Telepsychiatry Through Email Mode: Current Status and Consensus Guidelines.

Telepsychiatry Through Email in Indian Scenario

Telemedicine refers to a practice of prescribing, health education, and counseling through the utilization of communication technology.[1] The Telemedicine Practice Guidelines recognize text and audio modes of consultation.[2] Usually, emails are referred to as text-based consultations and are asynchronous. Despite the abrupt popularity of video-based services, several studies suggest that majority of the telemedicine services are asynchronous.[3] There are several reasons to focus on telemedicine through email. For example, several clinical establishments may find it extremely difficult to arrange for, train personnel for, or derive satisfaction from, offering video-based services. In many of these cases, email services could remain a feasible, valuable, and cost-effective telemedicine service.

The National Mental Health Survey of India highlighted the existing large mental health gap (mhGAP), wherein there are only about 9,000 psychiatrists in India, while the desirable number is approximately 36,000.[4, 5] Therefore, email telemedicine can assist in effective resource utilization and help each psychiatrist cater to a larger number of patients and increase outreach and, thus, compensate for the unequal distribution of psychiatrists.[6]

Telemedicine is also being utilized to overcome various challenges in healthcare delivery during the COVID-19 pandemic.[7] Though telemedicine was being practiced across India, the social distancing practices and lockdown related to the COVID-19 pandemic gave it an impetus. Hence, the government of India published the Telemedicine Practice Guidelines on March 25, 2020.[2] These were issued as guidelines for practice in general and not for psychiatry in particular. After that, the telepsychiatry operational guidelines were published by the Indian Psychiatric Society; Telemedicine Society of India; and the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, in May 2020.[8] These guidelines focused mainly on interactive video conferencing-based psychiatry services and did not elaborate on email-based telemedicine, such as how to set up an email channel or how to communicate using email.

There is scarce literature/guidelines available on telemedicine through emails. Hence, this article aims to address this deficit area by providing suggestions that can help enhance the quality of telemedicine through email, particularly for psychiatric services.

Email Mode as per the Current Telepsychiatry Operational Guidelines

As per the latest guidelines, email is identified as a recognized text-based asynchronous mode of communication.[2] On multiple occasions, the guidelines suggest and encourage the use of email mostly to augment the video teleconsultation process rather than as a primary modality of consultation. These include the use of email to:

request for the first consult,

verify the email address provided by the patient,

take consent,

share medical reports,

send e-prescription,

maintain email records, and

follow-up consults.

The current practice guidelines suggest that emails alone cannot be used for diagnosis during the first consultation and that video consultation is mandatory for prescribing the list A medications. Emails can, however, be used to follow up with patients within six months of being last seen. Email communications from a doctor should contain the registration number accorded to him/her by the State Medical Council/MCI, so that the patient may verify the identity of the doctor before further correspondence.

Advantages of Email as a Mode of Telepsychiatry

The benefits of email telemedicine are numerous. Emails can be convenient to use, provide easy access to treatment, improve follow-up and adherence to treatment, and help in transfer of the responsibility to the patient.[9] The utilization of email services also provides economic and ecological benefits.[10] It promotes collegiality and can be used for educational gains as well. It is seen as a method for effective case-based learning, which can lead to improved care for subsequent similar patients.[11] In branches of medicine dealing with chronic diseases, such as dermatology and rheumatology, dispensing of repeat prescriptions is made easier through the use of email services.[12] In specialties where high-quality images can be utilized for diagnosis, email has tremendous application. Such specialties include dermatology, pathology, ophthalmology, and surgery (wound care follow-ups) where attached digital camera images can be used for telediagnosis and follow-up, without worrying about low-bandwidth, which is of concern during video consultations.[13] Therefore, the review of the literature reveals that email telemedicine can be utilized by dermatology, radiology, ophthalmology, pathology, trauma surgery (burns and wound care), neurology, and dental specialties.

Email can be used for primary consultation, second opinion consultation, telediagnosis, treatment, and administrative purposes (such as for referrals). In several remote areas, the need for telemedicine through email has been established along with success of projects utilizing telemedicine through email.[14] It also deserves mention as an effective method of communication between healthcare workers in conflict areas due to wars.[11] It has also been effectively used by other stakeholders such as chaplaincy to provide the needed spiritual and emotional support as a part of a holistic approach.[15] Though, in general, text messages seem more convenient than email, the latter has the added advantage of storage and easy retrieval.

