PLATFORMS WITH PRODUCTS FACILITATING GROUP THERAPY

• The original research was scoped, so the first part identified how seven named telehealth providers dealt with identified topics within the product (platform) they deliver to the healthcare profession and patient population. Unfortunately, there was no provision within the scoping to address any "group therapy" aspects of their product offering. However, it is a misconception to think that the platforms discussed do not support group therapy.
• There are two essential requirements for a platform to be considered a candidate in the provision of group therapy. Firstly the platform must be HIPPA compliant. The second criteria is the platform needs to offer a video conferencing function. Overarching this is the basic functionality required of a platform to facilitate telehealth.

• When aspects of the telehealth interaction falling outside the realm of the platform developer and into that of the medical professional are removed from consideration, the following platforms could be used in the provision of group therapy:
•  GoToMeeting is HIPPA compliant. It provides video conferencing with up to 25 high definition feeds. This platform could therefore be used in the provision of group therapy sessions.
•  Zoom for Healthcare is HIPPA compliant. There is provision within the platform for video conferencing with up to 49 high definition feeds. This platform could therefore be used in the provision of group therapy sessions.
•  Vsee is HIPPA compliant. It also offers video-conferencing within its platform. The number of attendees is not detailed, as Vsee offers customized solutions in this area, so the customized product would be tailored to meet the individual needs of the healthcare provider.
• RingCentral is HIPPA compliant. RingCental offers video conferencing for up to 100 participants. It could be used in the provision of group therapy.

GROUP THERAPY BY TELEHEALTH

• Answering the question as written would require identifying the platform providers, the organizations using the platform for group therapy, and the group facilitators' individual practices. This is because several of the areas identified are beyond the provider's control, being the responsibility of the platform user. Details relating to the areas within the control of the platform developer for the platforms identified have been detailed above.
• An explanation is provided for the other areas, setting out why the provider does not influence the area. We have also reproduced the original research for these areas for completeness, as it reflects an overview of how the medical professional should address them based on the current practice guidelines. This is a matter of clinical judgment and practice for each medical professional facilitating group therapy.
• A health professional's responsibilities and ethical obligations are the likely reason there is no specific data relating to how these areas are addressed in practice. The only way this information would be available is if the group facilitator discussed the processes. This is highly unlikely beyond the most general terms, as it would allow the possible identification of participants and their health issues, which is ethically prohibited. HIPPA is very specific regarding this area; any specific examples would likely only come in a teaching or supervision context outside of the public domain.

Group Psychotherapy by Telehealth (CPT Code 90853)

• This code is specific to the reimbursement of medical professionals undertaking group therapy under Medicare. None of the four identified platforms identified have provided any information within the product literature relating to the capability to undertake Medicare invoicing. The only time this would be relevant is if the platform had Medicare invoicing capabilities, as was the case with SimplePractice (who does not offer group therapy infrastructure)
•  CPT 90853 was implemented in March 2020 to enable patients' ongoing treatment during lock down due to the pandemic. It was added to the temporary emergency provision of services rules changes for Medicare. CPT Code 90853 is a group psychotherapy code aimed at physicians who are treating "individuals in group homes or who want to foster group interaction for those individuals under "stay at home" orders."
• CBT 90853 extends Medicare coverage to these sessions. It had not previously been reimbursable under Medicare. This provision is most relevant to the organization and software programs that complete the invoicing for those organizations seeking reimbursement by Medicare for group therapy.
• The emergency provisions will remain in force until 23 October 2020, according to an announcement on 27 July 2020, extending them to that date.

Informed Consent

• The informed consent process is not a concern for the platform developer as it takes place within the confines of the clinical setting. In group therapy, it would likely be completed on a one-to-one basis before the first group therapy session. All of the platforms identified can facilitate this process as it would mirror that of a typical telehealth consultation.
• As part of the informed consent process and pursuant to the APA guidelines, it is important the group leader "describe at the outset the roles and responsibilities of all parties and the limits of confidentiality" when telehealth options are being considered in a mental health setting to each potential participant. They should also address any concerns or questions from the potential participants.
• It should be noted that there are very clear ethical guidelines relating to how informed consent is given and what practitioners must discuss with the patient. The issues that should be canvassed and the process of obtaining informed consent for group therapy are detailed below.
• One of the difficulties in conducting group sessions in the mental health context via telehealth is that while the physician is required ethically to maintain all members' confidentiality, in most states, the group members are not subject to the same legal or ethical obligations. This presents as an issue in any group psychotherapy setting, but in the telehealth context, there is greater potential for abuse, including:
• Attendance by a member at a non-secure location where a non-member is privy to the content being discussed and the participants in the group;
• The recording or screenshotting of group members; and
• The use of recorded material to identify members (and the possibility of extortion).
• Given the serious consequences of these disclosures and the heightened risk when the group therapy is being undertaken by telehealth, the APA suggests that members be given the option of not showing their face, wearing a disguise, using a fictious name, temporarily leaving the group, or finding another treatment modality.
• The group leader should make sure group members read, understand and sign an informed consent prior to the first session. It is essential the group leader ensures members understand the risks, benefits and limits to confidentiality associated with undertaking the sessions via telehealth.

