Practice of Telepsychiatry and its Current Legal Status.

INTRODUCTION

Tele-psychiatry is a practice of psychiatric care using data or interactive digital audio and video communication.[1] It can also be defined as the application of information and communication technology to provide psychiatric care.[2] Tele-psychiatry services may include a broad swath of clinical, preventive, diagnostic, and therapeutic care provided to users, located remotely from the source.

HISTORY

Tele-psychiatry can be considered to have its inception with the advent of closed-circuit television for academic, clinical, and emergency services in the United States in the 1960s.[4] Then followed the era of sophisticated technology of E-mail, message, bulletin-board, forum, website, etc. Evidence is available for its effective use in the assessment and treatment of many psychiatric illnesses commonly, schizophrenia, depression, anxiety disorders, eating disorders, etc. These services catered to most groups including children, adolescents, elderly, veterans, abuse victims, etc.[56]

TYPES OF TELE-PSYCHIATRY SERVICES

Based on communication technology

Synchronous or interactive

It is two-way interactive communication between the therapist and the client at a distant location. The common mode of transmission for synchronous telepsychiatry is video-conferencing, chat forums, telephone, etc. It mimics face-to-face consultation and the response is immediate. This method requires technology suited for real-time interaction.[78]

Asynchronous or store-forward[91011]

This involves the acquisition and transmission of medical data and clinical information through E-mail or web applications for later perusal by the therapist. Information type can be data, audio-visual material, recordings, etc. This form of communication is usually less expensive and typically demands lesser bandwidth.[78]

Based on referral/type of consultation[91011]

Traditional approach-Referral is made to a psychiatrist, who becomes the principal provider of psychiatric care

Consultative care approach-Here a primary care physician is the principal service provider, who consults the psychiatrist when needed

Collaborative approach-Psychiatrist and primary care physicians work collaboratively to provide mental health care.

Emergency tele-psychiatry

Both synchronous or asynchronous telepsychiatry is being practiced at many service delivery situations for emergency response to mental health problems.[12]

Consultation-liaison tele-psychiatry

Video-conferencing, telephone, E-mail, and other communication modalities are being increasingly utilized for the provision of consultation and liaison psychiatry services in primary care.

Tele-psychotherapy

Various forms of psychotherapy such as cognitive behavior therapy, supportive psychotherapy, group therapy, trauma-focussed therapy, crisis counseling, etc., are being provided through chat groups, video conferencing, telephone, online forums, and other such means of delivery.[131415]

Tele-psychiatry assessment

Tele-psychiatry services have been used for neuropsychological assessment and neurological tests via video conferencing.[1617]

Legal tele-psychiatry

Tele-psychiatry services may help provide for legal proceedings and court requirements. It aims to improve patient safety, reduce hospital’s risk liability and transportation time together with costs, and also is efficient for staff involved, who are spared travel.[14]

Tele-psychiatric education

Video-conferencing is being used as effective tool for imparting psychiatric education. It has been found to be cost-effective. The favorable outcome has been seen additionally in local/regional/national and even trans-continental educational programs.[18]

Tele-psychiatry models

Several models have been developed over a period that are known by the name of the country of origin minimal modifications in the technology used, problems addressed, functionalities incorporated, and purposes served. Some of these are briefly described below.

Columbia US model: Hyler et al.[19]

This model consists of the following:

A capturing device-video camera, microphone

Viewing device-computer, monitor, speaker

Coder-decoder (CODEC) software for conversion of analog signal to digital and vice versa.

Canada model: Elford et al.[20]

It is similar to the Hyler model with some modifications

The camera can be remotely controlled with pan, tilt, and zoom functions

Monitor at psychiatrist’s end supports picture in picture frame to view and control their image and that of patients

Extra microphone at user’s end for better sound

Data transfer is through geosynchronous satellite transmission, fiber-optic lines, integrated service digital network etc.

American Indian and Native Alaskan program model: Shore et al.[21]

Designed for providing services to veterans suffering from posttraumatic stress disorder. It was implemented in 6 stages:

Identification of at-risk or under-served population and feasibility of provision of service

Survey of possible areas of service delivery and available resources

Involvement of community and local organizations

Recruitment and training of staff. Creation of clinic(s)

Pilot run of service and improving delivery based on feedback received

Solidification of service.