Limitations of Email as a Mode of Telepsychiatry

Despite the several advantages, there are problems with telemedicine through email that are acknowledged.[9] Majority of the people find voice or video calls more convenient than emails. It is difficult to elicit the emotive clues from the words used in an email. Sometimes emails can consume considerable time, especially when mails are lengthy with several complaints that need to be addressed, particularly when the patient is difficult or dissatisfied or has frequent queries. Emails can become even more annoying when they are incomplete, with inadequate details to help identify the patient. They may sometimes be written in the patient’s vernacular language or in unreadable font and can be impersonal. Therapists may lose track of the treatment plan when communication happens over multiple emails. However, this can be overcome by having a summary of the treatment plan that is constantly updated for ready reference for future email correspondence. At times, because emails have the potential to be hacked and easily transferred, they may carry a greater potential to compromise patient confidentiality and make the service providers legally responsible for the damages caused.[13] Emails are generally not compensated and hence may not be received with the same interest by healthcare providers.[16] The other barriers identified for the use of telemedicine through email include concerns related to perceived work overload, technical barriers, privacy, and a lack of an accepted system of email telemedicine, which might apply to India as well.[17]

There are limitations acknowledged from the patients’ side as well. There can be more delays in responding to emails, which could lead to a delay in treatment and unanticipated worsening of the condition. When multiple therapists reply to the same client at different points in time, there may be a lack of consensus in the treatment approach, especially when one of them is not identified as the captain/in-charge, which can lead to confusion.[16] The responses of the therapist may also lack patient-centeredness, family-centeredness, and the holistic approach (psycho-social elements of the treatment process).

Due to these reasons, it is noted that a significant proportion of email consultations are often converted to face-to-face (F2F) consultations or used to augment but not substitute F2F consultations. In many cases, emails are utilized only for review consultation after an initial F2F or video consultation.

Relevance to Psychiatry

Email telemedicine is of particular relevance to psychiatry for several reasons.[18] These include:

In comparison to other clinical specialties, in psychiatry, emergencies are fewer, allowing a longer time frame to assess the problem at hand.

Many patients are on psychotropics for a long term and require periodic reviews for side effects, relapse of illness, and disturbances due to dosage adjustments. Email communication can serve as an effective and feasible tool to address queries related to these.

The solutions to emotional problems usually require much forethought, deliberation and collaboration. Email allows the mental healthcare professional (referred to as the therapist) time to put pen to paper.

Emails also allow clients sufficient time to process these recommendations, allowing time for introspection and reflection.

Emails allow more frequent and regular correspondence, thereby improving treatment adherence at a lesser cost to the patient and lesser inconvenience to the therapist. The availability of such a facility becomes an efficient measure to bridge the mhGAP, especially for patients needing to travel a long distance to access psychiatric consultation as opposed to medical consultations, which are easier to access in primary healthcare settings as well.

Emails can be used by the patients to convey a large amount of information in lesser time to update about their progress and even verify before conveying it to the therapist.

Storage and retrieval of emails are easier and cost-effective in comparison to video or audio telemedicine records.

In comparison to other clinical branches of medicine, emails offer an additional therapeutic benefit in psychiatry, considering the emotional nature of the problems.

Consensus Guidelines for Email as a Mode of Telepsychiatry

Types

The following are based on the authors’ consensus:

Single therapist answers to multiple clients: In this case, one therapist may be designated to answer all the emails received by the unit or during a specific time period.

Multiple therapists answer based on availability: There is no particular therapist/s designated with the task. Any of the psychiatrists who sees the email replies to it. Hence, this can be considered as a random assignment.

Single therapist answers to their allotted clients: In a more organized and centralized system, the coordinator manages the emails. He or she identifies the treating therapist and specifically directs the email to them and then forwards the reply to the client.

Categorization of Mails

Enquiry emails can usually be categorized in the following categories:

Process-related

About outpatient department (OPD) days (enquiry about working days and holidays)

Inpatient stay (availability of beds, cost-related issues)

Waitlist for inpatient facility

Booking of advance appointments for psychotherapeutic services/fixing time for F2F or telephone consultation depending on the mutual availability

Enquiry about the availability of doctors

Requesting for contact details of doctors

COVID-19-related enquiry (in the current scenario)

Treatment information related

Third-party (relatives and others) requests for patient’s details

Requests for bills, medical reports, discharge summaries, old prescriptions

Personal issues related to marriage, pregnancy, etc.

Requests for sending medications by courier

Consultation-related

Management of new problems

Review of old problems

Side-effects of medication

Stable patients requesting a refill of medications

Stable patients requesting optimization (usually reduction) of medications

Worsening of existing symptoms/unmanageability

Queries related to medical comorbidities

Follow up of investigations, especially the ones that are done at specialized centers and are usually not reported the same day, for example, serum lithium levels and clozapine assay.

Requests for new consultation after being lost to follow-up or for a follow-up consultation after more than six months of the last consult.

Patient education, counselling-related (including diet, exercise, relaxation strategies, problem-solving, and stress management)

Respectfully address it to the patient or the caregiver with an appropriate prefix such as Mr, Ms, Mrs, or Dr

Acknowledge the client’s email and emotion:

“Thank you for your email. I am sorry to hear about you/your (relation to the sender)’s problems.”

“Thank you for updating me about your progress.”

List the problems and reply in sequence.

Use simple language.

Use a courteous and open language. Though the communication is restricted, the words chosen can make much difference to the recipient. The words should indicate a willingness to help, openness, and empathy. For example, use of phrases such as “I understand the difficult situation you are in…” or “These must be very challenging times...” can go a long way.

Use short sentences with clear suggestions.

Avoid using technical words such as medical terms.