Number of Attendees

• The maximum number of attendees is limited by the platforms capabilities. For the four identified platforms the maximums are as follows:
• GoToMeeting — 25 
• Zoom for Healthcare — 49 
• Vsee — Customizable 
• RingCentral — 100 

• The reality is the group size will likely be less than the technologies capabilities. It will be set by the facilitator.

Platform Handling

• It is unclear what is meant by this topic and the description "How is the platform handled? (walk through the steps of how the doctors and patients handle the platform for conducting sessions)." This aspect, given it relates to doctors and patients falls outside of the control of the platform developer. The platform is the vehicle that facilitates the process, and has no role beyond that.
• The doctor and patients would enter the group therapy session by following the steps required by the platform they are using to facilitate the session. Details at this level are not provided in the information available from the four respective companies.
• Participants and the doctor would dial into the meeting. The meeting would proceed, with the process and content all protected and confidential information. At the end of the meeting participants would terminate their link. The doctor or facilitator would then be responsible for writing clinical notes that form part of the electronic health record.
• The provision for annotating and sharing notes would not be required during the meeting, as it is a group session and the notes are individual. Notes of this nature are not typically shared with patients as a matter of course, as in some instances notes can undermine the patients progress in a mental health setting.

Session Recording

• There is no information available relating to the capability of some of the providers to record video-conferencing sessions. The provider's responsibility in instances where a group session is recorded is to ensure the proper, safe, and secure storage of the recording in accordance with HIPPA protocols. Given all four providers are HIPPA compliant, they have all enacted the necessary security and encryption protocols in this area. The security protocols of each provider are detailed in part one of the original research.
• This recording would form part of each participant's clinical record and be included in their electronic health record. It should be noted Zoom for Healthcare and Vsee have provision within their platforms to annotate patient records so any recording could be incorporated into clinical notes. Storage of the information would fall under the companies protocols, which are part of their HIPPA compliance. In most instances, it is highly unlikely the sessions would be recorded. Details around the recording of group sessions are detailed below.
• Generally, members, including the group leader, are prohibited from recording the sessions without all members' express written permission.
• Should the group leader elect to record the sessions, having gained the members' consent, they have obligations placed on them in terms of the purpose of the recording and how it is to be stored.
• Those with recorded sessions must ensure the data is safe and not accessible to anyone else. Recommendations include the use of encryption and secure cloud storage.

Data Confidentiality, Sharing, and Access

• The rules around confidentiality and data sharing are the same as required in a physical setting.
• Data should remain confidential and not be shared or accessed beyond the treatment team in most instances. Group leaders may use recordings in the context of clinical supervision.
• From the platform provider's perspective, this means they must adhere to the required HIPPA protocols to ensure any information recorded or stored within the platform remains confidential. All four identified companies are recognized as meeting this requirement during the telehealth or group therapy sessions facilitated on their platform. Only, Zoom for Healthcare and Vsee store patient electronic record information. The security protocols of each are detailed in the original research and meet HIPPA requirements.
• The sharing of data is a feature of Zoom for Healthcare and Vsee's platforms, in that they can facilitate the sharing of electronic health records or parts of them to others. The actual sharing of the data is at the direction of the responsible clinician. It is assumed the platforms would have a capability for the treatment provider to release aspects of a patient's notes to various people the treatment provider has identified. However, this is not explicitly addressed in product literature.

User Feedback

• User feedback relating to the four platforms has been provided in the original research. Unfortunately, it does not detail how the platforms are used to facilitate group therapy or garner feedback from the stakeholders.
• Patient feedback was limited concerning the group therapy sessions. There was no discussion from the patients regarding the four platform providers and group therapy on social media, Reddit, health services review sites, or product review sites. The only patient feedback concerning group therapy sessions is related to the organizations that are conducting the sessions. This is set out in the original research.
• From the perspective of the organizations conducting group therapy, there was no direct feedback regarding performance. While there was some feedback of this nature on product review sites, it related primarily to the product's technical capabilities. It was unclear if it was addressing group therapy capabilities specifically. This feedback is part of the original project.

Ideal Practice for Online Sessions

• The best practices for online group therapy sessions changes the direction of the research. It would require an analysis of the best clinical practice guidelines from a range of organizations like the APA to determine the clinical practices adhered to and an explanation or overview of each practice. The first issue with this research is it would generally be a project in its own right. There is no capacity within this project to identify and provide that information.