VIEWPOINT |
https://doi.org/10.5005/jp-journals-10067-0111 |
Roadmap to Integrate National Telemental Health Program and MHCA: Signboards that cannot be Ignored
1Department of Community Medicine, MVJ Medical College and Research Hospital, Hoskote, Karnataka, India
2,3Department of Psychiatry, Woodland Hospital, Shillong, Meghalaya, India
4Department of Psychiatry, Spandana Nursing Home, Bengaluru, Karnataka, India
Corresponding Author: M Subramanyam, Department of Psychiatry, Spandana Nursing Home, Bengaluru, Karnataka, India, Phone: +91 9972328988, e-mail: drsubramanyam.math@gmail.com
How to cite this article: Samudyatha UC, Tesia P, Tesia S, et al. Roadmap to Integrate National Telemental Health Program and MHCA: Signboards that cannot be Ignored. Ind J Priv Psychiatry 2022;16(1):50–52.
Source of support: Nil
Conflict of interest: None
ABSTRACT
The Union Budget 2022 was remarkable for its landmark mention of Mental Health. It is expected that the National Telemental Health Program would bridge the gap between the scattered human resources and needs in the country. The policy decision is welcome to the medical community in general since we can easily fathom the advantages. However, we must focus on how the new venture can be made sustainable and patient centric.
Keywords: COVID-19, eHealth, Telepsychiatry, Mental Healthcare Act.
“Coronavirus disease-2019 (COVID-19) was like the first rain of the season—though it gives you a cold, it does wash off the dirt and lets the seeds sprout.”
As on date, COVID-19 “disease” has been confirmed in over 38 crore people worldwide and killed at least 56 lakh people.1 However, the COVID-19 “pandemic” has done much more than that. It shook the very foundations of healthcare systems. It challenged the sustainability of public health achievements that had been garnered over decades. It exposed the vulnerabilities in health system delivery. Despite all these, the COVID-19 pandemic has had a significant impact—the act of resilience. Different national health programs of India, such as National AIDS Control Programme and National Tuberculosis Elimination Program, underwent a rapid functional transformation to provide continuum of care. New avenues of healthcare delivery systems were sought after. Government of India published Telemedicine Practice Guidelines in March 2020 and launched e-Sanjeevani, a first-ever Government-run teleconsultation outpatient service. This was a welcome decision, because telemedicine had been gradually picking up in India over the past several years, and saw a spurt during COVID-19 and is expected to grow at a compound annual growth rate of 31% from 2020 to 2025.2 About 125 crore consultations took place through e-Sanjeevani by the year end.3 Online consultation agencies in India reported a growth of 302% in online consultations for mental health-related queries during the COVID-19 lockdown.4 The Union Budget 2022 prioritized mental health in particular and announced a National Telemental Health Program—a network of 23 telemental health centers of excellence, led by National Institute of Mental Health and Neurosciences (NIMHANS) with technology support from the International Institute of Information Technology, Bengaluru. This announcement should be viewed as a timely response to evolving needs of healthcare delivery system, well intended to address the gaps in accessibility, affordability, and availability to implement Mental Health Care Act (MHCA) in its true essence. With that positive note, it is essential that we direct our thoughts and efforts to focus on the sustainability of this venture.
The success or failure of eHealth interventions depends upon the access, quality, and cost containment.5,6 eHealth services also have the same underlying principle as that of establishment of primary health centers in the early years of independence—to improve the accessibility and affordability of people to quality-assured primary health care. However, with each passing year, human resources have been a major concern.7 Currently, India has a doctor-population ratio of 1:1456, with an urban-to-rural doctor density ratio of 3.8:1. There are 0.29 psychiatrists, 0.80 mental health nurses, 0.07 psychologists, and 0.06 mental health social workers per 1 lakh population in India.8 This must be viewed in the backdrop of the estimate that one in seven Indians suffer from mental disorders, amounting to about 1973 lakh patients.9 Launch of a digital platform exclusively for psychiatric issues would mean that there should be sustained, strong political will to recruit, train, and retain ample human resources for quality services. At this juncture, it is important that there are strategic public private partnerships and collaborative ventures of NIMHANS and Indian Psychiatry Association.
