Telepsychiatry Operational Guidelines – 2020Indian Psychiatric Society, &

Dr Suresh Bada Math, Dr Narayana Manjunatha,

Dr C Naveen Kumar, Dr Chethan Basavarajappa & Dr BN Gangadhar

Telepsychiatry Operational Guidelines – 2020
Indian Psychiatric Society, &
Telemedicine Society of India,
In collaboration with
National Institute of Mental Health and Neuro Sciences, (Institute of National Importance)
Bengaluru – 560029
ISBN: 978-81-945815-2-9
NIMHANS Publication No. 170 Copyright © NIMHANS, Bengaluru -560029
May 2020

Editors
Dr. Suresh Bada Math, MD, DNB, PGDMLE, PGDHRL, PhD in Law (NLSIU)
Professor & Head of Forensic Psychiatry Services,
Head of Tele-Medicine Centre and Unit-V (Psychiatry),
Consultant, Community Psychiatry,
Department of Psychiatry,
National Institute of Mental Health and Neuro Sciences,
(Institute of National Importance)
Bengaluru – 560 029
Email:- sureshbm@gmail.com, nimhans@gmail.com, sbm@nimhans.ac.in Phone:- 0802699 5276
Dr. Narayana Manjunatha, DPM, MD
Associate Professor of Psychiatry,
Department of Psychiatry,
Consultant, Tele-Medicine Centre,
National Institute of Mental Health and Neuro Sciences, (Institute of National Importance)
Bengaluru – 560029
Dr. C Naveen Kumar, DPM, MD, MAMS
Professor of Psychiatry,
Head, Community Psychiatry Unit,
Consultant, Centre for Disaster Management, Forensic Psychiatry, Legal Aid Clinic & Tele- Medicine Centre,
Department of Psychiatry
National Institute of Mental Health and Neuro Sciences,
(Institute of National Importance)
Bengaluru – 560029
Dr. Chethan Basavarajappa, DNB, FIPsyR, DDM, (PGDMLE), MANBD
Assistant Professor of Psychiatry,
Department of Psychiatry,
National Institute of Mental Health and Neuro Sciences, (Institute of National Importance)
Bengaluru – 560029
Dr. B N Gangadhar, MD, DSc,
Director,
Senior Professor of Psychiatry,
National Institute of Mental Health and Neuro Sciences, (Institute of National Importance)
Bengaluru – 560029

Copyright © NIMHANS, Bengaluru-560 029
Published by National Institute of Mental Health and Neuro Sciences, Bengaluru-560 029
All rights reserved. No part of this report may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the authors for commercial purposes. However, this document may be freely reviewed, freely transmitted, reproduced in part or whole, purely on non-commercial basis with proper citation. This is not for sale.
ISBN: 978-81-945815-2-9
NIMHANS Publication No. 170
Disclaimer- Medicine is an ever-changing science and at the same time Information Technology is also evolving rapidly. Further, to complicate things, Telemedicine Practice Guidelines, Rules, Regulations and Laws keep on changing, some advices may become redundant over time. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accordance with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, Information technology neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Author does not give any guarantee. Readers are advised to consult their legal counsel for current advice. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s).
Citation: Suresh Bada Math, Narayana Manjunatha, C Naveen Kumar, Chethan Basavarajappa, BN Gangadhar (2020). Telepsychiatry Operational Guidelines-2020. Pub; NIMHANS, Bengaluru-560 029. ISBN No: 978-81-945815-2-9
Correspondence:
Dr. Suresh Bada Math,
Professor & Head of Tele-Medicine Centre and Unit-V (Psychiatry),
Head of Forensic Psychiatry Services, Consultant, Community Psychiatry, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru – 560 029, INDIA
Email: sureshbm@gmail.com, nimhans@gmail.com, sbm@nimhans.ac.in Phone: +91 080 2699 5276

Foreword
Telemedicine can increase the reach to unreached for providing healthcare by leveraging technology. Telemedicine is not new to India. It has been in dormant mode since past two decades and now since Covid-19, it has come into forefront. It is well known that one cannot build healthcare capacity during a crisis. It takes time and investment to build a good public health system. In a significant and a strategic move, the Ministry of Health and Family Welfare on March 25, 2020 has issued the Telemedicine Practice Guidelines-2020 for enabling doctors to provide healthcare using telemedicine. The dormant telemedicine services have been put into maximum utility now by all stakeholders. Post-Covid, Telemedicine is going to stay here, and one needs to adopt and adapt to the new situation.
Telepsychiatry Operational Guide
This report represents a collaboration between the National Institute of Mental Health and Neuro Sciences, Bengaluru and the Indian Psychiatric Society & Telemedicine Society of India to create a resource guide in telepsychiatry for practicing psychiatrists of India and equally beneficial for Low and Middle-Income Countries. These guidelines focus mainly on interactive videoconferencing-based psychiatry services, although Telemedicine Practice Guidelines also recognizes Text and Audio mode of consultation.
Objectives of the guide
The purpose of this guide is to give practical advice to psychiatrists so that telepsychiatry services becomes part of normal day-to-day clinical practice. The main aim of this guide is to assist, educate and provide guidance to psychiatrists in setting up, implementation, administration and provision of telepsychiatry services.
This is not a standalone document. This guide should be used in conjunction with other national clinical standards, protocols, policies, procedures, laws, ethical regulations and the Telemedicine Practice Guidelines 2020. The reader of this guide is requested to first read the Telemedicine Practice Guidelines 2020, notified by the Ministry of Health and Family Welfare, New Delhi. The reader of this guide is also requested read above instruments in conjunction with other laws such as the Mental Healthcare Act 2017, The Rights of Persons with Disability Act 2016, Narcotic Drugs and Psychotropic Substances Act 1985, Drugs and Cosmetics Act, 1940 and Information and Technology Act 2000
Telepsychiatry Services
Telepsychiatry in the form of interactive videoconferencing has become a critical tool in the delivery of mental health care in this contemporary world. To enable telepsychiatry services, Psychiatrists need to comply with licensure laws by enrolling in the State Medical Register or the Indian Medical Register under the Indian Medical Council Act, 1956. Further, all psychiatrists intending to provide online consultation need to complete a mandatory online course within 3 years of its notification by the Board of Governors, in supersession of the Medical Council of India.
The unprecedented pandemic has threatened both health care provider and public at large in the field of medicines. This Covid-19 has emphasized the relevance of telemedicine to health professionals and services users. In this context, we are privileged to have drafted and edited this operational guideline and are enthusiastic about its utility to all our psychiatrists. Our sincere thanks to all our colleagues for their valuable comments and suggestions. Inputs from members of Indian Psychiatric Society and Telemedicine Society of India have added value to this guideline. However, if someone’s name has been inadvertently omitted, please accept our apologies. This telepsychiatry operational guidelines is an endeavour towards adapting to new situation of pandemic.