South Africa model: Chipps et al.[22]

It is an improved version of the Shore model.[21] This model evolved through the following stages:

Situation analysis and need assessment

Assessment of feasibility, sustainability, and benefits

Understanding of available technological, programmatic, and organizational infrastructure

Assessment of infrastructure required and cost of implementation

Delineation of role and responsibility of stakeholders

Adoption of relevant national guidelines and local policies

Training of coordinator and support persons

Program evaluation and monitoring.

Queensland Australia model: Wood et al.[23]

This model emphasized the following three key areas:

High-quality coordination by a trained coordinator

Provision of support to the clinician and local staff to improve service quality and confidence amongst service providers

Outreach visits for complex cases, peer support, and better understanding of rural constraints.

New South Wales, Australia model: Saurman et al.[24]

It is a model for the delivery of emergency psychiatric care. It works on the policy of “no wrong door,” i.e., no caller is refused assistance. Service delivery includes information, as well as telephone triage, clinical care, follow-up, etc.

HISTORY OF TELE-PSYCHIATRY IN INDIA

Schizophrenia Research Foundation (SCARF) pioneered tele-psychiatry services in India in 2007, to reach out to tsunami victims and make available quality mental health care. Tele-psychiatry brings a ray of hope by reaching a wider spectrum of unreached masses in rural areas. It helps reduce the stigma of illness and increase referrals, and also works toward bridging the Mental Health Gap.[2526]

TELEPSYCHIATRY MODEL IN INDIA

Synchronous

Post Graduate Institute of Medical Education and Research Chandigarh “Tele-enabling model”– ”Psychiatrist-on-web” application[27]

A pioneering initiative at developing and implementing a model telepsychiatry application for providing mental health care in remote areas by nonspecialists using a medical knowledge-based decision support system was undertaken in 2010 at Post Graduate Institute of Medical Education and Research Chandigarh. This model involved the delivery of comprehensive mental health care to patients in remote areas. Considering the acute and insurmountable shortage of psychiatrists, particularly in remote rural areas, this system relied on the creation of a software application that could generate automated diagnosis and management guidance to nonspecialists and mental health paraprofessionals thus obviating the need for the presence of a psychiatrist for every patient that was to be treated using the system. Psychiatrists are needed for consultation for difficult cases, emergencies, or for those cases who require specialized treatment methods like autism, etc. This is called as “tele enabling model” wherein nonspecialists are enabled to diagnose and treat mental disorders with guidance from the CDSS. It worked on “Psychiatrist-on-web” application; a net-based software package with codified medical knowledge and logical decision support system. Software package has separate adult and child versions with indigenous diagnostic tools of acceptable sensitivity and specificity for most disorders. There is the option to suggest both pharmacological and nonpharmacological intervention. Psychological management includes psychoeducation, self-guided relaxation, counseling to patient/caregiver, or parenting guide (in child version). This system has provided psychiatric care to patients in the states of Himachal Pradesh, Jammu and Kashmir, and Uttarakhand.

STEP (Schizophrenia Research Foundation Telepsychiatry in (Puddukottai) model[25]

STEP involved the following phases:

Establishing base– A place with limited psychiatric services but easy infrastructure availability

Awareness campaign-About mental illnesses and the facility

Provision of teleconsultation-Planning on types of cases, allotted times, monitoring for relapse or adverse drug reaction

Provision of free medication

Case documentation and ensuring accountability.

Schizophrenia Research Foundationmodel for mobile tele-psychiatry service[26]

SCARF pioneered mobile telepsychiatry unit, a custom-modified bus. Various components are as under:

Mobile unit with consultation room and onboard pharmacy. In the consultation room, patient and caregiver communicate with psychiatrist using Wifi, flat-screen TV and camera

Tele-consultation with the psychiatrist, dispensing free medicine, and follow-up

Psychosocial intervention-Included psycho-education, stigma removal, and information about government schemes

Awareness program-About the available service; with street plays, pamphlets, posters etc.

Ganyari model[28]

This model being used in tribal and rural areas of Bilaspur provides out-patient consultation and occasional emergency service via skype and high-speed Internet. The patient end is manned by the resident doctor or a paramedic. Computer program “Team-viewer” helps simultaneous viewing of patients’ electronic medical records.

