontally and use washable tempera paints to make apple prints on paper using the different colors apples can be.
  • Find a simple recipe to make applesauce or another food from apples.
  • Eat apple slices with peanut butter and talk about how it tastes, and about the messiness and stickiness.
  • Make a pretend apple out of PlayDoh.
  • Compare the “fake” apple with the real one, explaining that you can eat a “real” apple but not the “pretend.” This models analytical thinking.
  • Bring in another fruit, such as an orange, and do the same steps.
  • Try making and drinking homemade orange juice.
  • Compare an apple to an orange.
  • Show video clips of people picking apples and oranges, showing how both grow on a tree.
  • Add bananas, doing the first seven steps (tastes great with peanut butter).
  • Roll the items across the floor and talk about how they roll. Compare.
  • Use this method to teach about common fruits you either purchase or see in the market.

Of course, just relating these steps to parents isn’t enough, because they have a tendency to take over for their child if they see the child struggling. For example, it’s tempting for them to place the child’s hands on the paper to make the apple prints, which removes the child from the process and leads to a loss of interest. To help parents avoid this, I explain that learning involves making mistakes. Other suggestions I provide include:

  • When speaking to your child, keep your sentences simple and to the point (approximately three to four words per utterance: “Are you hungry?” versus “Are you ready to go have some sandwiches for lunch?” Expanding utterances will come along a bit later!
  • Speak slowly because it may take the child additional time to process the information.
  • Do not require the child to look you in the eye when you are speaking to him. A glance at your face, especially at this age, should suffice. Toddlers are busy-bodies and need to keep moving and exploring.
  • If you ask a child a comprehension question, he or she may provide a quick or rote answer to be able to do what he wants to do.
  • Allow time to just play with your child. Let the child direct the play. Have a few toys out to choose from and follow his or her lead.
  • Make simple remarks about what is going on, but avoid asking questions to probe for an answer: “What color is your truck? How about that car? What is this part of the car called?” This is play time, not teaching time.
  • Model out loud how to think about items: “You have a big, blue truck! Wow! Mine is small. I have a small, yellow truck. “
  • Model out loud how to problem-solve (over-and-over-and-over again): “Oops! The wheel came off my truck. Hmmm. How can I fix it? {looking over the whole truck while thinking….} If I get something to help the wheel stay on, I should be able to fix it. If I use glue, the wheel may not spin.”
  • Allow some “quiet” play time as well and let your child do the talking (or not if he so chooses). This is a great opportunity to just sit and listen to what your child is saying (to you and/or the toys).

I have parents send me some YouTube video of them performing some of these activities with their child. In subsequent sessions, we discuss what works well (and not so well) with the child, and I share more activity ideas and literature with them.

Tracy Sippl, MS, CCC-SLP, is a Seymour, Wisc.-based speech-language pathologist and tele-therapist with Cumberland Therapy Services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. This post was adapted from a post on the Cumberland Therapy blog,  Right Therapy–Right Results–Right Now.

How To Become a Telepractitioner—Without Going Private

teletherapy pic
Working in schools for 23 years was very rewarding for me, but in 2012, I found myself looking for a different avenue for delivering speech-language pathology services. Simply, I was ready for a change.

Therapy sessions seemed to have become more condensed, requiring me to work with groups rather than specific students, which was not always beneficial for them. Incorporating technology into therapy sessions seemed to help my students maintain focus, motivating them to work. Whether I used technology to help students practice articulation drills, writing organization or social skills, they enjoyed it.

Could I find a job opportunity that would allow me to bring together my interests in working from home and using technology to provide speech-language services? The answer seemed to be “telepractice,” also known as “teletherapy.”

I knew leaving my position in the schools would be a bit intimidating. Questions began swirling through my mind: What were the “pros” and the “cons” of leaving my current position? Would it be worth leaving the schools to work from home? Did I want to provide treatment as an employee of a company or as a private provider?

I’ve always wanted to work from home; being able to transport my children to and from school and spending time with them afterward was a major motivator. I’ve also longed for scheduling flexibility that working from home would allow (the ability to throw in a load of laundry between sessions or plan in the evening without needing to drive back to work). But would I miss the staff camaraderie? What about students’ hugs? Would I feel isolated? Since I began providing telepractice treatment, the answer to each of these potential drawbacks has been “no.” To me, the “pros” have far outweighed the “cons.”