  • Editors Message from President, Indian Psychiatric Society 8 May 2020
    It is a matter of great pleasure and pride that Indian Psychiatric Society and National Institute of Mental Health and Neurosciences, Bengaluru in collaboration with Tele-medicine Society of India is coming out with the tele-psychiatry guidelines e-book for our country. It will be of immense help for members of Indian Psychiatric Society and other mental health professionals. It will not only be helpful during the period of lockdown in COVID-19 pandemic but also in times to come. As we are aware that distance from treating place, cost and inconvenience involved in travelling and seeking help are also one of the barriers in treatment seeking. Encouragement of tele-psychiatry practice in India may be helpful for the significant proportion of such people. The mental health professional scarcity and their availability only in the city areas can also be circumvented through tele-psychiatry practices. The patients and their family members having only a smart phone and internet connection can access the doctors with much ease. I am sure it will be very much helpful for patients living in far-flung areas and help in reducing the treatment gap of the psychiatric patients from seeking help to mental health professional’s through this platform.
    Most of the useful psychotropic medications are included in either list A or list B of tele- psychiatry guidelines. Psychotherapy can also be conducted using tele-psychiatry platforms. These guidelines are also in keeping with Mental Health Care Act-2017.
    I congratulate and thank to all the contributors of this valuable document.
    Dr P K Dalal
    Professor and Head
    Department of Psychiatry,
    King George’s Medical University, Lucknow Telemedicine Society of India
    Telemedicine Society of India (TSI) HQ
    Registered under Societies Registration Act, 1860.
    Regd. Office: Room No.303. 2nd Floor, School of Telemedicine & Biomedical Informatics (STBMI) SGPGIMS, Raebareli Road, Lucknow. Uttar Pradesh-226014. India.
    PRESIDENT (2019-2020)
    Maj. Gen. (Dr.) Ashok Kumar Singh (Retd.)
    Rajasthan
    IMMEDIATE PAST PRESIDENT (2019-2020) Mr. Vimal Wakhlu
    New Delhi
    PRESIDENT ELECT (2019-2020)
    Colonel (Dr) Ashvini Goel (Retd) New Delhi
    VICE PRESIDENT (2019-2020)
    Dr (Prof.) P.K. Pradhan Uttar Pradesh
    CHIEF OPERATING OFFICER (COO)
    Mr. Baljit Singh Bedi
    New Delhi
    HONY. SECRETARY (2019-2021)
    Dr. Murthy Remilla Karnataka
    JOINT SECRETARY-CUM-HON. TREASURER (2019-2021)
    Mr. Repu Daman Chand
    Uttar Pradesh
    EXECUTIVE COMMITTEE MEMBERS (2019-2021)
    Dr. Sibananda Mohanty, Odisha
    Mr. D. Satheesh Kumar Tamil Nadu
    Mr. Farooq Ahmad Wani Jammu & Kashmir
    Ms Bagmisikha Puhan NCR
    Mr. Bijoy. MG, Kerala
    Ms. Nishu Tyagi, New Delhi Mr. Shiv Mishra, Uttar Pradesh
    08th May 2020
    The unprecedented pandemic across the globe has heralded a series of developments over the recent few weeks. This pandemic has further emphasized the relevance of Information Technology to healthcare professionals in reaching the under-served and those in the outreach. This pandemic has posed a challenge but has also given an opportunity to reach the rural population through technology. The timely release of Telemedicine Practice Guideline 2020 is thus most welcome.
    Medical and healthcare field is changing and evolving at a rapid pace and at the same time Information Technology has been having exponential growth since the past decade. Both the rapidly evolving fields are in the process of amalgamating with newly formed laws/rules and regulations coming together, bringing in welcome synergy but also apprehensions and doubts in the minds of many. Hence readers are also encouraged to confirm the information contained herein with other sources and keep looking into relevant updates and amendments from MCI as well as from Government of India with regard to Data Privacy and Protection laws.
    The Tele-psychiatry Operational Guidelines is an attempt to bring the psychiatry practice, which is the need of the hour during pandemic, under the ambit of Information Technology and the Mental Healthcare Act 2017. A plethora of technological information is available on Telemedicine practice. However, trying to impart all this to a busy psychiatrist would be counter-productive. The Tele-psychiatry Guidelines have made this information simple and patient friendly.
    Telemedicine Society of India takes this opportunity to thank the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru (an institution of National importance), in undertaking this effort to bring in the Tele-psychiatry Operational Guidelines. At the same time, the endorsement and contribution of Indian Psychiatric Society is commendable. The Telemedicine Society of India (TSI) endorses the Tele- psychiatry Operational Guidelines in conformity with the provisions of Telemedicine Practice Guidelines issued by the Board of Governors in Supersession of MCI Act 1956.
    Stay at Home, Stay Safe, Stay Healthy! Warm regards and best wishes,
    Maj. Gen. (Dr.) Ashok Kumar Singh (Retd.)
    President, Telemedicine Society of India (TSI)
    Telephone: +91-7357228799; ashok.lilki@gmail.com, chomure@gmail.com
    Contact: Telephone +91 522 2668838, +91 522 2495530
    Fax: +91 522 2668893 email: contact@tsi.org.in, hon.secretary.tsi@gmail.com & joint.secy.tsi@gmail.com
    Website: http://www.tsi.org.in TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Sl Content No
    Page No
    1 Legality of Telepsychiatry (Telemedicine) Practice
    1
    Advertisement of Telepsychiatry practice online or on social media
    24 4 Electronic Health Record/ Electronic Medical Record 10
    3 Technology of Telepsychiatry
    6
    5 Stepwise Operational Guidelines for Telepsychiatry Consultation 5.1 Before Telepsychiatry Consultation
    5.2 During Telepsychiatry Consultation
    5.3 After Telepsychiatry Consultation
    12
    6 6.1 Initiation of telepsychiatry consultation by a family member with patient 16 6.2 Initiation of telepsychiatry consultation by a family member without patient
    6.3 Telepsychiatry consultation between a healthcare worker & a psychiatrist
    7 Prescribing Medication Online in Psychiatry 7.1 List O
    7.2 List A
    7.3 List B
    7.4 List C
    7.5 Online Prescription, Confidentiality, Transmitting & Dispensing
    22
    8 Tele-therapy/Tele-psychotherapy/Tele-counselling 26 1 New Consult Proforma 28 3 Minimum Basic Standard Guidelines for Documentation of Tele-therapy 38 5 Telepsychiatry Prescription 43
    References 47
    Appendix
    2 Follow-up proforma
    33
    4 Formal Authorization Letter for Representation
    41
    6 The Board of Governors in Supersession of MCI Modification in Medicine List in Telemedicine Practice Guidelines
    45 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  1. Legality of Telepsychiatry (Telemedicine) Practice
    The Ministry of Health and Family Welfare, New Delhi with NITI Aayog released the “Telemedicine Practice Guidelines” in the country and to provide statutory basis, it has been included as an amendment to the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, by adding Regulation 3.8 titled, “Consultation by Telemedicine” in the said Regulations. The “Telemedicine Practice Guidelines” are included as “Appendix 5” to the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. The proposed amendment in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, along with the Board of Governors, Medical Council of India approved, “Telemedicine Practice Guidelines-2020” was placed for the approval of the Ministry of Health and Family Welfare, Government of India by Letter No. MCI211(2)/2019 (Ethics)/ 201853 dated 24.03.2020 and the Ministry has vide Letter No.V.11012/07/2020-MEP dated 25.03.2020 accorded approval to these Amendments. This guideline is not only applicable during the pandemic, but will be relevant post-pandemic also. These guidelines also do get legal status under the National Commission Act, 2019.
    1.1 Laws that need to be adhered to while practicing telepsychiatry
    The psychiatrist shall observe the laws of the country in regulating the practice of tele- psychiatry and shall also not assist others to evade such laws. Psychiatrist should be cooperative in observance and enforcement of laws and regulations of the land. A psychiatrist should observe the provisions of the legislations like Mental Healthcare Act, 2017; the Rights to Persons with Disabilities Act, 2016; Drugs and Cosmetics Act, 1940 & Rule 1945; Narcotic Drugs and Psychotropic Substances Act, 1985; Pharmacy Act, 1948; Medical Termination of Pregnancy Act, 1971; Transplantation of Human Organ Act, 1994; Environmental Protection Act, 1986; Pre–natal Sex Determination Test Act, 1994; and Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954; and such other Acts, Rules, Regulations made by the Central/State Governments or local Administrative Bodies or any other relevant Act relating to the protection and promotion of public health.
    Registered Medical Practitioner would be required to fully abide by the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002 and with the relevant
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    provisions of the Information Technology Act, 2000 (Amended in 2008), Information Technology (Intermediaries Guidelines) Rules, 2011, the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules 2011, Data protection and privacy laws or any applicable rules notified from time to time for protecting patient privacy and confidentiality and regarding the handling and transfer of such personal information regarding the patient. This shall be binding and must be upheld and practiced.
    a. Psychiatrists practicing telepsychiatry shall uphold the below
    a) professional clinical standards, protocols, policies and procedures to provide care
    b) allpsychiatristsintendingtoprovideonlineconsultationneedtocompleteamandatory online course within 3 years of its notification from Board of Governors in supersession of the Medical Council of India.
    c) ethical norms of Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation, 2002)
    d) laws as applicable to traditional in-person care
    b. Adhere to Mental Healthcare Act, 2017 and Rules, 2018 during Telepsychiatry Consultation
    c. Do not prescribe prohibited (List-C) medications online
    they are habit forming drugs, requires permission/ license/ permission/ registration (variable State Rules/ Regulations for Narcotics Drugs and Psychotropic Substances Act, 1985 and varying requirement) and Telemedicine Practice Guidelines-2020 prohibits List-C