National Institute of Mental Health and Neurosciences ECHO (extension for community health outcomes)[29]

This model has been using HUB and SPOKEs knowledge-sharing networks, led by expert teams of NIMHANS. They use smartphone app multipoint videoconferencing to conduct virtual sessions with community providers. The focus of this weekly session/clinic is on “case-based learning to understand the complexities,” “following best-practices like algorithms, guidelines along with clinical wisdom for knowledge diffusion,” “using technology to leverage scarce resource, s” and “web-based monitoring for the outcome.”. This live virtual session is accessible through smartphones. These live sessions are linked to a mobile e-learning certification through which learners can access the learning materials as well as relevant questions anytime and anywhere. NIMHANS provides accreditation for the learners who have completed this blended learning ( virtual + e-learning). In this way, remote primary care doctors, nurses, counselors and other clinicians learn to provide excellent specialty care to patients in their communities. NIMHANS Digital Academy has created huge synergies between academicians from tertiary medical institutions and remote health care practitioners in implementing “best practices in addiction and mental health.

Asynchronous

Balasenorwala et al. model[7]

This telepsychiatry model is in practiced in Maharashtra. Primary care physician refers with the investigation on E-mail. Psychiatrists diagnose and advise based on E-mail content.

Tele-psychiatry practice in many developed countries like Australia is better established and accepted. There are tele-psychiatry models catering to sub-specialties with established legal and ethical frameworks. The practice of tele-psychiatry in India in comparison, is in infancy, with its application only in limited areas. We are still in process of establishing guidelines, infrastructure considerations and gaining acceptance of the population. While developed countries currently dwell on legal, ethical, procedural, and privacy issues; it is the cost and connectivity which are more challenging issues in India, at present.[225]

HARDWARE REQUIREMENTS

Common hardware requirements include a power source, desktop computer, work stations, high bandwidth Internet communication to support transmission of images and voice, telephone lines, connectivity/satellite communication at remote locations, etc.

SOFTWARE REQUIREMENTS

The remote workstation should have at the least-one computer, bio-signal recorder or imaging device, connectivity, open/proprietary architecture, operating system and other services like printer, document sharing, firewall, security etc., Software architecture can be web based (browser), web application (application within a web browser), app in smart phone or tablets or remote app (locally deployed terminal connecting to remote processing system)[30]

CONNECTION TYPE

It can be of following types:

Point to point-two locations only

Multi-point connection-more than two connections simultaneously

Synchronous versus asynchronous

Fixed (better resolution) versus mobile terminal (high portability).

TELE-CONSULTATION PLATFORMS

These are platforms which provide various services relevant to telepsychiatry. Common few platforms are CarePaths, CloudVisit, SecureVideo, etc.

ADVANTAGES

Various advantages of telepsychiatry are as under:[225]

Access in remote areas

Reduces cost of travel for patients, care-givers

Ease of access from home or nearby location

Reduces risks during travel to psychiatric centers

Less time-consuming

Larger choice of therapists

Reduction of stigma.

Challenges:[225]

High cost of system installation and solution platform

Resistance to change and slow clinical acceptance

Uncertainty of required information and communication technology infrastructure

Lack of standards (data exchange security, safety, privacy)

Lack of regulatory body

Accreditation of service provider

Licensing of healthcare professionals

Reimbursement and insurance claims.

TELE MEDICINE PRACTICE GUIDELINES IN INDIA

On March 25, 2020, the consultation through telemedicine by the registered medical practitioner (RMP) under the Indian Medical Council Act, 1956, has been made permissible. The telemedicine practice guideline is a part of the Indian Medical Council (Professional Conduct, Etiquette, and Ethics Regulation, 2002) that have been formulated.[30]

Subsequently, the telepsychiatry guidelines were accepted and released by NIMHANS in June 2020.[31]

There are four models of teleconsultation proposed in the guideline depending upon who is consulting whom:

Patient to RMP

Caregiver to RMP)

RMP to RMP

Health worker to RMP

Following guidelines are proposed pertaining to the most common forms of teleconsultations practiced:

Protection of data and confidentiality

The issue of data protection and confidentiality has been a significant concern for the patient as well as providers. In general, there are two sets of ways in which infringement of privacy and confidentiality of private psychiatric information can be compromised.

Electronic health record (HER) transmission (asynchronous)

1. In the process of teleconsultation, the patient and family are likely to share any personal information with the psychiatrist. Often E-mail, text messages, mobile apps, social media apps, or dedicated electronic health records are used for the data or image transmission. For a long time, it was not clear about the safety of communication through an un-encrypted messaging service, i.e., SMS or E-mail. It has mentioned that the onus lies on a psychiatrist, and he must employ professional discretion to choose the mode (in-person/text/audio/video) of consultation during any time so as not to compromise on the confidentiality and privacy of the patient data and psychiatric record.