Clarify regarding the complaints when needed. Specify the format in which the answer is expected. For example, if the complaint is about worsening sleep disturbances, you might want to enquire about naps during the day, time of taking evening medication, etc.

Avoid using abbreviations such as AM or HS. Simply mention, please take one tablet after dinner.

Mention what to anticipate in the coming weeks.

Suggest homework/assignments (e.g., for patients receiving cognitive behavioral therapy).

Can suggest mobile phone apps (Headspace, Calm), books (Feeling Good by Dr David Burns), YouTube videos (Jacobson’s progressive muscular relaxation technique), etc.

Keep templates for brief management of anxiety, insomnia, etc.

Provide review date (F2F or email) with instructions (with what and when to be updated).

End with greetings and the name and details of the doctor.

Place disclaimers including emergency-related information and contact details.

Templates to Respond to Queries

Having a few standard templates to reply to emails can save time and also ease the process of correspondence. A few templates are given below.

Sample 1: Template to Book Appointment in OPD

Dear Mr/Ms_____,

Thank you for contacting us. Please come to the (location) at (time) on (days of the week). The timings of the registration are from __to__, and the consultation usually finishes by __.

Please bring a copy of a valid photo ID of the patient for submission at the time of registration. Please bring all past medical records, blood or other test results, and the tablets that you are taking. It would be of great help if you bring a written account of your problems in chronological order; do not worry if this is not possible.

(Additionally, the mail can include details about preparation for investigations, address concerns related to patient stay if required, and mention availability of canteen and restrooms. An informational leaflet about route map and other details can be attached, if available.)

Best wishes,

Name of the doctor/department

Sample 2: Template for Responding to Request for a Medical Report

Thank you for your mail. Due to confidentiality issues, we are unable to send patient-related details without obtaining written informed consent from the patient. For this, it is advisable if the patient can come and make an appointment and meet the doctor, who will complete the process after discussion regarding the requirements.

Please bring a copy of this email to the appointment.

Sincerely,

Name of the doctor/department

(If another treating doctor is making the request, it is advisable to request the new treating doctor for a written request on a letter-head with details including his signature, date, and medical registration number and consent from the patient.)

Sample 3: Services During COVID-19 Outbreak

We (name of the hospital) are continuing to offer our services during the COVID-19 outbreak. The timings are _____.

Due to the COVID-19 situation, the arrangements for the OPD are a little different. There will be screening, and seating has been provided with sufficient space for social distancing. (Further, details of the process of consultation can be elaborated.) A canteen and coffee kiosk are available.

People are being screened for symptoms of COVID-19. Anyone with symptoms will NOT be sent away without being seen. They will be guided to be seen in a separate area. This is being done to keep everyone safe. Hence, we request everyone to be truthful when being asked questions at the reception area.

Facilities for washing hands are provided. All patients and relatives must come with masks and are expected to wear them properly at all times.

All this means that service may be slow. We will do our best to avoid unnecessary delays. Please cooperate with all instructions and help us to serve you adequately and safely.

Sincerely,

Name and address for further correspondence

Challenges Specific to India and Recommendations

Challenges Related to Patient Representatives

Owing to the poor access to the internet, it is not unusual for the family of the patient or extended families or neighbors or the friends at the local internet center to reach out to the doctor, on behalf of the patient. This eventually raises several issues regarding the amount of information that can be disclosed and tampering of prescription and misuse of psychotropics.

Challenges Related to Privacy

Problems concerning emotional disorders are often personal, and privacy is requested. Ordinary free email services may not provide the same security features provided by purchased email services such as Microsoft 365. The use of a security certificate for HTTPS and storage of these medical records can further add to the expenses of the healthcare institution. Even though considered expensive, they are essential for the upgrading of the health services to suit the needs of the current technological era.

Legal Challenges

The concerns include difficulty in confirming the identity of the patient over email, especially when representatives of the patient reach out to the doctor. Providing disclaimers regarding impersonation may help. It is also a common practice to send emails with disclaimers that “this email correspondence cannot be used for medico-legal purposes,” etc. However, it must be noted that any document can serve as a legal document in the court of law and can serve as evidence in the easily approachable consumer courts. Many therapists hope that this phrase might indirectly discourage clients from using these for legal purposes. In some cases, this phrase may inadvertently suggest that they can be used as legal documents.

Current medical education courses need to orient doctors towards Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, and with the relevant provisions of the Information Technology Act, 2000, and other data protection and privacy laws.

Other Practical Challenges

The use of email telemedicine is sometimes seen as an alternative way to compensate for the unavailability of a 24-hour telephone helpline, which needs to be discouraged. Email consult may not be accepted the same way as phone or video consult, making clients dissatisfied when charged for these services.

Conclusions and Future Directions

Despite the rapid growth of technology in telemedicine, the email, with its specific advantages, can continue to serve as an effective and feasible tool for health communication. As communication technology becomes more easily available and affordable, access to the internet will be more widespread, helping to overcome barriers related to email telemedicine. Periodical audits to assess the patient satisfaction and challenges faced by the therapists can help to improve the quality of services.