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    1.2 Medico-legal issues in telepsychiatry consultation
    a) Encourage Telepsychiatry consultation through appointment (text/audio/video)
    b) Verify the identity of the patient and the family members before consultation
    c) Psychiatrist should ensure that there is a mechanism for a patient to verify the
    credentials and contact details of the consulting psychiatrist
    d) Presence of patient is essential during the telepsychiatry consultation
    e) Encourage the patient and their family member to fill the proforma (Appendix-1 & 2)
    before telepsychiatry consultation
    f) Please do follow Mental Healthcare Act, 2017 during provision of telepsychiatry
    consultation
    g) Patient has the right to choose in-person consultation anytime / stage
    h) In all cases of emergency, the patient must be advised for an in-person interaction
    with a psychiatrist at the earliest
    i) Psychiatrist has the professional discretion to choose the mode (in-person
    /text/audio/video) of consultation during anytime / stage
    j) Reasonable degree of care should be taken to secure the patient’s privacy and
    confidentiality
    k) Issue prescription only after diagnosis / (at least) provisional diagnosis.
    l) Do not prescribe prohibited (List-C) medications online
    m) Explicit consent to be taken from patient before transmitting prescription to any
    pharmacy
    1.3 Patient in Conflict with Law (Forensic Psychiatry)
    a) Psychiatrist need to enquire if patient is in conflict with law in all telepsychiatry consultation
    b) It is the professional discretion of the psychiatrist to advise for in-person consultation or inpatient admission for patients in conflict with law for assessment and diagnosis as well as to issue any form of medical certificates.
    c) Follow Mental Healthcare Act, 2017 for issuing the basic medical records or issuing any certificates.
    d) To consult with the medical board before issuing any certificate.
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  2. Advertisement of Telepsychiatry Practice Online or Social Media
    Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 (6.1 Code Advertising) dictates soliciting of patients directly or indirectly by a physician, by a group of physicians or by an institution or an organization is unethical. A physician shall not make use of him / her (or his / her name) as subject of any form or manner of advertising or publicity through any mode either alone or in conjunction with others which is of such a character as to invite attention to him/her or to his/her professional position, skill, qualification, achievements, attainments, specialties, appointments, associations, affiliations or honors and/or of such character as would ordinarily result in his/her self-aggrandizement.
    A medical practitioner is however permitted to make a formal announcement in press regarding the following: (1) On starting practice, (2) On change of type of practice, (3) On changing address, (4) On temporary absence from duty, (5) On resumption of another practice, (6) On succeeding to another practice and (7) Public declaration of charges. Further (Code 6.1.2), clearly says that printing of self-photograph, or any such material of publicity in the letter head or on sign board of the consulting room or any such clinical establishment shall be regarded as acts of self-advertisement and unethical conduct on the part of the physician. However, printing of sketches, diagrams, picture of human system shall not be treated as unethical.
    Rule of thumb is, do not indulge in advertisement on social media or internet to solicit patients.
    There is a thin line between informing and advertising. Informing is providing information and it is part of the advertisement. Advertisement generally has three components to inform, to persuade (cognitively or emotionally), and to remind. However, practitioners are allowed to a formal announcement (inform) in press regarding the starting of practice, change of type of practice, change of address, name of the institution, type of patients seen, facilities, fees and resumption of another practice.
    2.1 Caution: – Many online telemedicine portals/ platforms/ applications (also called as intermediaries) do advertise doctors’ photo, patient’s rating or voting of the patient about the doctor on various parameters and so forth. Further, many online platforms use patient’s response and doctor’s reply to be available online to general public. This is a serious issue, which needs to be curtailed at any cost. Please do refrain using such platforms, unless the Medical Council or National Medical Commission permits such practices.
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    As per the Telemedicine Practice Guidelines (Code 5.2), Technology Platforms shall conduct their due diligence before listing any Registered Medical Practitioners/psychiatrist on its online portal. Platform must provide the name, qualification and registration number, contact details of every RMP listed on the platform. The guidelines do not endorse photograph, rating, voting, online patient’s recommendation of a doctor and making patient’s and doctor’s response public. The ideal way to reach out to patients is to offer telepsychiatry services to your own patients. Please do mention about your availability on telepsychiatry practice and methods to reach you for appointment and doing telepsychiatry consultation.
    2.2 Social Media and Professional Boundaries: Social media has blurred the boundaries between public and private life of a psychiatrist. This may invite a risk of professional boundary crossings / violation. Do not mix social and professional relationships on social media and, where appropriate, direct them to your professional social media profile. It is advisable to have separate professional social media account and personal social media account.
    2.3 Do Not Share Patient’s Data on Social Media: Psychiatrist should refrain circulating patients’ image / video / audio / case notes on any social media, without proper written irrevocable informed consent. Once information is published online, it will be difficult to remove as other users may share it or distribute it further or comment on it.
    2.4 Identity on Social Media: If you identify yourself as a psychiatrist, publicly on accessible social media, you should identify yourself by name and be responsible for the uploaded content because it is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.
    2.5 Comments on Colleagues in Social Media: Psychiatrist should treat colleagues fairly and with respect on social media. Psychiatrist should not bully, harass, character assassinate, make gratuitous, unsubstantiated or unsustainable comments about colleagues online. Please monitor/ watch your behavior online.
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  3. Technology of Telepsychiatry
    a. Dedicated Office Mobile /Landline number and Email ID
    Have a dedicated work phone/ office mobile line number/ professional social media account/Email ID for telepsychiatry consultation services. This will keep the Psychiatrist well organized and help manage their telemedicine services. Have a dedicated official email ID
    and/or professional social media account for telepsychiatry patient services. This will help organized communication with the patients.
    b. Internet Connection
    Heart and soul of telepsychiatry is good internet connectivity. Have at least two internet service providers so that your telepsychiatry consultation is uninterrupted. A wired connection is less prone to interruptions, so try to use an ethernet cable. However, Wi-Fi technology has improved a lot. Please do remember not to move away from the range of your router. A general rule of thumb in Wi-Fi networking is that Wi-Fi routers operating on the 2.4 GHz band can reach up to 150 feet indoors and 300 feet outdoors. But this further reduces, if there are concrete walls and acoustic walls (sound proof walls). Please be within the range of Wi-Fi router to provide telepsychiatry services and if required, install Wi-Fi range extender.
    c. Hardware
    Psychiatrist need to resist buying an office full of new bulky hardware for telepsychiatry consultation. A simple laptop with an inbuilt HD camera, earphone with mic, stable internet service provider (at least 512kbps), connection with a good router, backup electricity / generator and all-in-one printer (scanner, copier and printer). Simple and ease of implementation are imperative to a seamless session.
    The scale of investment on telemedicine technology depends on available resources, clients’ demand, number of teleconsultations planned and acceptance of the service providers. A large multi-specialty hospital (huge nursing homes, medical colleges & tertiary centers) system requires significant resources in place, however a solo psychiatry or small group practice may be able to still conduct telepsychiatry consultation with simple hardware
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    technology like laptop and internet, even on a smartphone. Invariably decisions to invest will be based on cost and usability potential. However, please do remember the hardware technology changes very fast. Do not choose a telepsychiatry solution, which endorses expensive equipment, high costs of maintenance and requires intensive training for staff. Telepsychiatry solution should be economical and easy to use by all stake holders including patients.
    d. Software
    A psychiatrist may choose an application that best suits them, but the patients may not want to use it at all because of complexity and lack of access to technology. This may lead to the psychiatrist thinking that the telemedicine technology does not work, which is not the case. A psychiatrist should make an attempt to find out what is the simple technology that the patients have best access to. Psychiatrist also needs to find the best way to extend care to his/her patients, so that they are easily adopted, consumed and communicated seamlessly. At present, most of the telemedicine solutions are moving to the cloud. Some telemedicine providers still insist on and force the psychiatrist to purchase a software system that needs to be installed on a medical practitioner’s computers. These software solutions may require additional equipment like data storage hardware or servers, which adds burden in terms of economy and maintenance charges.
