Perceived advantages and disadvantages of telepsychiatry - An online survey of psychiatrists in India.

Context: Telepsychiatry is being practiced in India for many years but was formalized only in 2020. It has many advantages and disadvantages. Aims: This study aimed to understand the perceived advantages and disadvantages of telepsychiatry practices in India. Settings and Design: An online survey with ethics approval by the Indian Psychiatric Society (IPS) Ethics Review Board. All psychiatrists who are members of the IPS and whose email address was available with the society were sent the survey link by email. Methodology: Information about existing telepsychiatry consultation practices in India and perception of advantages and disadvantages by the practitioners were collected between June and July 2020. Statistical Analysis: Frequency, percentages, mean, and standard deviation were calculated.
Results: Responses by 340 responders were analyzed. Majority of the responders felt that telepsychiatry would provide easy accessibility to mental health services (n = 283, 83.24%) and would lead to less exposure to infections (n = 222, 65.29%). Half of the responders (n = 177, 52.06%) felt that there would be an increased doctor shopping resulting in poor care and nearly three-fourth (n = 245, 72.06%) felt that mental health professionals would fall into a problem while dealing with a suicidal or a homicidal patient. Some expressed that the inability to do physical and central nervous system examinations could lead to missing out comorbidities. About one-third (n = 117, 36.56%) felt that the patient recording the consultation would be a legal issue. Conclusions: This online survey showed that psychiatrists perceive many advantages and some disadvantages in practicing telepsychiatry. Copyright:

INTRODUCTION

Advances in science and technology were directly or indirectly used in aiding medical diagnosis and treatment. However, utilization of digital and communication technology in the medical field has been low and slow.[1] The utilization of this technology is catching up slowly and steadily.[2] Although the Telemedicine Society of India was started in 2001, telemedicine and telepsychiatry practice was formalized only in 2020 by the Telemedicine Practice Guidelines[3] and the Telepsychiatry Operational Guidelines (TPOG).[4] Before this, lack of legal backing formed the major hindrance in telepractice.[56]

Telepsychiatry services are provided in different ways. An example of the asynchronous way of providing telepsychiatry is by email communication, where the Registered Medical Practitioner (RMP) sees and responds to the message later in time. Models of synchronous telepsychiatry services include collaborative model,[7] where the psychiatrist collaborates with other RMPs for providing care; on-consultation training model,[89] where the psychiatrist observes and trains RMPs during their consultations; tele aftercare model,[101112] where the psychiatrist provides online consultation for their follow-up patients; and hub-and-spoke model,[1314] where training of trainers can be done. All these models have their own advantages and disadvantages.

In general, telemedicine has many advantages such as providing access to health care reducing costs of health care. It also has some disadvantages such as legal hassles. Some may prefer face-to-face settings, and some disorders by the virtue of their type may require in-person consultations only. When we are about to embark on formal telepsychiatry in the coming years, it becomes imperative to understand the perceived advantages and disadvantages of practicing telepsychiatry by mental health professionals (MHPs) in providing the services.

In this background, this survey aimed to understand the current telepsychiatry practices in India and to draw consensus on the medications that can be listed in Lists O, A, B, and C in TPOG-2020.

In this article, we discuss the advantages and disadvantages of telepsychiatry practices as perceived by the mental health professionals in India.

METHODOLOGY

This online survey was conducted using the Survey Monkey platform.

Ethics approval was provided by the Indian Psychiatric Society (IPS) Ethics Review Board instituted by Research, Education, and Training Subcommittee of the IPS.

The members of the IPS whose email addresses were available with the society were sent the survey link by email. The link opened to a covering letter detailing the purpose of the survey. An option to either continue or opt out was provided. Once a respondent opted to undergo the survey, the next page explicitly asked for their consent. The survey was conducted between June and July 2020. The data collected were anonymized before analysis.

A semi-structured online proforma was developed by the researchers for the purpose of the survey that included sociodemographic details of the respondents (age and years of clinical and telepsychiatry practice), perceived advantages and disadvantages for patients and MHPs, and perceived legal issues.

Statistical analysis

The data were analyzed using the statistical package for the social sciences (SPSS), it is a free software for statistical analyses.[15] Frequency, percentages, mean, and standard deviation (SD) were calculated.

