Coronavirus disease 2019 pandemic: Time to optimize the potential of telepsychiatric aftercare clinic to ensure the continuity of care

The World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) as pandemic on March 11, 2020.[1] As on March 18, 2020, India has reported 151 cases of coronavirus and three deaths, all in the elderly and with other medical comorbidities. In this background, the Government of India has declared this as a “notified disaster,” and many states are shutting down of public places such as malls, school, colleges, pub, public gatherings, restaurant, conferences, and marriage ceremonies and public events such as Indian Premier League cricket matches. This shutdown aimed at stopping the person-to-person spread of corona virus. However, this shutdown undoubtedly impacts the economy and also much required medical care of persons with corona virus and also other chronic noncommunicable diseases (NCDs) including psychiatric disorders. To address the issue of continuity of care, telemedicine is the best alternative option available.

The Tele Medicine Centre at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, a pioneer academic hospital dedicated for neuropsychiatric care, piloted the telepsychiatric after care (TAC) clinic for continuity of care of already registered patients with psychiatric disorders, and reported the higher acceptability, feasibility and possible clinical effectiveness.[2] This report also demonstrated savings of their travel time and money for their in-person follow-ups.[2]

We wish to share our more than 3 years of experience TAC clinic at Tele Medicine Centre, NIMHANS, Bengaluru. It is a stand-alone live, interactive video consultation (means without integrated electronic health record) meant for nonemergency consultations provided on an appointment basis for prescription refill kind of follow-ups (not for first consultations) of Indian citizens only, where treating psychiatrist will choose suitable patients (not opened for patients request at present) similar to choosing patients for electroconvulsive therapy. We have operational guidelines including guidelines for selection of patients for TAC, referral form, and customized consent form for patients laid focus on limitations of TAC clinic such as nonemergency routine follow-up, right of a psychiatrist to abort video consultation (VC) in view any unforeseen situation including suicidal risk, etc. In the past 3 years, TAC clinic provided 780 teleconsultations for 232 patients with various psychiatric disorders.

The long-term vision of Tele Medicine Centre is to integrate TAC in mainstream follow-up outpatient clinic for every psychiatrist (at least five TAC consultations per psychiatrist per day within their mainstream regular in-person follow-ups). This integration into mainstream outpatient clinic has already begun in the year 2019 and successfully integrated 28 TAC for five patients till date. We are going slowly on this integration in view of clinical, technical, and policy issue of institute and of country and gathering wide acceptance among psychiatrists.

Dorsey and Topol reported that the crucial gap of digital medicine between visionaries and acceptance by pragmatists has narrowed substantially in the past decade and advocate for the integration of telemedicine with mainstream care, especially in low- and middle-income (LAMIC) countries with shift of care from hospitals/clinic to homes and mobile devices.[3] We share the opinion of Dorsey and Topol[3] that patients and family who benefitted from TAC are comfortable in using their smartphones than discomfort and orthodox use of desktop with fixing external camera or any other bigger devices. Another advantage of TAC is that family members can join TAC with patients from different locations of their convenience (e.g., family members join from their workplace without availing leave) using multipoint videoconference technology.

In the absence of clear-cut telemedicine laws in India, it would be difficult to generalize the same to other hospitals even in this needy time of the pandemic. Although TAC cannot be substituted for in-person follow-ups, they can be considered as a complementary, convenient, and cost-effective alternative for patients, especially during this COVID-19 pandemic.

The WHO in its interim guidance on February 27, 2020, while advocating rational use of personal protective equipment for COVID-19, suggests the use of telemedicine for the evaluating suspected cases of coronavirus disease with the aim of stopping transmission to health-care staffs.[4] This document did not comment on the use of teleconsultations for NCDs. Further, LAMIC countries do not have resources to provide care in hi-tech hospitals; however, alternatively, leveraging the available home care at the residence through telemedicine is the best recommendation one can think of to face this enormous public health challenge. Hollander and Carr recommended the use of teleconsultations for both patients and clinicians (work from home) during this COVID-19 pandemic which greatly limits travel and exposure to infections and allows for the uninterrupted continuity of care of already established patients.[5] However, Greenhalgh et al.,[6] in an editorial of the British Medical Journal, raised the many clinical, technical, organizational, and policy questions of VC beyond COVID-19.

Government of India needs to address the contentious issue of telemedicine consultations such as virtual physical examination (VPE), interstate jurisdiction, privacy issue with and without electronic health record-based video consultations, and validity of digital/scanned prescriptions of video consultations to an exponential increase in the use of VC for bigger public benefits.

To curtain the spread of COVID-19 pandemic, the United Nations of America loosen strict rue of telehealth to facilitate telephone and video consultations of senior citizens form commonly used videoconference platforms such as FaceTime and Skype.[7] Authors hope that our country shall optimize the potential of video consultations during this COVID-19 pandemic and evolve comprehensive telemedicine rule soon.

Video consultations in India should go beyond COVID-19 and encouraging it as an integral part of the health policies, both at the national and state levels. Although the recent National Health Policy 2017[8] talks about digital health, recent controversy[9,10,11] remains for telemedicine consultations. Till recently, there was no telemedicine guideline in India leads to the misuse of this service. However, on March 25, 2020, the Medical Council of India released detailed documents with the title “Telemedicine Practice Guidelines- enabling registered medical practitioners to provide healthcare using Telemedicine.”[12] Readers are requested to go through this 51-page document for further information. Meanwhile, Tele Medicine Centre, Department of Psychiatry, NIMHANS, Bengaluru, is working on the concept of VPE and planning for a pan-India consultative meeting involving all stakeholders to evolve the specific guideline for telepsychiatric consultations.