    Telemedicine Practice Guidelines-2020 do not prohibit use of social media video conferencing applications such as WhatsApp, Skype, Facebook and so forth, which have simple user interface and are popular among the general rural public. Psychiatrists should not shy away from utilizing them, if patients are comfortable using such application knowing the risk involved. Choose a telemedicine software or an application that is very simple to use and effective. Psychiatrists are always trained to think from the patient’s perspective. Every piece of technology that we incorporate should be patient centric, secure, effective and easy to use.
    e. Camera for telepsychiatry consultation
    Please do invest in a good camera for telepsychiatry consultation and place the camera at Eye-Level. If you are using an integrated or external camera for your laptop please set it up
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    so that the camera is approximately at eye-level. Psychiatrists need to look into the camera and nod along to convey listening. Looking at the camera makes eye contact and is needed to develop rapport.
    If possible, avoid taking notes during the video consultation. If you decide to take notes during the tele-video consultation, please do mention that you are taking notes lest, the patient perceives it as you being distracted or not engaged in the consultation and may come in the way of building rapport.
    f. Sound / Audio
    Another source of great discomfort is the background noise. This can be a major barrier to communication, so psychiatrists need to; a) find a quiet place (isolated place) so that no one can disturb / interrupt and b) wear headsets (with cuff), which can help curtail noise from outside and personal details of the patient is not aired on the speakers.
    If you have planned to have telepsychiatry consultation in a busy outpatient setting, invest in a good sound-proof room to avoid outside noise and also to decrease the echo. However, sound acoustic can be improved to some extent by having furniture and floor mats inside the room. Psychiatrists shall ensure privacy during teleconsultation and all possible measures to be considered so that clinical consultation / discussion should not be overheard by others outside of the room where the service is provided
    g. Telepsychiatry Chamber
    Please establish the telepsychiatry consultation room such that it is close to your in-person Out-Patient Department (OPD) consultation chamber. It is advisable for both (in-person and virtual consultation) chambers to be the same. However, if you want to have a dedicated room, avoid keeping it away from the OPD. Providing telepsychiatry services will be inversely proportional to the distance between your in-person consultation room and telepsychiatry consultation room. If you are also planning to do telepsychiatry consultation from your home, please do have a dedicated room for the same (similar to in-person consult). Room should be aesthetically similar to in-person consult chamber.
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    h. Lighting for telepsychiatry consultation
    Psychiatrist should ensure that there is enough of light (if possible natural light or LED white light) so that patient can identify the psychiatrist clearly. Generally, avoid colored room lighting. Recommended, is a warm, white LED light (3200K-4000 Kelvin) inside the telepsychiatry consultation room. Avoid placing camera facing a doorway or window or any other source of light. Three-point lighting avoids the shadow as shown in the figure no-1
    Avoid clutter in the background and do not have shiny or reflective backgrounds. Be mindful of your background. Light blue matt background looks excellent for telepsychiatry services. Room color can make a dramatic difference to the quality of the video consultation.
    Hospital/Clinic Name with Logo
    Figure No-1. Three-point artificial lighting avoids the shadow from all direction and identification of the psychiatrist is done easily
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  4. Electronic Health Record (EHR) / Electronic Medical Records (EMR)
    Psychiatrists may want to choose a telemedicine platform that is already integrated with an Electronic Health Record or without. Telemedicine Electronic Health Record gives a framework which ensures encoding, storing and retrieval of the medical records that are maintained online. However, there is an option for psychiatrists to choose standalone telemedicine solution without EHR and can enter all the notes into patient’s physical file (similar to traditional in-person documentation) directly. Telepsychiatry platform can be used only for giving appointment, video-conferencing, generating and transmitting prescription. EHRs should not be seen as the center piece of care but an augmentation to the telepsychiatry consultation. However, psychiatrist needs to comply with Mental Healthcare Act, 2017, Sec 25 which is about the need to maintain basic medical record.
    a. Medical Records in Telepsychiatry Consultation
    All psychiatrists need to maintain the records as mentioned in
    a) Mental Healthcare Act, 2017 (Basic Medical Records) & b) Telemedicine Practice Guidelines 2020
    As per the Mental Healthcare Act, 2017, Sec 25 specifies that all persons with mental illness shall have the right to access their basic medical records and it is prescribed in the Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018 Rule 6(3), Form B. For the purpose of documentation Appendix-1 & 2 can either filled by Patient &/or patient’s family member &/or Psychiatrist. Appendix-3 to be filled by the Psychiatrist only.
    As per telemedicine practice guidelines, the following records/ documents for the treatment period, as prescribed from time to time need to be maintained. These include, Log or record of Telemedicine interaction (e.g. Phone logs, email records, chat/ text record, video interaction logs etc.). The Psychiatrist should retain patient records, reports, documents, images, diagnostics, data (Digital or non-Digital) etc. utilized in the telemedicine consultation. Specifically, in case a prescription is shared with the patient, the Psychiatrist is required to maintain the prescription records as required for in-person consultations.
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    b. Audio or Video Recording: If you are planning to record audio or video of the telepsychiatry consultation, please do take explicit consent before the consultation. Covert recordings (audio or video) by either the patient/patient’s party or the healthcare provider are illegal since everyone being recorded must consent to be recorded. Explicit consent is must from all the parties involved in consultation.
    c. Securing the devices: Telepsychiatry service providing devices should be kept in the possession of the psychiatrist or by the authorized person. Unauthorized access to such devices should be prohibited and shall not be allowed access to sensitive information stored on the device. Psychiatrist should have the capability to secure it, remotely disable or wipe their telepsychiatry service providing device in the event of its loss or theft.
    d. Access to Basic Medical Records: Requests for access to basic medical records shall require written authorization from the patient as per the Mental Healthcare Act, 2017, Sec 25 in a prescribed format. If professionals are storing the audio/visual data from the telepsychiatry consultation, these cannot be released unless the patient authorization indicates specifically that this is to be released. Upon direction and written approval by the patient, the patient’s record shall be made available to patient only.
    e. Jurisdiction in terms of specialization; all doctors are aware of the jurisdiction of their specialization. If any damage occurs because of trespassing into an area that is of not his/her specialization, the repercussions will be dealt in a similar manner as in case of in-person consultation. Further. Sec 106 of Mental Healthcare Act, 2017 clearly depicts that no medical practitioner shall discharge any duty or perform any function not authorized or specified or recommend any medicine or treatment not authorized by the field of his/her profession.
    f. Jurisdiction in terms of territory; a psychiatrist is entitled to provide telemedicine consultation to any patients from any part of India as per the telemedicine practice guidelines. However, this issue to practice in certain State by registration under specific laws has not been clarified. For example, the psychiatrist needs to register under Clinical Establishment Act or Private Clinical Establishment Act before practicing under respective State laws (such as Karnataka, West Bengal and so forth). Health being a State subject under federal structure of our constitution, State laws and policies will prevail, until constitutional amendments are made.
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    5 Stepwise Operational Guidelines for Telepsychiatry Consultation
    5.1 Before Telepsychiatry Consultation
    Before you start telepsychiatry consultation, please do look into patient’s demographic details, medical records and chief complaints (reason for consultation). Psychiatrist should explore patient’s cognitive capacity, history regarding cooperativeness with treatment and professionals, medication compliance, current and past difficulties with substance abuse, and history of violence or self-injurious behavior/suicidal attempt.
    Psychiatrist and patients should discuss any intention to record (audio/video) telepsychiatry services and how this information data is to be stored? where? how long? and how privacy will be protected? Psychiatrist should take explicit consent for recording of audio/video consultation with patient. In a similar way, patient sharing the consultation (audio/video) recording needs to be documented in a written agreement pertaining to this issue can protect both the patient and the psychiatrist. It is important to educate the patient not to record and post any consultation video, audio or photos in social media. Further, Psychiatrist needs to follow the clinical practice guidelines similar to in-person consult. Check all the hardware and software before you start telepsychiatry consultation.
    b. Spectacles: If you wear spectacles, use antiglare glasses so that reflection of light from the monitor/light is not seen. This may come in the way of making eye contact during consultation.