I researched telepractice some more on the ASHA website, which reviews studies pointing to teletherapy’s efficacy, and joined ASHA Special Interest Group 18, Telepractice. I later attended a teletherapy training in Maine that tasks that would ordinarily take 60 minutes to complete when providing “onsite” speech/language therapy could be accomplished during approximately 35 minutes of teletherapy!

Next, I considered providing teletherapy as a private practitioner, but I balked at the additional marketing and operational work that would require, even though I knew it would mean being my own boss and making my own schedule.

After careful consideration, I decided to accept an offer to become a teletherapist with a company I knew delivered quality training and treatment. At my company’s direction, I attended American Telemedicine Association-accredited training provided by Michael Towey.

Regarding equipment, I recommend using:

• A laptop with at least a 15” screen and built-in webcam (or you can use an external webcam).
• A headset with attached microphone or external speakers with an external microphone (I prefer a headset because the microphone is always close to the students’ mouths).
• A document camera for use during therapy. You can find most of this equipment on Amazon.

The software I use is a HIPPA-compliant, video-conferencing platform provided by my employer. It is important to consider security and compliance when selecting a Web-conferencing platform (Skype, for instance, is not compliant). Some telepractice companies require that you purchase your own equipment as well as their telepractice software. Be sure to consider that in your research.

For materials, I have found different online resources to draw from: SLP blogs (such as, eNewsletters, and ASHAsphere. I often use my own materials via a document camera. Once I received the necessary equipment and became comfortable with it, I worked on reviewing each student’s IEP, listing goals/objectives for each, and documenting IEP/re-evaluation due dates. Training a paraprofessional was the next step because I needed someone to: chaperone students coming to and leaving from therapy, be a behavior manager as needed, serve as a technology problem-solver, help as a student-response “confirmer,” and be a “skill-carryover” assistant when possible.

Connecting with students via teletherapy has a different “feel” when compared to onsite therapy. While working in the schools, students would draw pictures for me, hug me, and stop in my speech room to see how my day was going. Obviously hugs aren’t available over the Internet, but I have found that there are other ways to connect with students.

Frequently, when students first join the session, their faces light up, and I’ll hear, “Good morning, Mrs. Sippl! What are we doing today?” If my students earn a few minutes of free-choice time at the end of a therapy session, frequently they will ask to draw or color online. Once they’re done, they’ll explain that the drawing is for me and that I need to print it out to hang on my wall. As you can see, the “connection” with students is not lost. It is just different.

Based on my own telepractice experiences, my sense is that students are able to accomplish more in less time compared with face-to-face therapy. Teletherapy has its own rewards, and students find ways to show you how important you are to them. Once, as I was working with a Kindergarten student, she looked at me and exclaimed, “Hi, Mrs. Sippl! I’m so excited to see you today! I love you!”

Tracy Sippl, MS, CCC-SLP, is a Seymour, Wis.-based speech-language pathologist and tele-therapist with Cumberland Therapy Services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. 

Telehealth = Tell Me The Definition!

Yes, we know it’s coming, but what does it mean?  Some use the word “telehealth” to describe a virtual service delivery model between a patient and clinician.  Others expand the definition beyond the patient and clinician to also include innovative platforms.  Until the term is defined in the Scope of Practice for the American Speech-Language Hearing Association (ASHA) or American Academy of Audiology (AAA), acknowledged by insurance companies, and understood by policy makers, we will continue to vaguely use this term.  In the meantime, this is my humble perception of “telehealth” in the future.  Specifically, these are my ideas for a mobile application that is beneficial for the manufacturers, profitable for the audiologist, and most importantly, easily accessible and user-friendly for our patients.

What’s your definition of Telehealth?

(This post originally appeared on TinaTheAuD)

Tina Penman, CCC-A, AuD, is a clinical and research audiologist.  She received a BS in behavioral neuroscience (2006) and clinical doctorate in audiology (2010) from Northeastern University.  She has enjoyed her time serving ASHA as the SIG 8 CE Content Manager and looks forward to continued service to the organization.

Disclaimer:  Content represents only the blogger’s views.  Content does not represent the views of the blogger or any other organizations the blogger belongs to or represents.