There are further issues about access to these discussions, storage of data or misinterpretation of data, etc., in case of malfunction of the instrument like the computer, server, hard disc, or phone. Psychiatrists must pay attention to these issues and put in place all the necessary safe gaurds.

Video consultation or teleconsultation

The video consultation has the risk of any other person who is not intended to join, may join and listen to the conversation. Confidentiality must be maintained during videoconferences, as outsiders can witness the consultation without being visible on the screen.

As per the telemedicine guidelines, psychiatrists should retain records/communication, reports, documents, interaction through (phone logs, E-mail records, chat/text, video interactions, prescription copy) that occurred during the teleconsultation.

In the USA, the Health Insurance Portability and Accountability Act (HIPAA), which covers the privacy and security of patients’ protected health information, which are transmitted electronically. It is the responsibility of the provider or hospital or organization to follow HIPAA standards. According to the General Medical Council, the UK, clinical specialists need to make sure of the confidentiality of the patient’s electronic data while receiving, storing, and transferring the data. They should feel responsible for the security and privacy of electronic data.[30]

In the current guideline, the onus on data protection and confidentially lies with the psychiatrist. Hence, psychiatrists should equip himself or herself with adequate knowledge and skill in this area.

Informed consent

Patient consent is necessary for any teleconsultation. If the patient initiates the telemedicine consultation, then the consent is implied, which is similar to any patient coming to OPD. In an in-person consultation, it is assumed that the patient has consented to the consultation by his/her actions.

A recorded explicit consent is needed if a caregiver or any health worker initiates telemedicine consultation. The telepsychiatry operational guideline also emphasizes on taking consent for the recording of the conversation. Along with consent, the psychiatrist should verify and confirm the patient identity before consultation by reviewing identification proof.

The situation where the capacity to consent by the patient is absent as per the mental health act 2017, section 81, the in-person consultation needs to be advised.

The psychiatrist (providers) has a responsibility to provide an explicit informed consent form, which should include the responsibility of the patient. Consent should be specific, precise, and unambiguous.[30] One of the ways to handle the issue to obtain an advanced patient’s informed consent. The necessary components maybe.[30]

A full description of the therapy procedures,

A full description of the probable problems after the therapy and the likely risks,

A full description of the positive issues expected,

Clarification of alternative processes that can be applied for that individual patient,

A demand that can be responsive to the emergence of any problem.

Telehealth competence

The obligation to provide competent care has different implications at different points along the continuum of electronic interactions between physicians and patients or prospective patients. It can vary from sharing general mental health advice on a website to personalized consultations. The practice guideline often ignores this aspect. Clinicians and educators have first to improve their care via clinical and technological competence to be aware of the ethical and implementational issues in Telepsychiatry. CanMEDS competency framework has divided into the level (1) Novice, level, (2) Advanced levels, (3) Competent, level, (4) Proficient, level, (5) Expert.[32]

The telepsychiatry guideline has tried to address a few of the above issues by suggesting the following:

All psychiatrists intending to provide online consultation need to complete a mandatory online course within 3 years of its notification from the Board of governors in supersession of the Medical Council of India (MCI)

Ethical norms of the Indian Medical council to be followed.

Malpractice and liability

Malpractice liability is a significant barrier in the practice of telemedicine in general and also applicable to Telepsychiatry. This part, often known as tele-negligence, is understudied but can be a potential issue in any telehealth consultations. The malpractice liability risk increases substantially in this direct-to-consumer (DTC) telemedicine conducted either by telephone, computer, or smartphone. Furthermore, researchers and regulators have raised concerns about DTC telemedicine, including substandard verification of patient identity, suboptimal diagnosis and treatment, and inadequate medical history taking, which has led to malpractice litigation.[6]

LEGAL ASPECTS OF TELEPSYCHIATRY

Introduction

During the outbreak of the pandemic COVID-19 and the consequent lockdown in India, when social distancing is mandated, the MCI has encouraged the doctors and health workers to practice telemedicine, whenever appropriate, to provide healthcare services. The Board of Governors, appointed by the government in supersession of MCI (Board of Governors) under the sanction of the Ministry of Health and Family Welfare, published a notification dated March 25, 2020 (Amendment) to amend the Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulations 2002) under the Indian Medical Council Act 1956 (IMC Act) to regulate Telemedicine in India.