    c. Maintain appointment time: Psychiatrist should maintain appointment for telepsychiatry consultation similar to in-person consultation and avoid odd hours elective consultation. For follow-up consult appointment date and time may be fixed at the time of exit of previous in- person or tele-consultations. Provide patients any alternate contact details to change in appointment time/date if need
    a. Dressed Professionally: Telepsychiatry services has made consultation easy for both psychiatrists and patients. Psychiatrists providing services should dress in a professionally/formal attire similar to in-person consultation. Do not be in casual clothes during telepsychiatry consultation.
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    5.2 During the telepsychiatry consultation
    a. Identifying the patient: A psychiatrist should verify and confirm patient’s identity before consultation and issuing a prescription. Identification should be by name, age, address, email ID, phone number, registered ID or any other identification as may be deemed to be appropriate. Tele-psychiatry consultation along with the family members would be allowed only if the patient is consulting along-with an adult/nominated representative whose identity needs to be ascertained and after obtaining informal consent from the patient.
    b. Location of the Patient: Psychiatrist shall enquire about the location where the patient is receiving telepsychiatry services. Location of the patient should be documented. However, it is not necessary for the psychiatrist to reveal their specific location to the patient. Enquiring about patient location is critical for the following reasons:
    i. Psychiatrist shall know and abide by the laws in the jurisdiction where the patient is receiving telepsychiatry services
    ii. If the patient has travelled abroad and initiated a telepsychiatry consultation, the psychiatrist needs to explain to the patient about the Telemedicine Practice Guidelines which excludes consultations outside the jurisdiction of India
    iii. Patient may require referral to nearest mental health establishment or to a local psychiatrist for in-person consultation for any potential psychiatric emergency conditions
    iv. To inform the local police/ambulance services for emergency intervention to save patient’s life (attempted suicide) or someone else’s life (homicidal attempt)
    v. 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 Sec 19)
    Before you close the telepsychiatry consultation, explain if any investigation is required, the prescription of medication, health education, counselling, next follow-up, feedback on consultation and what they need to do next. Psychiatrist and the patient should also discuss whether or not the psychiatrist will be available for phone or any other means of contact between telepsychiatry consultation/ sessions and also call out the conditions under which such contact is appropriate. This should also include a discussion of emergency management between sessions and ways to deal with such situations or in-person consult.
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    c. Duration of telepsychiatry consultation.
    Generally, telepsychiatry consultation between patient and psychiatrist lasts for 10-15 minutes and up to 30-45 minutes for a tele-psychotherapy session. In addition, each telepsychiatry consultation or tele-psychotherapy session also requires preparation in the form of, going through the medical records, establishing connection, post consultation documentation, generating prescription and transmitting it.
    d. Unable to complete the telepsychiatry consultation
    Before or during the telepsychiatry consultation, there is a high possibility of technology related problems due to various reasons such as, internet interruption or communication device malfunction. In such situation, attempts should be made to re-establish the contact either by video or audio and to complete the consultation. If it is not possible, new tele- psychiatry appointment can be given or in-person referral can be considered. Fees and charges for such Telepsychiatry consultation will be determined case-by-case, depending on, the matter which was discussed during the Telemedicine consultation, time spent on consultation and re-establishing the contact, at which point the telepsychiatry consultation was terminated, and if any the reason for premature termination of the telepsychiatry consultation. Further, either of the party may terminate telepsychiatry consultation at any time before or during the consultation and respective party will be responsible for the consultation charges.
    e. Asynchronous Telepsychiatry Consultation:
    A psychiatrist shall not 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 shall not prescribe medicine. This asynchronous consultation is prohibited because both patient and psychiatrist need to introduce themselves to each other and the psychiatrist needs to verify the identity of the patient, consultation to be given live and interactive in a real-time mode with health advice, counselling and medication. These are possible only on a live consultation (synchronous model). It would be highly unethical for an offline consultation through a health worker. However, psychiatrist can take the video evidence of seizures, abnormal behavior, signs, symptoms and so forth but consultation needs to be live before prescribing the medicines.
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    5.3 After telepsychiatry consultation
    After completing the consultation, request the patient to send you the feedback, as an optional step. This is also a great opportunity to know, whether there was any communication problem on the patient’s side and also request them to provide suggestion for further improvement in the telepsychiatry services
    The best approach for a psychiatrist to start tele-psychiatry is using already existing systems like smart phone with internet connection, email and SMS to stay connected with the patients. To conclude, a large hospital setting may require significant resources in place and investment, however a solo psychiatrist or small group of psychiatrists can practice telepsychiatry consultation with laptop, internet and printer. A rule of thumb to have a successful telepsychiatry consultation is to choose a technology and hardware that best works for the patient and not just the psychiatrist.
    a. Prescribing Injectables in telepsychiatry consultation.
    Prescriptions for psychotropic injectable medicines can only be given if the consultation is between a Psychiatrist and a Registered Medical Practitioner. In certain circumstances, it may be prescribed to a Health Worker for administration to a given patient. In such a scenario, the Psychiatrist must be confident of the setting of the facility and the technical expertise of the Health Worker.
    b. Generating and transmitting prescription
    The guideline indicates that, the psychiatrist needs to collate adequate and relevant information to arrive at a provisional diagnosis through synchronous (live interactive) telepsychiatry consultation before generating prescription. Psychiatrist shall provide photo, scanned, digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform. In case the psychiatrist is transmitting the prescription directly to a pharmacy, he/ she must ensure explicit consent of the patient, which is a mandatory requirement.
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    6 Initiation of Telepsychiatry consultation by a family member or a healthcare worker
    As per 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 or any person authorized by the patient to represent the patient. Please adhere to Mental Healthcare Act, 2017 regarding the advance directive and nominated representative. This kind of consultation can be either with patient or without patient. Patient can be a child or an adult.
    All telepsychiatry consultation initiated by a family member or nominated representative or a care-giver will be accompanied by explicit consent from patient (Appendix-4)
    Telepsychiatry consultation needs to be stopped or referred for in-person consult, if patient
  • refuses to consent for telepsychiatry consultation.
  • patient has capacity to consent for treatment (as per Sec 4 & 81 of Mental Healthcare act, 2017). However, ascertaining the presence or absence of capacity to consent can be assessed through video-consultation only
  • is dangerous to self (suicide/deliberate self-harm) and/or others (violence/homicidal)
  • requires emergency care
  • in conflict with law (Forensic psychiatry) cases
  • is a survivor or perpetrator under the Protection of Children from Sexual Offences Act, 2012, Sec 19 (mandatory reporting to be done). Once the detailed evaluation and assessment is completed through in-person, follow-up can be planned through telepsychiatry consultation. Based on the ‘professional judgement’ and ‘best interest the child’ principle, the psychiatrist either may choose telepsychiatry / teletherapy or in-person consultation or therapy
  • if family member and/or patient is asking for a certificate or basic medical records, in such scenario, psychiatrist is advised to follow the Mental healthcare Act, 2017
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    6.1 Initiation of telepsychiatry consultation by a family member with patient
    The family member could be a nominated representative (as per advance directive), or family member or any person authorized by the patient to represent the patient. Please adhere to Mental Healthcare Act, 2017 regarding the advance directive and nominated representative. Patient is present with the family member during the telepsychiatry consultation needs to be considered and can be done as per the flowchart no-1.
    For children (less than 16 years)
    a) Please verify the identity and age proof of the patient. Also verify the ID of the family
    member and also procure a verified document establishing his/her relationship with the patient. Once the psychiatrist is satisfied, please follow the telemedicine practice guidelines for first consult and follow-up consult
    For adult patients
    b) Please verify the identity and age proof of the patient. Also verify the ID of the family member and also examine a verified document establishing his/her relationship with the patient.
    c) Once the psychiatrist is satisfied please do capacity assessment as per Mental Healthcare Act, 2017, Sec 81 (guidance document)