Telehealth Regulatory and Legal Considerations: Frequently Asked Questions

computer screen

Photo by narcosislabs

Telehealth, the use of electronic communications and information technology to deliver health-related services at a distance, is a promising service delivery model for occupational therapy, physical therapy, speech-language pathology, and audiology. However, prior to engaging in telehealth, practitioners in the United States should be aware of the most current policies and practices related to telehealth and licensure, reimbursement, HIPAA compliance, and malpractice insurance coverage. The questions and responses below are designed to serve as a catalyst for further inquiry into the federal and state regulatory requirements associated with the use of telehealth technologies to deliver occupational therapy, physical therapy, speech-language pathology, and audiology services at a distance.

1. Is there a need to secure licenses in two states (i.e., where the practitioner resides, and where the client is located), before engaging in telehealth?

Current medical and legal practices dictate that it is the location of the client that determines the state in which the practitioner must be licensed. At the present time, if that location is in a different state from the one the practitioner is licensed to practice, then the practitioner would need to secure a license from the state where the client is located unless the state has exemption provisions within its licensure laws. Although not all states have laws, regulations, or policy pertaining to the use of telehealth, it is possible that a regulatory board receiving a complaint on a practitioner delivering services through telehealth who does not hold a license in the state where the client is located would fall back on the “operating without a license” penalty provision that exists in every state.

There are consultation and licensure exemption provisions in various states. For speech-language pathology and audiology, some states allow individuals to work in another state without a license for up to 30 days in a calendar year. In this situation, the practitioner must hold a license from another state that has equivalent licensure requirements and must provide services in cooperation with a speech-language pathologist or audiologist who is licensed within the state where the temporary practice will occur. Although this exemption exists in some states, it remains untested for use with services provided via a telehealth service delivery model.

Similarly, a few states permit an occupational therapist licensed in another state to practice temporarily by notifying the state’s licensure board for occupational therapy of the intent to practice within the state on a temporary basis, paying a fee, and submitting required documentation and credential verification.

Additionally, the Department of Defense (DOD) and the Veterans Health Administration (VHA) have their own licensing requirements and credentialing and privileging process because they operate on federal property (military installations, VA hospitals, etc.). Practitioners must hold a license in one of the US states, District of Columbia, or US territories, and be credentialed (i.e., authentication process to validate qualifications) through the DOD or VHA system in order to practice. Once the credentialing and privileging process is complete, a practitioner using telehealth can engage in inter-state practice if the client is located on federal property at the time of service delivery. This provision is not extended to services provided off federal property.

The Service Members Telemedicine & E-Health Portability Act (STEP) (H.R. 1832), proposed on May 11, 2011 by Representative Glenn Thompson may provide a solution to health disparities among military personnel who are eligible for federally funded health care services. If passed by Congress, the STEP Act will enable health care professionals (DOD civilian employees and personal services contractors) to use telemedicine and e-health applications to treat service members where they are located, including in their homes. Currently, health care professionals must obtain licenses in states where their clients are located if services are provided off federal property (i.e., in the clients’ homes or communities). Under the STEP Act, health care professionals providing therapy/treatment to service members through telehealth and e-health technologies will not be required to obtain additional licenses in the states where their clients are located (Thompson, 2011).

2. Do state laws differ concerning if and how telehealth can occur?

Yes, states have different laws concerning if and how telehealth can occur. The American Speech-Language-Hearing Association (ASHA) and the Federation of State Boards of Physical Therapy (FSBPT) have written model practice act language for states to consider when crafting laws and policies related to telehealth. States may use the model practice act language verbatim; apply part(s) of a model practice act, or create their own language to meet state-specific needs. The legislative and regulatory language and policies vary by state for occupational therapy, speech-language pathology, audiology, and physical therapy. Currently, among the state boards overseeing speech-language pathologists and audiologists, 14 states and the District of Columbia have some provision, statutes, regulations, or policy, regarding the use of telehealth/telepractice (American Speech-Language-Hearing Association, 2011). Similar to provisions for speech-language pathologists and audiologists, several states have statutes, regulations, or policy related to the use of telehealth by occupational therapists and physical therapists.

With inconsistent adoption and non-uniformity of language regarding the use of telehealth, it is extremely important to check a state’s statutes, regulations and policies before beginning to practice; such information can be found through a number of mechanisms. The state licensure board within the state where a practitioner plans to practice should be regarded as the leading authority on the use of telehealth as a service delivery model within the state. Most state licensure boards have websites that can be easily accessed through a search engine. Generally state laws, regulations, and policies governing practice within the state can be found on these sites. It is always incumbent upon practitioners to know their scope of practice laws and regulations for the states in which they render services. Professional associations may also be a resource for preliminary information gathering.