Definitions

The concept of Telemedicine has been discussed for the last few years in India but before the notification of Guidelines, it had no legal status. The current Guidelines define Telemedicine as:[30]

“Delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communications technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”

The Guidelines also define another important concept, i.e., Telehealth as:

“The delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services and self-care via telecommunications and digital communication technologies.”

WHO CAN OFFER TELEMEDICINE CONSULTATION?

The Guidelines comprehensively set out the standards, norms, and procedures to be followed by any person who has enrolled in the State Medical Register or the Indian Medical Register under IMC Act (“Registered Medical Practitioner/RMP”) while practicing telemedicine in India through any mode of communication such as telephone, video, and devices connected over LAN, WAN, Internet, mobile or landline phones, chat platforms such as WhatsApp, Facebook, and Messenger either for exchange of information in real time or in synchronous modes for first consults or for follow-up patients. The Guidelines mandate RMPs to complete an online training session to be provided by BoG within 3 years of the date of notification of the Guidelines. Till then, the principles mentioned in the Guidelines are required to be followed. It is to be remembered that ethical norms and standards applicable on in-person medical consultations also apply over telemedicine.

The Guidelines emphasize that the core of telemedicine practice is the professional judgment skill of an RMP. The RMP (here psychiatrist) will decide whether the remote consultation is sufficient or in-person consultation is needed for a particular patient. In all cases of emergency, the Guidelines insist for an in-person consultation. If an alternative in person care is available, consultation through telemedicine should be avoided in case of an emergency and should be limited to first aid, life-saving measures, advice on referral, and counseling. However, if alternative care is not available, then RMP may provide telemedicine consultation to the best of his judgment.

TELEPSYCHIATRY OPERATIONAL GUIDELINES-2020[31]

Indian Psychiatric Society in collaboration with the National Institute of Mental Health and Neuro Sciences, Bengaluru, and the Telemedicine Society of India has created Telepsychiatry Operational Guidelines for practicing psychiatrists of India.

The main aim of this guide is to assist, educate and provide guidance to psychiatrists of India in setting up, implementation, administration, and provision of telepsychiatry services across the country.

Below are the important features of Telepsychiatry Operational Guidelines:[31]

MAINTAINING ETHICS, PRIVACY, AND CONFIDENTIALLY[31]

The Guidelines emphasize the need to maintain medical ethics and the practice of applicable laws and principles of privacy, confidentiality while dealing with the personal records of the patients during telepsychiatry consultation.

The psychiatrist should also adhere to Mental Healthcare Act, 2017 and Rules, 2018 during telepsychiatry consultation.

OVERVIEW OF TELEPSYCHIATRY CONSULTATION

Psychiatrists should have a dedicated work phone/office mobile phone/professional social media account/e-mail id for telepsychiatry consultation services to keep him well organized for telemedicine services.

For an uninterrupted telepsychiatry consultation good Internet connectivity is necessary. Therefore, psychiatrists should have at least two Internet service providers connection. As a wired connection is less prone to interruptions, so it is better to use an ethernet cable.

It is better to have a simple laptop with an inbuilt HD camera, earphone with mic, stable Internet service provider, backup electricity/generator, and all-in-one printer (scanner, copier, and printer). However, an individual psychiatrist may conduct telepsychiatry consultation with a simple laptop and Internet, even on a smartphone.

Every psychiatrist should try to find out a simple user-friendly technology that his patients have the best access to. It is to be remembered that the Telemedicine Practice Guidelines-2020 does not prohibit the use of social media video conferencing applications, namely, WhatsApp, Skype, Facebook, etc., which are very simple to use and are popular and accessible to most even in the rural areas.

MAINTAINING MEDICAL RECORDS

As per Telemedicine Practice Guidelines, the following records/documents need to be maintained for the treatment period– Log or Telemedicine interaction (e.g., Phone logs, E-mail records, chat/text record, video interaction logs, etc.). The Psychiatrist should also retain patient records, reports, documents, images, diagnostics, data (Digital or non-Digital), etc., used in the telemedicine consultation. Moreover, the Psychiatrist is required to maintain the prescription records as required for in-person consultations.