RESULTS

Of 354 responders who read the covering letter and continued to the next page of consent, 13 did not provide consent and one was not a clinician. The responses from the rest 340 responders were analyzed. The responders had a mean of 17.37 years of clinical experience (SD 12.2). Majority of the responders were practicing telepsychiatry either informally (n = 286, 84.15%) for about 5 years (SD 7.81) or formally (n = 246, 73%) for about 2 years (SD 4.75). Formal telepsychiatry practice meant that the practitioner had regular appointment-based telepsychiatry consultation, having a formal setup including a consultation chamber and dedicated hardware/software for the use of telepsychiatry. Informal practice of telepsychiatry meant that there was no formal setup or appointments; the consultations would be on-demand basis.

Majority of the responders felt that telepsychiatry would provide easy accessibility to mental health services (n = 283, 83.24%) and would lead to less exposure to infections (n = 222, 65.29%), especially true in the current pandemic [Table 1]. Some participants felt that with telepsychiatry there would be flexibility in terms of time, more treatment seeking behavior, reduced stigma, better follow-up and adherence, possibility of assessment of other family members and home atmosphere, reduced waiting time, travel time, and ease in getting a second opinion from the MHPs would be other benefits of telepsychiatry [Table 1].

Table 1

Perceived advantages of telepsychiatry

Item	n (%)
Patients*
Time saving for the patients	265 (77.94)
Reduction in travel time	275 (80.88)
Reduction in waiting time	223 (65.59)
Cost-effective	219 (64.41)
Accessibility to any psychiatrist in the country	245 (72.06)
Able to maintain the treatment records more effectively	113 (33.24)
Reduction in leaves/absence from work	186 (54.71)
Reduction in the chance of hospital-acquired infection	221 (65)
Others	32 (9.41)
Mental health professionals*
Cost-effective (may not have to spend much on the rents and running a clinic) – reduction in overhead costs	189 (55.59)
Can provide consultation, even while traveling (for example, while attending a conference)	212 (62.35)
Have more clients across the country	181 (53.24)
Improves quality of care	51 (15)
Ensures close monitoring of patients	94 (27.65)
Patients from far-off places do not have to come for therapeutic drug monitoring	206 (60.59)
Improve treatment adherence	138 (40.59)
Can legally charge for all kinds of consultations	89 (26.18)
Additional income source	85 (25)
Can interview as many caregivers/family members	133 (39.12)
Can interview caregivers/family members who cannot come to the clinic	208 (61.18)
Can provide psychotherapeutic interventions in the home setting	157 (46.18)
Others	18 (5.29)

*The sum total would be>100% as some of the participants reported more than one benefits

Half of the responders (n = 177, 52.06%) felt that there would be increased doctor shopping resulting in poor care and nearly three-fourth (n = 245, 72.06%) felt that MHPs would fall into a problem while dealing with a suicidal or a homicidal patient. Some participants expressed that the inability to do physical and central nervous system examinations could lead to missing out comorbidities [Table 2]. Other disadvantages reported included digital illiteracy, lack of privacy due to intrusive family members, network connectivity issues, lack of nonverbal communication cues, lack of human touch, difficulty in establishing rapport, difficulty in procuring prescribed medications, and increased time spent for using technology.

Table 2

Perceived disadvantages of telepsychiatry

Item	n (%)
Patients*
Poor continuity of care	116 (34.12)
Increase the cost of care, no more free consultations	42 (12.35)
Lack of insurance coverage	91 (26.76)
Increase in cost due to need for gadgets	65 (19.12)
Poor quality of care	136 (40)
Others	73 (21.47)
Mental health professionals*
Have to receive calls at any time of the day	191 (56.18)
Legally liable, if does not respond to the calls	137 (40.29)
Increase in cost of care – due to setting up of teleconsultation setup	41 (12.06)
Patients may not pay for the consultations	153 (45)
More legal hassles	168 (49.41)
More documentation	139 (40.88)
Others	27 (7.94)

*The sum total would be>100% as some of the participants reported more than one disadvantages

Although nearly half of the responders (n = 148, 45.82%) could not comment on whether litigations would increase against the doctors, about one-third (n = 117, 36.56%) felt that the patient recording the consultation would be a legal issue. Others felt that the lack of clarity in boundaries due to calls at odd hours, family issues such as an adult consenting for treatment and parents objecting the same, lack of physical examination and hence missing a sign, and breach of privacy could also potentially lead to litigations against the doctor [Table 3].