3. Do any states expressly disallow telehealth?

There are a wide variety of regulatory mechanisms that may disallow the practice of telehealth or create barriers for its use within various professions. Problems can arise when the interpretation of the language of a statute, regulation, or rule creates barriers for the use of telehealth. One such example of restrictive language would be a requirement that the clinician conduct an in-person physical exam of the client before providing telehealth. Moreover, such restrictions are not universally applicable across all professions and their areas of practice. For example, a client seeking assistance from an occupational therapist to identify and implement ergonomic principles and work space modifications to promote health and prevent injury may not require an in-person evaluation prior to a remote consultation. Instead of an arbitrary requirement, clinical reasoning should dictate which clients are appropriate for services delivered through telehealth.

For speech-language pathology and audiology, Delaware has a regulation that states: “Licensees shall not evaluate or treat a client with speech, language or hearing disorders solely by correspondence. Correspondence includes telecommunications (Delaware General Assembly Title 24 Professional Regulation, 2006, Section” Thus the Delaware Board, through an unfortunate choice of wording, significantly limits the use of telehealth within their state for speech-language pathologists and audiologists by defining telecommunication in this way. Because amendments and revisions of statutory and regulatory language take time and money, careful consideration of practice language and its interpretation is warranted. It is important for practitioners to review the state practice act, board regulations, and any relevant board opinions/interpretations in the state in which they reside, to determine what restrictions or requirements may come into play as they relate to the use of telehealth. Before embarking on inter-state telepractice, practitioners will also need to check the state practice act for the client’s state of residence. If a state’s practice act does not mention telehealth or have any published opinions or positions, practitioners should contact the state board for further clarification to ensure that they do not violate any aspect of their license.

4. Can services delivered through telehealth be billed the same way as services provided in-person?

Practitioners are encouraged to contact the reimbursement entity prior to engaging in telehealth to determine if and how services delivered through telehealth are reimbursed. Medicare does not currently recognize occupational therapists, speech-language pathologists, audiologists, or physical therapists as telehealth providers. Some state Medicaid programs do reimburse for services delivered through telehealth by rehabilitation professionals, though qualifying circumstances vary by state. Private insurance reimbursement for services delivered through telehealth varies by state. Some states have legislation that requires insurance companies to reimburse for a service delivered through telehealth if that same service delivered in-person would be reimbursed. If a practitioner does bill for services delivered through telehealth, the modifier “GT” is generally used along with the appropriate CPT/HCPCS code. The use of this modifier identifies the service delivery model as telehealth and enables the collection of data on the frequency and types of services delivered using a telehealth service delivery model.

5. If practitioners fulfill the requirements to maintain licensure (e.g., continuing education obligations) in their state of residence, do they also need to fulfill the requirements to maintain licensure for the state in which the client resides?

Provided a practitioner holds a license in his/her home state and the state where the client resides, the practitioner is required to comply with the laws, regulations, rules and policies where the licenses are held, including continuing education requirements, which vary between states. For example, in occupational therapy, continuing education (CE) hours required for licensure renewal range from 0-24 hours per year; some states calculate hourly requirements annually while others calculate hours biannually. An activity that is defined as continuing education for which hourly credit is allocated also varies by state. Some states require that the CE hours are earned from state-approved continuing education providers. Other states may also accept activities for which the practitioner has engaged in over the course of the renewal period, including scholarly activities such as presenting at a conference, engaging in research, or contributing to articles, chapters or books. This is not an exhaustive list and many other variations on CE requirements between states and the rehabilitation professions do exist and require careful review before embarking on multi-state telehealth practice.

6. Will professional malpractice insurance cover services delivered through telehealth?

Malpractice policies for services delivered through telehealth vary by carrier. Practitioners should therefore consult with their malpractice insurance carrier prior to engaging in telehealth. Consideration of the insurer’s licensed coverage area is also warranted if a practitioner intends to practice in multiple states using a telehealth service delivery model.

7. Does a sole practitioner need to abide by HIPAA regulations?

Telehealth is a service delivery model. Services rendered through telehealth must comply with the same rules, regulations (federal, state, institutional) and practice stipulations that apply to services delivered in-person. Two major areas to consider when reviewing HIPAA compliance are security and privacy. Practitioners should become familiar with the HIPAA Breach Notification Rules and technology encryption requirements. Excellent resources are available for practitioners to complete a risk analysis for privacy, security, and HIPAA compliance when using Voice over the Internet Protocol (VoIP) (Watzlaf, Moeini, & Firouzan, 2010; Watzlaf, Moeini, Matusow, & Firouzan, 2011). When states have differing requirements for privacy, security, and informed consent, practitioners are encouraged to follow the most restrictive laws and regulations (particularly when the greatest restrictions occur where the client is located).