REMEMBER LOCAL STATE LAWS WHILE PRACTICING TELEPSYCHIATRY

A psychiatrist can provide telemedicine consultation to any patient from any part of India as per the guidelines. However, to practice in the certain states of India by registration under specific laws has not been clarified in the guidelines. A psychiatrist needs to register under Clinical Establishment Act or Private Clinical Establishment Act before practicing under respective State laws (e.g., in Karnataka, West Bengal, and so forth).

INITIATION OF TELEPSYCHIATRY CONSULTATION

The telepsychiatry consultation is started by the patient through voice call, video, or text. Thereafter, the psychiatrist may accept to undertake the consultation.

Before starting telepsychiatry consultation, a quick observation on patient’s demographic details, medical records, and chief complaints (reason for consultation) should be done. The psychiatrist should try to explore the patient’s cognitive capacity, history regarding cooperativeness with treatment and professionals, medication compliance, history of substance abuse, and history of violence or self-injurious behavior/suicidal attempt.

It is advisable that psychiatrist and patients should discuss any intention to record (audio/video) telepsychiatry services and how this information data is to be stored and how privacy will be protected. However, it is important to educate the patient not to record and post any consultation video, audio, or photos in social media.

Psychiatrists should maintain appointments for telepsychiatry consultation and avoid odd hours for elective consultation.

IDENTIFICATION

Psychiatrist should confirm the identity of the patient to his satisfaction by asking for patient’s name, age, address, E-mail id, phone number or any other identification that may be reasonable. In the case of telepsychiatry consultation along with the family members can only be allowed if the patient is consulting along with an adult/nominated representative whose identity needs to be ascertained and after obtaining informed consent from the patient.

Location of the patient

Psychiatrist should enquire about the location of the patient from where he is doing telepsychiatry consultation and it should be documented. Since the Telemedicine Practice Guidelines exclude consultations outside the jurisdiction of India. Moreover, it is also required to inform the local police/ambulance services for emergency intervention to save patient’s life in case of attempted suicide or someone else’s life in case of homicidal attempt. Furthermore, mandatory reporting of certain diseases is tied to the jurisdiction where the patient is receiving services and also mandatory reporting of certain acts under the law (POCSO Act, 2012 s 19).

WHAT TO DO IN CASE OF TECHNICAL FAULTS DURING TELEPSYCHIATRY CONSULTATION?

In case of Internet interruption or communication device malfunction before or during the telepsychiatry consultation, attempts should be made to re-establish the contact and to complete the consultation. If not possible, a new telepsychiatry appointment can be given or in-person referral can be considered.

ASYNCHRONOUS CONSULTATION IS PROHIBITED

The Telemedicine Practice Guidelines also prohibits a psychiatrist to allow his/her assistant to do the interview in his/her absence and do the video recording of patient. Later based on the video record of that interview (Asynchronous), he should not prescribe medicine.

HOW TO PRESCRIBE INJECTABLE MEDICINES IN TELEPSYCHIATRY?

Prescriptions for psychotropic injectable medicines can only be given if the consultation is between a psychiatrist and an RMP. In certain situations, it may be prescribed to a health worker for administration to a given patient after assessing the technical expertise of the said health worker.

PRESCRIPTION GENERATION

After making a provisional diagnosis through live interactive telepsychiatry consultation, a psychiatrist should provide the photo, scanned, digital copy of a signed prescription or e-prescription to the patient via e-mail or any messaging platform. If the psychiatrist wants to transmit the prescription directly to a pharmacy, he/she must ensure explicit consent of the patient, which is a mandatory requirement.

WHAT TO DO IF FAMILY MEMBER WANTS TO INITIATE TELEPSYCHIATRY CONSULTATION ?

According to the Telemedicine practice guidelines-2020, telepsychiatry consultation can be initiated by a family member. The family member could be a nominated representative (as per advance directive), or family member/any person authorized by the patient to represent the patient. A psychiatrist should adhere to Mental Healthcare Act, 2017 regarding the advance directive and nominated representative in such situation. It is important to verify the identity and age proof of the patient and the ID of the family member. Also, examine a verified document establishing his/her relationship with the patient. If capacity to consent is present in patient (in the case of adult), always take the consent of the patient through video consultation and document it. It is always better to ask the patient whether he feels safe and comfortable talking about their problem in presence of family members. If the psychiatrist suspects that the patient is being coerced by family members, it is advisable for in-person consultation.