    d) If capacity to consent is present in patient, please do take the consent of the patient through video consultation and document it. However, if the psychiatrist feels that patient is being coerced, ask them for in-person consult. Please do ask the patient, do they feel safe and comfortable talking about their problem in presences of family members. Once the psychiatrist is satisfied, please follow the telemedicine practice guidelines for first consult and follow-up consult.
    e) If capacity to consent is absent in patient,
  • Advice for in-person consult for all first consult
    For follow-up patient, check for the advance directive and follow it. If there is no advance directive, please do take the consent of the family member/nominated representative through video consultation and document it. Once the psychiatrist is satisfied, please follow the telemedicine practice guidelines for follow-up consult. However, if the psychiatrist feels that patient is being coerced by family members, advise them for in-person consult
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    Flowchart No-1. Initiation of telepsychiatry consultation by a family member with patient
    Initiation of telepsychiatry consultation by a family member with patient
    Check ID of the patient and age proof
    Check ID of the family member and a verified document establishing his/her relationship with the patient
    For adult patient
    Assessment of Mental Capacity (MHCA, 2017 Sec 81) on video consult by a psychiatrist
    For Children (less than 16years) continue as per Telemedicine Practice Guidelines
    Capacity to consent present Capacity to consent absent
    Take consent from patient and ask if he/she feels safe and comfortable to consult in presences of family members. Continue as per Telemedicine Practice Guidelines For both first consult and follow-up consult
    In-person consult to be advised for all first consult
    Follow Advance Directive/ Take consent from Nominated Representative
    In-person consult
    Continue as per tele-follow consult
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    6.2 Initiation of telepsychiatry consultation by a family member without patient
    A family member initiating a telepsychiatry consultation without a patient can be considered only in follow-up telepsychiatry consult and is to be done as per the flowchart no-2.
    First Consult –In-person consult to be advised for all first/new telepsychiatry consult without patient. Please do health education and providing information to the patient’s family member about the Mental healthcare Act, 2017
    Flowchart No-2. Initiation of telepsychiatry consultation by a family member without patient
    Tele-follow-up consult
    Initiation of telepsychiatry consultation by a family member without patient
    In-person consult to be advised for all first consult
    Follow-up Consult – (In-person consult in past six months). If the patient is eligible for telepsychiatry follow-up consult as per the telemedicine practice guidelines. Please verify the identity of patient and check for the formal authorization letter. Also verify the ID of the family member and also verify the document establishing his/her relationship with the patient. Once the psychiatrist is satisfied please follow the telemedicine practice guidelines for follow-up consult. Every such follow-up consultation (in absentia of patient) should be accompanied by recently issued formal authorization letter by the patient. However, if psychiatrist has a) documented the diagnosis of dementia b) severity as ‘moderate’ or ‘severe’, c) loss of capacity to consent by the patient and d) psychiatrist is able to recognize the family member can provide telepsychiatry follow-up consult without authorization letter also.
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    Check for authorization letter, valid ID and verified document establishing his relationship
    If no proper documents advice In-person consult with patient
    Continue as per tele-follow up consult TELEPSYCHIATRY OPERATIONAL GUIDELINES
    6.3 Telepsychiatry consultation between a healthcare worker and a Psychiatrist
    Healthcare worker such as Nurse, Allied Health Professional, ANM or any other health worker can initiate telepsychiatry consultation for both independent and supported assessment
    a) during a home visit, or from medical camps or from wellness centers / primary health centers/ any other health establishment
    b) from any community settings or rehabilitation centers
    c) from any prison or any other correctional settings
    d) from custodial institution such as beggar’s homes, orphanages, women’s
    protection homes, children homes and any institution having persons with mental
    illness
    The collaborative telepsychiatry consultation initiated by the healthcare worker can also be part of assessment of persons with mental illness in any community settings or custodial settings under Sec 100, 101, 102, 103 and 104 of the Mental Healthcare Act, 2017 for assisting the law enforcement agencies or persons in-charge of the institution in evaluation of persons with mental illness. Assessment and intervention can also be part of the Section 94 of the Mental Healthcare Act, 2017 outside the mental health establishment.
    A. Role of healthcare worker
    Collaborative telepsychiatry consultation initiated by the healthcare worker shall adhere to the following steps after explaining the risk and benefits of telepsychiatry consultation;
    a) healthcare worker needs to verify the identity of the patient, age, address, email-ID, phone number, any advance directive, nominated representative, appropriate documentation and other details required
    b) healthcare worker should have taken history and examined the patient personally through in-person consult
    c) if the patient requires emergency care, he/she needs to be shifted to mental health establishment
    d) capacity to consent assessment to be attempted
    e) consent of the patient and/or the nominated representative to be taken before
    initiating the telepsychiatry consultation. Further, health care worker will provide health advice, counselling and providing medications, if required.
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    B. Role of Psychiatrist in collaborative telepsychiatry consultation
    a) psychiatrist needs to verify the identity of the patient again
    b) capacity to consent for assessment
    c) obtain the consent to continue for telepsychiatry consultation
    d) assess for the need of emergency care
    e) If no emergency care is required, continue the telepsychiatry consultation as
    depicted in the flowchart below
    Flowchart No-3. Initiation of telepsychiatry consultation by a healthcare worker
    Healthcare worker in a community setting Check for patient’s ID, Age, Address and so forth
    Assess Capacity to Consent for treatment
    Capacity to Consent Present
    Consented for telepsychiatry Refused for telepsychiatry Stop the consultation
    Initiate the telepsychiatry consultation with psychiatrist
    Capacity to Consent absent. Check for advance directive and follow it
    No advance directive. Take consent from the nominated representative
    Initiate the telepsychiatry with psychiatrist & follow the Mental Healthcare Act, 2017 to provide care under Sec 94 or 100 or 101 or 102 or 103 or 104 (whichever is appropriate) or plan for in-person consult or complete the consult
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  1. Prescribing Medications Online in Psychiatry
    Prescribing medications, via telemedicine consultation is at the professional discretion of the psychiatrist but it entails the same professional accountability as in the traditional in-person consult. If a medical condition requires a particular protocol to diagnose and prescribe as in a case of in-person consult, then same prevailing principle will be applicable to a telemedicine consult. For example, before starting Tab Lithium, psychiatrist needs to do renal function test, thyroid function test and serum electrolytes before starting medicines online similar to in- person consult. Psychiatrist should gather adequate and relevant information about the patient’s psychiatric condition and arrive at diagnosis or at least provisional diagnosis before prescribing medicine online. If psychiatrist is unable to arrive at diagnosis or provisional diagnosis, please consider in-person consultation.
    Prescribing medications via telepsychiatry also depends upon certain criteria such as
    a) the type of consultation (first/follow-up consult),
    b) mode of consultation (text/audio/video) and
    c) the categories of the medications list (List-O, A, B & C)
    d) prescribe medications with Generic Name only
    The categories (List O, A, B &C) of medicines that can be prescribed via tele-consultation will
    be as notified in consultation with the Central Government from time to time.
    7.1 List ‘O’ drugs
    Over the Counter (OTC) drugs are those that do not require, by law, a prescription from a doctor to be sold. These medicines can be dispensed by a pharmacist without the need for a prescription. Most OTC drugs are usually categorized into pain relievers (paracetamol), ORS, Vitamins, food supplements, eucalyptus oil, tincture iodine, cough lozenges, anti-allergens, laxatives, vitamins, antacids and so forth. Medicines that may be deemed necessary during public health emergencies such as pandemic or disaster
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    7.2 List ‘A’ drugs
    List A medications are those containing relatively safe medicines with low potential for abuse. These medications can be prescribed during the first/new consult via video consultation only and for tele-follow up consult any mode of consultation is allowed (text/audio/video) for re- filling the medications. Further, List-A are Psychotropic Drugs/Medicines as per sub-section (10) of Section 18 of Mental Healthcare Act, 2017 was notified as per letter F.No. V. 15012 /04 /2019-PH-I dated 16 Aug 2019.
    To prescribe medicines under this List-A, live (synchronous) tele-video consultation is a must for first consult and any mode (text/audio/video) for tele-follow up consult
    Anti-depressants
  2. Imipramine 2. Escitalopram 3. Fluoxetine
    Oral Antipsychotics
  3. Haloperidol 2. Risperidone 3. Olanzapine
    Anti-epileptics
  4. Phenobarbitone
  5. Diphenylhydantoin
    Mood stabilizers
  6. Lithiumcarbonate 2. Carabamazepine 3. SodiumValproate
    Anti-cholinergic drugs
  7. Trihexyphenidyl
    Sedative- Hypnotics /Benzodiazepines
  8. Clonazepam 2. Clobazam
    (Appendix-6, MCI amendment dated 11/04/2020)
    Injectables: – Online Prescription shall be given by a Psychiatrist to a RMP or to a Healthcare worker only through collaborative tele-video consultation