Workspace, workload, and workflow are also essential components of human resources. Technocentric digital innovations have high rates of failure, because such innovations consider the technology above the user.10 Thus, design of the digital platform must be built to enable the use of various standardized tools used in psychiatry, assess risk, save, review, and share history of the patient while interacting with the patient and family members. In this regard, it is an advantage that we have had experience with telepsychiatric models such as Schizophrenia Research Foundation (SCARF) Telepsychiatry in Pudukkottai (STEP), Postgraduate Institute of Medical Education and Research (PGIMER) Psychiatrist On Web application, and Hub and Spokes model of NIMHANS.11 One of the common features of successful telepsychiatric models is that they all have a team of outreach mental health workers (a trained doctor, nurse, or social worker).
Telemedicine platforms must also include an option of drug delivery, linkage to the nearest health center, or laboratory facility and provisions for other on-site treatment support. On-site treatment support should include the services that have to be provided to the patient at home or a health center, such as physical examination, certain psychotherapeutic interventions, and supporting patients and families to link to care. Thus, on the provider end, there must be a “hub” and a “spoke,” referring to the specialist and outreach team, respectively. In Karnataka, NIMHANS piloted projects to train medical officers in primary health center (PHC) to identify, treat, and adequately refer patients requiring mental health services. This can be replicated to a dedicated outreach team of doctors, mental health nurses, and paramedical staff, at least at Taluk level, in order to ensure linkage and continuum of care. Teleconsultation alone, without the support of outreach teams or in-built drug delivery system, will limit the quality of care and scope of services.
The patients who come to the doorstep of a hospital form the tip of the ice berg. Lack of awareness, stigma, neglect, and cost continue to be hinder mental health care. Telepsychiatry is found to be, to a certain extent, helpful in addressing these issues.12,13 Nevertheless, accessibility to telepsychiatry services will need to be promoted in a big way, responsive to the needs of special groups.14,15 Though digital platforms appear to be readily accessible, it must be noted that not all platforms or websites are equally accessed. The decision of accessing a particular agency for telepsychiatric care or counseling would greatly depend on the popularity and patient centricity of the platform, which in turn depends on the design, waiting time, round-the-clock availability, online and offline services, and finally, advertising tactics. If the aim of the Government’s initiative is expansion of free, high-quality telepsychiatry facilities, then it must invest in popularity. Similarly, telepsychiatry services must be culturally appropriate and overcome language barriers.11,16,17 Thus, 23 proposed telemental health centers of excellence can restrict their jurisdiction of service.
With advent of newer technologies in clinical practice, newer ethical issues emerge, which need to be addressed with new recommendations18 along with available telemedicine and telepsychiatry guidelines.19,20 To begin with, the professional competencies of the team of healthcare workers have to be established, with additional training in telemedicine. The patients should be able to know and choose whom they want to consult, state whether they are ready for an in-person consultation if required and when to withdraw from the consultation, along the lines of MHCA. In the virtual mode, it is essential that there are mechanisms to verify the identity, age, and address of the patient and/or caregivers. Specific guidelines should be in place to deal with advance directives, patients who are in conflict with law, abuse victims, and patients abusing narcotic drugs and psychotropic substances. Special circumstances such as disasters and pandemics must also be anticipated while preparing guidelines. The outreach teams can assist the central teams in cases requiring on-site action. It must also be ensured that state-specific laws (such as on alcohol) are followed.
Additionally, guidelines to ensure patient confidentiality and data security must be formulated with detailing of the data sharing processes (in case of professional/legal communication and research purpose). In fact, an important part of implementing these guidelines and recommendations is that they do not compromise the design of the platform or digital experience of the user.
Apart from internal monitoring and review of indicator-based performance to assess quality, effectiveness, and patient satisfaction, it is essential to carry out operational research activities to inform the authorities regarding operational issues of the program (including cost-effectiveness and ethical concerns). On a final note, it must be stressed that the telepsychiatry services must not overburden the existing health system. Intersectoral convergence and communication between peripheral health workers and a psychiatrist through telepsychiatry platform is desirable and must be facilitated. However, Telemental Health Program must not be considered as an alternative to the existing healthcare systems, which must be continuously upgraded with resources and training.
ORCID
UC Samudyatha https://orcid.org/0000-0003-1305-1969
M Subramanyam https://orcid.org/0000-0001-6837-3442
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