Table 3

Perception of legal issues

Item	n (%)
Increase in litigation against the doctors
Yes	127 (39.32)
No	48 (14.86)
Cannot say	148 (45.82)
Legal issues foreseen by mental health professionals
Patient recording the consultation	117 (36.56)
Patient blaming you for not asking appropriate questions	41 (12.81)
Patient blaming you for providing poor services	99 (30.94)
Other (please specify)	63 (19.69)

Other legal issues foreseen by the participants were difficulty in ascertaining the identity of the patient, impersonation, missing out on comorbid medical conditions/adverse effects/vitals due to lack of physical examination, restricted view of patient’s surroundings leading to a possible breach of confidentiality, malingering, issuing legal certifications, network issues leading to terming it as poor service, and abusing the prescribed drugs.

DISCUSSION

The current study showed that many practitioners believe that telepsychiatry is beneficial for both patients and MHPs. There are also some disadvantages and legal issues that can be foreseen at this point.

A recent study from New York University showed that teleconsultation could support psychiatry, geriatric care, and palliative care consultations.[16] They also found that using telemedicine would reduce hospital admissions and noted positive clinician and family perspectives.[16] Cost benefits, improved access to health care, and better outcomes are also noted in some of the studies.[17] A study from Bangladesh on the scenario of telemedicine in South Asia in 2015 found that various models of telemedicine offer cost benefit.[18] Although most people prefer face-to-face consultations, during the COVID-19 pandemic, teleconsultation offers safety and access to homebound people.[19] This study showed the perceived benefits in accessibility. This study also showed perceived benefits in time and stigma. In a low- and middle-income country such as India, where the psychiatrist-to-population ratio is abysmal, most of the psychiatrists live in the first- and second-tier cities, and the transportation network is poor. In this scenario telepsychiatry can help to reach the unreached. A good network of primary health centers is already established in the country, and providing a second opinion to primary care physicians can help millions.

Patient privacy issues,[20] impersonality of teleconsultation,[20] and limitations in physical examinations leading to misdiagnosis[1720] were noted as some of the disadvantages of telemedicine. A recent survey conducted in India, including 154 participants across the specialties, showed that connectivity issues, lack of time to collect adequate medical information and to counsel the patients, challenges in retention of patients, and technical aspects were the barriers to practice telemedicine.[21] This study also echoes the same concerns, with additional concerns of digital literacy, network issues, and difficulty in procuring prescribed medications.

Telepsychiatry could also potentially lead to increased litigations. Better data security laws can prevent data breaches. With the advent of newer technologies such as virtual reality, the communication between people would improve, thus leading to a better user experience of communication. This would help give human touch and hence build better rapport with the patient. There are currently studies going on in looking at the feasibility and accuracy of virtual physical examinations.

Smartphone users in India are estimated to reach 76 crores of Indian populations[22] which is almost half of its population. Almost equal number of people are using the Internet.[23] With improvement in bandwidth and digital literacy in the country, utilization of telepsychiatry would become easier. Roping in the Pharmacy Council of India in policy making toward prescription management in general and validation of e-prescriptions, in particular, would help in streamlining the process and, in turn, translating telemedicine to better utilization.

Acquainting ourselves with the legal guidelines with proper usage of telepsychiatry would help in tackling legal hassles. Currently, many practitioners feel that legal hassles may increase due to teleconsultation. Many Governments including India, South Korea, Japan, and Indonesia[19] eased restrictions and made telepractice easier for their citizens. Countries such as Australia included teleconsultations for insurance coverage.[19] Training of RMPs in telemedicine will help in a better understanding of the methods and legalities of telepsychiatry practice.[2124] The legal issues were foreseen by the MHPs, except for the lack of physical examination, all can occur during in-person consultations too. Providing reasonable care for the patients during any form of consultation, be it in-person or tele, being empathetic, and communicating appropriately would be beneficial.

CONCLUSIONS

Many advantages such as accessibility, time and cost benefits, and safe environment, and disadvantages such as poor continuity of care, probable doctor shopping, lack of insurance coverage, and legal liabilities are present in practicing telepsychiatry. Many legal issues foreseen by the MHPs such as patient recording the consultation, blaming for poor service or for not asking appropriate questions, malingering, impersonation, lack of physical examination, confidentiality, and prescription drug abuse are present both during tele and in-person consultations.

These data would help in devising the curriculum for TPOG, 2020. A similar study after training in telepsychiatry and penetration of telepsychiatry in routine practice would help in tailor-making the curriculum to the needs of the fraternity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.