In conclusion, practitioners and their clients are poised to benefit from the use of emerging technologies to deliver health care services. Practitioners interested in using telehealth should become familiar with all pertinent legislation, regulation, and policies related to licensure, reimbursement, and malpractice coverage for services rendered through telehealth. Additionally, practitioners’ respective professional associations, the American Telemedicine Association and its Telerehabilitation Special Interest Group, the Center for Telehealth and e-Health Law (CTel), and regional telehealth resource centers may be able to provide additional information for professionals interested in using telehealth as delivery model.


1. American Speech-Language-Hearing Association. (2011). State licensure telepractice provisions. Retrieved from
2. Delaware General Assembly Title 24 Professional Regulation. (2006). 3700 Board of Examiners of Speech/Language Pathologists, Audiologists & Hearing Aid Dispensers, Section Retrieved from
3. Thompson, G. (2011). Thompson STEP Act passes U.S. House of Representatives. Retrieved from
4. Watzlaf, V., Fahima, R., Moeini, S., & Firouzan, P. (2010). VoIP for telerehabilitation: A risk analysis for privacy, security, and HIPPA compliance. International Journal of Telerehabilitation, 2(2), 3-14. doi:10.5195/IJT.2010.6056
5. Watzlaf, V., Fahima, R., Moeini, S., Matusow, L. & Firouzan, P. (2011). VoIP for telerehabilitation: A risk analysis for privacy, security, and HIPPA compliance – Part II. International Journal of Telerehabilitation, 3(1), 3-10. doi: 10.5195/IJT.2011.6070

(This post originally was published in International Journal of Telerehabilitation;; Vol. 3, No. 2, Fall 2011; doi: 10.5195/ijt.2011.6077)

Interested in Telepractice? ASHA’s Special Interest Group on Telepractice (SIG 18) was formed in 2010 in response to the growing interest and in telespeech and teleaudiology. SIG 18 sponsors continuing education via Perspectives  and short course and panel presentations at the ASHA convention, and SIG members have access to a private group in the ASHA Community for professional discussion and resource sharing. Consider joining SIG 18 today!


Jana Cason, DHS, OTR/L, is an Associate Professor in the Auerbach School of Occupational Therapy at Spalding University in Louisville, Kentucky. Dr. Cason is a national and international presenter and author on topics related to telehealth and telerehabilitation. Dr. Cason serves as chair of a Telehealth Ad Hoc Committee with the AOTA, is a member of the American Telemedicine Association (ATA) Telerehabilitation Special Interest Group (SIG) Executive Committee, and is co-chair of the ATA Telerehabilitation SIG’s Licensure Portability Sub-Committee.   

Janice Brannon, MA is the Director of State Special Initiatives in the Government Relations and Public Policy Division at the American Speech-Language Hearing Association (ASHA). She provides lead support on ASHA’s government relations response to telehealth and state licensure issues. Ms. Brannon’s experience in government relations has led her from the halls of Capitol Hill to her own consulting firm. Ms. Brannon has been a participant in the White House Working Group on Telemedicine, contributed to the discussion on the Nurse Licensure Compact while at ANA and recently was appointed co-chair of the ATA Inter-professional Work Group on Licensure Portability, Telerehabilitation SIG.

The Time Has Come for Speech-Language Pathology License Portability

State map of USA

Photo by Kevin Hutchinson

Over the past decade, a chronic shortage of speech-language pathologists has left K-12 schools and healthcare settings in many parts of the United States struggling to provide speech therapy services. The problem has taken a financial toll, driving the cost of services up as institutions spend increasing time and funds searching for speech-language pathologists.

Telepractice offers a promising solution by enabling practitioners to conduct live therapy sessions with clients “anytime, anywhere” using real-time videoconferencing. Telepractice allows practitioners to flexibly “go where the work is” without actually having to physically travel or relocate. Speech-language pathologists who no longer engage in full-time practice but still wish to work part-time, can contract with school districts to provide speech therapy services via telepractice. Ultimately, telepractice addresses a labor problem that impacts many health professions.