TELEPSYCHIATRY CONSULTATION BETWEEN A HEALTH CARE WORKER AND A PSYCHIATRIST

According to the Telemedicine practice guidelines-2020, Healthcare worker, namely, Nurse, Allied Health Professional, ANM or any other health worker can initiate telepsychiatry consultation for both independent and supported assessment during a home visit, or from medical camps or from wellness centers/primary health centers/any other health establishment. It can be done from any community setting or rehabilitation centers. It can also be initiated from any prison or any other correctional settings. The Guidelines also allow to initiate from custodial institution such as beggar’s homes, orphanages, women’s protection homes, children homes, and any institution having persons with mental illness.

PRESCRIBING ONLINE MEDICINES

The Telemedicine practice guidelines allow psychiatrists to prescribe medicines to the patient through telemedicine consultation with certain restrictions depending on the type of consultation. The Guidelines categorizes the medicines to List O, List A, List B and Prohibited List depending on the safety of the medicines, mode of communication used by the psychiatrist for telemedicine, and the prohibitions placed by the Drugs and Cosmetics Act 1940 and Narcotic Drugs and Psychotropic Substances Act 1985.

It is important to note that prescribing medicines without appropriate diagnosis by a psychiatrist will amount to professional misconduct. A psychiatrist should prescribe medicines as per Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation 2002 and not in contravention with the Drugs and Cosmetics Act and Rules.

List O: Medicines those are safe to be prescribed through any mode of telemedicine (those used for common conditions or those which may be deemed necessary during public health emergencies)

List A: Medicines those can be prescribed during the first consult which is a video consult and are being re-prescribed for re-fill in case of follow-up consultation. This will be an inclusion list containing relatively safe medicines with low potential for abuse

List B: Medicines those can be prescribed to a patient who is undergoing a follow-up consultation in addition to those which have been prescribed during the in-person consultation for the same medical condition

Prohibited list: Medicines those cannot be prescribed in telemedicine consultation.

TELE-THERAPY/TELE-PSYCHOTHERAPY/TELE-COUNSELING

The Telemedicine practice guidelines entitle a psychiatrist to provide teletherapy/tele-psychotherapy/tele-counseling to his patients from any part of India using any mode of communication (text/audio/video). It is important to note that tele-therapy entails the same professional accountability, ethical standards, and laws applicable as in the traditional in-person therapy.

FEES FOR TELEPSYCHIATRY/TELE-THERAPY

According to the Guidelines, a psychiatrist can appropriately charge for the consultation provided using telepsychiatry and can also provide an invoice for the same to the patient.

In conclusion, the release of the Telepsychiatry Operational Guidelines 2020 by the Indian Psychiatric Society and NIMHANS, Bengaluru in collaboration with the Tele-medicine Society of India has given a legal identity to the telepsychiatry practice in India which will help the psychiatrists to impart their accumulated knowledge and resource legitimately to their patients in need at a distance especially during a pandemic or postpandemic. Patients no longer have to travel a long distance to the hospitals/chambers and stand in long queues for hours to consult a psychiatrist for a minor problem. The Guidelines have paved way for the consultations to be done by any sort of reliable and user-friendly communication medium while protecting the interests of patient. Moreover, it will help to reduce the treatment gap of the psychiatric patients from seeking help to mental health professionals.

FUTURE OF TELE-PSYCHIATRY

Some of the systems that are currently under consideration for development or may be seen in future are listed below:

National tele-psychiatry networks with control node at a tertiary-care center, speciality nodes at various medical colleges and patient nodes at rural hospitals or healthcare centers

Mobile tele-psychiatry services network

Portable mobile tele-psychiatry kiosks

Low cost tele-psychiatry infrastructure with rural tele-ambulance system

National tele-psychiatry portal

National tele-psychiatry resource centre

Positive mental health kiosks

Electronic resources in psychiatry

Start-ups for digital psychiatry platform and online pharmacy

International collaborative tele-psychiatry network

Larger governmental commitment

Virtualization of hospitals

Robust tele-psychiatry practice guidelines

Use of space technology in tele-psychiatry.

Telepsychiatry is here to stay and is poised to revolutionalize the practice of psychiatry in India and the world. There are several formats, models and services envisaged, some of which are already in process and could go well beyond the conventional face-to-face consultation model and potentially can universalise the mental health care.[3334]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.