Covid-19 and Tele-Health: Time to Move from Practice to Policy

To the editor,

The COVID-19 pandemic has resulted in several changes in the landscape of health-care service delivery. Many care providers have adopted virtual health delivery to circumvent disruptions caused by the pandemic-related physical restrictions and ensure continuity of health-care services. ¹ The term “telehealth” refers to remote delivery of health-care services using telecommunication technology. It encompasses a range of approaches, including, but not restricted to, direct video-based communication, the use of apps and web-based platforms for remote monitoring, and collaborative video consultations involving health-care providers at both ends. Evidence suggests that telepsychiatry consultations are as reliable as in-person encounters concerning clinical assessments, treatment outcomes, and client satisfaction.^2,3 Consequently, there has been an increase in telepsychiatry services with time, particularly following the onset of the COVID-19 pandemic. Several policy changes were implemented in the past year to smoothen the practice of telepsychiatry and address barriers and concerns related to licensing, security, prescribing, and reimbursement. ⁴ Here, we propose some more issues that may be relevant for consideration by health-care institutions and policymakers for better organization of telehealth services during and beyond the pandemic:

There is a need to vertically integrate digital mental health-care delivery between psychiatric institutions and community health services. This will also pave the way for a stepped care approach and decongest tertiary care services in countries like India with a high treatment gap in psychiatry. ⁵

Mental health training programs should have a separate module on telepsychiatry and licensing requirements. A dedicated curriculum that focuses on a competency-based approach to training in telepsychiatry, both in didactic and clinical curricula, with defined sub-competencies for each level of competency, may be considered. The competencies should be aligned to the principles laid out in the telepsychiatry guidelines. Regulatory agencies such as the National Medical Commission should oversee the development and implementation of these modules.

Use of Health Insurance Portability and Accountability Act (HIPAA)-compliant platforms to ensure safety and privacy for consumers should be considered; currently, such practices have limited uptake in low- and middle-income countries like India. ⁶ Regulatory agencies should spell out the recommended videoconferencing platforms, taking ideas from reputed international institutions (HIPAA requirements). A checklist may be evolved to ensure the incorporation of minimum essential security features, such as end-to-end encryption.

Many institutions may be using ad-hoc technical solutions for the time being that may not be feasible in the long term. Institutions aiming for a shift to a virtual or hybrid care model in the long term must evolve care delivery platforms that can be seamlessly integrated with hospital information systems and electronic health records. Regular engagement with and education of health-care staff at all levels and involving them in responding to operational challenges is necessary to encourage staff buy-in and ensure continuity of services. ⁷

Currently, there has been a shift of health-care delivery to an entirely virtual mode in many institutions. However, as and when the pandemic recedes, organizations will have to decide what services must be offered in person and what to offer virtually. Relevant considerations here will include demographic characteristics of patients, such as their geographical distance from care hubs, need for ongoing medication, level of psychotherapy support needs, etc. ⁸

Another vital issue to be considered here is the scheduling of virtual versus face-to-face follow-up visits for patients who need regular reviews and drug refills. At present, there are no clear policies for the same, and it is left to individual discretion. In this regard, there is a need for clear policies and guidelines that consider the natural course of the illness and the degree and duration of clinical stability. Though every scenario cannot possibly be covered, some broad guidelines on this aspect may be framed by nodal agencies and disseminated widely.

As health-care organizations consider future-proofing telehealth services, assessment of clinical outcomes and utilizing this information to chart future courses of telehealth services will be a key component. To facilitate this objective, organizations must consider establishing telehealth monitoring committees, which will also function as a regulatory body.

The use of artificial intelligence (AI) has augmented the efficacy of telepsychiatry services. The use of AI is expected to fill the deficit of mental health professionals and provide more integrated mental health services to people in remote areas. ⁹

COVID-19 pandemic, despite its disruptive impact on mental health-care service delivery, also offers an opportunity to restructure care delivery in a more user-friendly, personalized, and resource-effective way. Therefore, institutions and nodal agencies would do well to think beyond the pandemic and utilize the opportunity to redesign mental health-care delivery models to more effectively address the needs of the mentally ill persons.