  9. Inj Fluphenazine
  10. Inj Haloperidol
  11. Inj Promethazine
    Caution Note: –
    a) Zolpidem and Lorazepam; although they are under essential drug list of the DMHP but, they fall under the ambit of NDPS act, hence do not prescribe online
    b) Injectable Risperidone and Injectables Olanzapine; needs to be given under the supervision of a psychiatrist only. Avoid prescribing online (telepsychiatry)
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    7.3 List ‘B’ drugs
    The List-B includes ‘add-on’ medications which are used to optimize an existing psychiatric condition. This list is dynamic in nature, depends on central government notification and introduction of new molecules into the market. The medications under List-B can be prescribed in tele follow-up consultation only and it can be in any mode (text/audio/video). Tele-follow up consult means patient is consulting with the same psychiatrist within 6 months of his/her previous in-person consultation and this is for continuation of care of the same health condition. List-B Psychotherapeutics Drugs/Medicines are those excluding List ‘A’ and List ‘C’. Please keep yourself updated on these lists.
    List-B is exhaustive, not restrictive, as follows
    Antipsychotics: Aripiprazole, Quetiapine, Clozapine, Lurasidone, Ziprasidone, Chlorpromazine, Paliperidone, Iloperidone, Amisulpiride, Asenapine, Zuclopenthixol, Flupentixol, Thioridazine, Droperidol, Pimozide, Trifluoperazine, Loxapine, and other antipsychotics
    Anti-depressants: Sertraline, Paroxetine, Desvenlafaxine, Mirtazapine, Citalopram, Vortioxetine, Vilazodone, Duloxetine, Venlafaxine, Doxepine, Clomipramine, Nortriptyline, Bupropion, Trazodone, Nefazodone, Amitriptyline, Fluvoxamine, Reboxetine, Milnacipran, Protriptyline, Maprotiline, Amoxapine, Moclobemide and other antidepressants
    Anti-cravings and Aversive drugs: Disulfiram, Topiramate, Baclofen, Naltrexone, Acamprosate and other anti-craving agents
    Anti-Dementia drugs: Donepezil, Rivastigmine, Memantine, Galantamine and other drugs used in the treatment of Dementia
    Anti-ADHD drugs: Atomoxetine, Clonidine, Modafinil and other drugs
    Mood Stabilizers: Oxcarbazepine, Lamotrigine, Divalproex sodium and other drugs Beta-blocker: Propranolol
    Anti-anxiety drugs: Buspirone & Pregabalin
    Injectables: – Online Prescription shall be given by a Psychiatrist to a RMP or to a Healthcare worker after collaborative telemedicine consultation – Zuclopenthixol, Flupentixol, Paliperidone and Aripiprazole
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    7.4 List ‘C’ drugs (Prohibited for Online Prescribing)
    These are the Psychotherapeutics Drugs/Medicines which are Prohibited to be prescribed during telepsychiatry consultation. They are as follows
    a) Schedule X of Drug and Cosmetic Act, 1940 and Rules, 1945
    b) Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic
    Substances Act, 1985 (Such as:- Methadone, Buprenorphine, Ketamine, Morphine, Tramadol, Codeine, Benzodiazepines, Zolpidem and so forth)
    7.5 Online Prescription
    Telemedicine Practice Guidelines-2020 empowers registered medical practitioners to prescribe medicines online. Psychiatrist need to follow the prescription guidelines as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 (Amended on 2016) for a) issuing the prescription online (format see appendix-5) and b) prescribe drugs with generic names, legibly and preferably in capital letters and he/she shall ensure that there are a rational prescription and use of drugs.
    Confidentiality: Psychiatrist also needs to abide Sec 23 of the Mental Healthcare Act, 2017 (Right to Confidentiality) – Psychiatrist may consider writing ICD or DSM code of a particular diagnosis/provisional diagnosis on the prescription. Psychiatrist shall use his/her professional judgment in documenting sensitive information or symptoms or signs on the prescription. Psychiatrist shall take explicit consent from the patient a) before transmitting the prescription directly to a pharmacy and b) to get the medicines dispensed from a pharmacy to the patient directly. In both the situation, patient has the right for prescription.
    Transmitting: Psychiatrist may take the written/printed prescription in the form of a) photo or b) scanned document or c) digital copy of a signed prescription or d) e-Prescription. Psychiatrist can transmit the prescription via email or any messaging platform.
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    Dispensing Medicine: Issue of online dispensing of drugs by the psychiatrist themselves is a contentious issue from ethical and legal perspective. Please do not involve in online dispensing or selling medicines to your patients. Psychiatrist–patient relationships are of trust and confidence, where the fiduciary (psychiatrist) must act in the interests of the beneficiary (patient). Psychiatrist should refrain from selling and couriering medicine to his/her patients.
    7 Tele-therapy/ Tele-psychotherapy/Tele-counselling
    A psychiatrist is entitled to provide teletherapy to patients from any part of India. Irrespective of the tool of communication text/audio/video) used, the core principles of tele-therapy /tele- psychotherapy/ tele-counselling practice remain the same. Tele-therapy entails the same professional accountability, ethical standards and laws applicable as in the traditional in- person therapy. Teletherapy has its own set of limitations, hence following set of guidelines
    to be adhered;
    needs
    a) A detailed in-person psychiatric assessment needs to be carried out before initiating
    tele-therapy.
    b) Tele-therapy can be conducted concurrently with psychiatric consultation for
    prescribing medicines or sequentially after consultation by a same or different
    psychiatrist.
    c) Providing tele-therapy without an appropriate diagnosis/ provisional diagnosis needs
    to be avoided.
    d) Suitability of patient for online therapeutic alliance to be taken into account before
    considering and also during tele-therapy.
    e) Thepsychiatristneedstoquicklyassesstheneedforemergencycareservicesbefore
    starting each session. In all cases of emergency care or crisis related therapy, the patient must be advised for an in-person interaction with a psychiatrist or any registered medical practitioner at the earliest.
    f) Depending upon the patient’s psychiatric and mental status condition, Psychiatrist needs to decide, if a family member/s to be allowed during the teletherapy sessions or not.
    g) Psychiatrist providing teletherapy shall uphold the same professional standards, ethical norms and laws as applicable to traditional in-person therapy
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    h) Please do maintain professionalism with regard to appointment, dressing, duration, timings of the therapy and privacy during the teletherapy sessions
    i) The Psychiatrist should exercise their professional judgment to decide whether a teletherapy consultation is appropriate in a given situation or an in-person therapy is needed or referred or stopped completely in the interest of the patient.
    j) All communications (such as electronic and non-electronic, therapeutic and non- therapeutic, synchronous and asynchronous) between psychiatrist and patient shall be documented and filed in the patients’ medical record, similar to traditional record- keeping policies and procedures. The psychiatrist will document the basic medical record therapy notes as per the Mental Healthcare Act, 2017, Sec 25 (Appendix-3)
    k) The psychiatrist can choose not to proceed with the tele-therapy consultation at any time. At any step, the psychiatrist may refer or request for an in-person therapy consultation.
    l) At any stage, the patient has the right to choose to discontinue the tele-therapy consultation.
    m) Informed consent should be administered to all patients either in-person or during tele- therapy session (Appendix-3)
    8.1 Fee for Telepsychiatry Consultation and/or Tele-therapy
    Tele-psychiatry consultations and/or tele-therapy should be treated the same way as in- person consultations from a fee perspective. Psychiatrist may charge an appropriate fee for the tele-psychiatry consultations and/or tele-therapy provided, however a receipt/invoice for the fee charged for providing telepsychiatry consultation and/or teletherapy shall be issued
    27|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-1
    (An optional proforma)
    New Consult proforma to be filled by the Patient and Patient’s family member / nominated representative or by the treating psychiatrist
    28|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-1
    New Consult Proforma
    Proforma complies with MHCA, 2017 Sec 25 and the Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018 Rule 6(3), Form B.
    Name………………………………………….. …………….ID card No……………………………..Date….. Father’s/Mother’s Name ……………………………………………………………………………………… Age……………………. Gender……………………………………………………………………………….. Advance Directive (Yes/No)…………………………………………………………………………………… Address ……. ……………………………………………….. ………………………………………………… ……. ……………………………………………….. ……………………………………………….. …………. Patient’s phone number…………………………………Email Id…………………………………………… Alternate phone number……. ……………………………………………………………………………….. Height……………………….Weight…………………………..LMP (if applicable)…………………. Location of Patient during the Consultation (address)……………………………………………. ………………………………………………………………………………………………………………….
  12. Reason for consultation/ symptoms and duration
    1………………………………………duration…….2……………………………………… duration …. 3……………………………………… duration ……4………………………………………. duration…. 5……………………………………… duration ……6……………………………………… duration…..
  13. Please do explain the symptoms below (if required please add additional paper) –
  14. Any stress (please explain):-
    29|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  15. Please do mark, if there are any injuries/pain/symptoms to help the doctor understand and localize your problems on the diagram below (if required please add more pages for describing your problems/symptoms)
  16. Past history and treatment history: (Please do send past treatment slips)
  17. Any present medical illness and on treatment: (Such as diabetes, hypertension, thyroid problem and so forth)
  18. Marital/Family Conflict: (Elaborate)
    30|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  19. Legal conflict/issues (police case/FIR/Civil case/job related) :
    please elaborate
  20. Any consumption of alcohol, tobacco, drugs etc ……………………