This cost-effective approach is being successfully employed by school districts across the United States, reducing costs while providing high-quality therapy. Research indicates that speech therapy delivered through telepractice has comparable quality and outcomes as speech therapy services delivered in-person (American Speech-Language-Hearing Association, 2005; Boisvert, Lang, Andrianopoulos, & Boscardin, 2010; Boswell, 2007; Grogan-Johnson, Alvares, Rowan & Creaghead, 2010; Grogan-Johson et al., 2011).

Although technology has removed geographic constraints, one major barrier remains: time consuming and expensive licensing practices due to a lack of state license portability. While the professional requirements for licensing speech-language pathologists are very similar from state to state, each state has its own licensing process. As a result, speech-language pathologists who want to practice in multiple states must complete applications in each state where a license is sought; submit required documentation; pay licensing fees; and, endure processing times that significantly vary by state. This duplicative process might be warranted if important state-to-state variations in professional requirements for licensing were to exist; however, there is a high degree of consistency in licensing requirements across states.

Though the professional requirements are typically similar, license application processing times and fees vary by state. Some states process applications electronically, while others use a paper-based format. Depending on the state, the processing times for applications range from weeks to months. All states charge licensing application fees (typically $150 and higher) for the initial application, with similar charges for annual license renewal. In some states, licensees must provide fingerprints along with their license application. States do not share fingerprint information; applicants must send fingerprints to the state where the license is requested through an approved process.

The importance of licensure portability was recognized fifteen years ago when the United States Congress passed the Telecommunications Act of 1996 which urged the healthcare industry to develop multi-state licensure models. Similarly, the US Federal Communications Commission called on state licensing boards to accommodate multi-state licensure for health care practitioners. In 2000, the National Council of State Boards of Nursing (NCSBN) instituted the Nurse License Compact (NLC). The NLC allows nurses licensed in a compact state (currently 24 states) to practice in other compact states through a mutual license recognition model. Physicians have labor mobility through an expedited license model.

True license portability for speech-language pathologists is long overdue. License portability would facilitate inter-state practice and thus enable speech-language pathologists who live near state lines to practice in adjacent states where personnel shortages may exist. Greater labor mobility is necessary to serve geographically shifting populations in the US.

It is time to remove the barriers to licensure portability! A national initiative that creates a model for licensure portability for the rehabilitation professions is needed. Licensure portability will enable speech-language pathologists to provide services wherever and whenever needed, thereby unleashing the full potential of telepractice to reduce costs and administrative burdens, increase access to services, broaden career opportunities for speech-language pathologists and improve outcomes for K-12 students and clients in diverse practice settings. A mobile, flexible workforce positioned to use telepractice for inter-state practice could alleviate the chronic shortage of speech-language pathologists.


1. 1. American Speech-Language-Hearing Association. (2005). Speech-Language Pathologists Providing Clinical Services via Telepractice: Position Statement [Position Statement]. Retrieved from
2. 2. Boisvert, M., Lang, R., Andrianopoulos, M., & Boscardin, M. (2010). Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review. Developmental Neurorehabilitation, 13, 423-432.
3. 3. Boswell, S. (2007, March 6). Ohio grant addresses personnel shortage: Innovative strategies meet short-and long-term goals. The ASHA Leader.
4. 4. Grogan-Johnson, S., Alvares, R., Rowan, L. E., & Creaghead, N. (2010). A pilot study comparing the effectiveness of speech-language intervention provided by telehealth and traditional side-by-side intervention. Journal of Telemedicine and Telecare, 16, 134-139.
5. 5. Grogan-Johnson, S., Gabel, R., Taylor, J., Rowan, L., Alvares, R., & Schenker, J. (2011). A pilot exploration of speech sound disorder intervention delivered by telehealth to school–age children. International Journal of Telerehabilitation, 3(1), 31-42.

(This article was originally published in the International Journal of Telerehabilitation Vol. 3, No. 2, Fall 2011, DOI:10.5195/ijt.2011.6079 (


Melissa Jakubowitz, M.A., CCC-SLP is currently the Vice President of SLP Services at PresenceLearning and  has been a speech-language pathologist for more than 20 years, working in schools and  private practice before joining PresenceLearning in January 2010. She is a former president of the California Speech-Language-Hearing Association and has been an active member of ASHA serving on Legislative Council for 12 years and on the ASHA Board of Ethics.