10. Any allergy to medicines …………………………………………………..

To be filled by Psychiatrist Clinical findings:
Provisional Diagnosis ………………………………………… Treatment Advised and Follow-up recommendation
31|Page NIMHANS, IPS& TSI- 2020

TELEPSYCHIATRY OPERATIONAL GUIDELINES
Consent Form
Yes, I consent to avail consultation via telemedicine. I know the potential risks, consequences and benefits of telepsychiatry consultation. I will ask doctor or pharmacist, if I do not understand any of the information provided in the prescription. I will stop prescribed medicines in case of any adverse reaction/side effects. I will contact the psychiatrist immediately or go to the nearest registered medical practitioner for in-person consult
Note:

  1. Filling this proforma will facilitate
    a) To understand what information and history is required for effective consultation. Adequate and reliable information that is required for arriving at a provisional /definitive diagnosis.
    b) Arriving at diagnosis and planning treatment management
    c) Psychiatrist to effectively spend time with the patient during consultation rather than documentation
    during the consultation.
    d) Please do remember that online consultation time is fixed per session. The average online
    consultation time is approximately 10 to 15 minutes, which is similar to in-person consultation time.
    e) Filling this proforma by patient/family members is optional
    f) This proforma will be retained in the patient’s file in the hospital along with a copy of all the
    investigations and a copy of the prescription
  2. Information to the patient and patient’s family members
    g) Presence of patient is advisable during the telemedicine consultation. This is as per the Telemedicine Practice Guidelines-2020 and Mental Healthcare Act, 2017
    h) If the patient is not willing to come for telepsychiatry consultation, please follow Mental Healthcare Act, 2017 and request for in-person consult or home visit by the mental health care professionals for Mental Capacity Assessment (please, check if home psychiatric service is available)
    i) The Telemedicine Practice Guidelines have stated (Code 4.1.1.2) that the patient / patient’s family member will be responsible for the accuracy of the information shared with the doctor.
    Please read Telemedicine Practice Guidelines available online from MoHFW, New Delhi. (Available online at https://www.mohfw.gov.in/pdf/Telemedicine.pdf)
    j) If symptoms are severe and/or severe side effects of medicines and/or emergency care is required, please do not wait for telemedicine consultation appointment. Please do in-person consultation at the nearest psychiatrist or registered medical practitioner at the earliest
    k) Neither of the party (patient/patient’s party or psychiatrist) will not do audio or video recording, without prior explicit consent. Covert recordings (audio or video) are illegal since everyone being recorded must consent to be recorded. Explicit consent is must from all the parties.
    Patient’s Signature:……………………………………………. Date:………………………
    Family member’s Signature ………………………………………Date……………………. (if applicable)
    .
    32|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-2
    (An optional proforma)
    Follow-up Consult proforma to be filled by the Patient and Patient’s family member / nominated representative or by the treating Psychiatrist
    33|Page
    NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-2
    Follow-up consult Proforma
    Proforma complies with MHCA, 2017 Sec 25 and the Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018 Rule 6(3), Form B.
    Hospital No/MRD No of in-person consult ……………………………………………….. Name………………………………….. …………….ID card No……………………………..Date……….. Father’s/Mother’s Name ………………………………………………………………………………………
    Age……………………. Gender……………………………………………………………………………….. Advance Directive (Yes/No)…………………………………………………………………………………… Address ……. ……………………………………………….. ………………………………………………… ……. ……………………………………………….. ……………………………………………….. …………. Patient’s phone number…………………………………Email Id…………………………………………… Alternate phone number……. ……………………………………………………………………………….. Height……………………….Weight…………………………..LMP (if applicable)…………………………. Last In-person (face-to-face) visit date……………………………………
    Location of Patient during the Consultation …………………………………………………….
  3. Compared to how you were during the previous consultation, how much improvement do you currently find in you? Please mark the percentage of improvement on the scale below
    0% I——————20%—————40%———I——–60%—————80%——————–I 100%
    No improvement Completely improved
  4. How many times have you missed taking your medicine since previous consultation?
  5. Have you experienced any side-effects due to medication?
    34|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  6. Symptoms and duration 1………………………………………duration…….2…………………………………… duration ….
    3……………………………………… duration ……4………………………………….. duration….
    5……………………………………… duration ……6………………………………….. duration….
    Please do explain the symptoms below (if required please add additional paper) –
    Please do mark, if there are any injuries/pain/symptoms to help the doctor understand and localize your problems on the diagram below (if required please add more pages for describing your problems/symptoms)
  7. Any medical illness and treatment history: (Such as diabetes, hypertension, thyroid problem and so forth)
  8. Marital/Family Conflict: (please elaborate)
    35|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  9. Legal conflict/issues (police case/FIR/Civil case/job related) requiring certificate: (please elaborate)
  10. Any consumption of alcohol, tobacco, drugs etc

9. Any other information

To be filled by Psychiatrist Clinical Findings:
Provisional Diagnosis ………………………………………… Treatment Advised and Follow-up recommendation
Psychiatrist Signature ……………………………..Date…………………..Time………………….
(If the patient develops signs and symptoms from non-psychiatry specialty during follow-up consult, please do refer him/her to the respective specialist (as a first consult) explaining the need for such consultation similar to in-person consult. Please continue to treat, if the patient has new symptoms in psychiatry specialty)
36|Page NIMHANS, IPS& TSI- 2020

TELEPSYCHIATRY OPERATIONAL GUIDELINES
Consent Form
Yes, I consent to avail consultation via telemedicine. I know the potential risks, consequences and benefits of telepsychiatry consultation. I will ask doctor or pharmacist, if I do not understand any of the information provided in the prescription. I will stop prescribed medicines in case of any adverse reaction/side effects, I will contact the psychiatrist immediately or go to the nearest registered medical practitioner for in-person consult
Note:

  1. Filling this proforma will facilitate
    a) To understand what information and history is required for effective consultation. Adequate and reliable information that is required for arriving at a provisional /definitive diagnosis.
    b) Arriving at diagnosis and planning treatment management
    c) Psychiatrist to effectively spend time with the patient during consultation rather than documentation
    during the consultation.
    d) Please do remember that online consultation time is fixed per session. The average online
    consultation time is approximately 10 to 15 minutes, which is similar to in-person consultation time.
    e) Filling this proforma by patient/family members is optional
    f) This proforma will be retained in the patient’s file in the hospital along with a copy of all the
    investigations and a copy of the prescription
  2. Information to the patient and patient’s family members
    g) Presence of patient is advisable during the telemedicine consultation. This is as per the Telemedicine Practice Guidelines-2020 and Mental Healthcare Act, 2017
    h) If the patient is not willing to come for telepsychiatry consultation, please follow Mental Healthcare Act, 2017 and request for in-person consult or home visit by the mental health care professionals for Mental Capacity Assessment (please, check if home psychiatric service is available)
    i) The Telemedicine Practice Guidelines have stated (Code 4.1.1.2) that the patient / patient’s family member will be responsible for the accuracy of the information shared with the doctor.
    Please read Telemedicine Practice Guidelines available online from MoHFW, New Delhi. (Available online at https://www.mohfw.gov.in/pdf/Telemedicine.pdf)
    j) If symptoms are severe and/or severe side effects of medicines and/or emergency care is required, please do not wait for telemedicine consultation appointment. Please do in-person consultation at the nearest psychiatrist or registered medical practitioner at the earliest
    k) Neither of the party (patient/patient’s party or psychiatrist) will not do audio or video recording, without prior explicit consent. Covert recordings (audio or video) are illegal since everyone being recorded must consent to be recorded. Explicit consent is must from all the parties.
    Patient’s Signature:……………………………………………. Date:………………………
    Family member’s Signature ……………………………………Date…………………….. (if applicable)
    37|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-3
    Minimum Basic Standard Guidelines for Documentation of Tele- therapy/ Tele-counselling. This proforma needs to be filled by the consulting psychiatrist and will be filed in the patient’s medical record
    38|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-3
    Therapy/Counselling Reporting Form
    Patient’s name:……………………………………………………………………Age:…………………….. Patient’s Verification ID………………………………………………………………………………………. Gender:……………………….. Date…………………. Time…………………….. Duration of session:………………………………………………………………………………………….. Psychiatric diagnosis………………………………………………………………………………………… Session number:…………………………………………..Session participants:………………………… …………………………………………………………………………………………………………………. Therapy method: Individual/Family/Couple/Group Therapy
    Objectives of the session: 1.
    2.
    3.
    Key issues/themes discussed: (Psychosocial stressors/Interpersonal problems/Intrapsychic conflicts/Crisis situations/Conduct difficulties/Behavioural difficulties/ Emotional difficulties/ Developmental difficulties/ Adjustment issues/ Addictive behaviours/Others)
    Therapy techniques used:……………………………………………………………………………………
    Therapist observations and reflections: …………………………………………………………………….. (if required additional sheets can be added)
    Plan for next session:
    Date for next session:
    Psychiatrist’s Name:……………………………Signature……………………….. Reg No………………………. Date:…………………………….
    (As per the Mental Healthcare Act, 2017, Sec 25 specifies that all persons with mental illness shall have the right to access their basic medical records and it is prescribed in the Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018 Rule 6(3), Form B)
    39|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Consent Form
    Yes, I consent to avail tele-therapy via telemedicine. I know the potential risks, consequences and benefits of tele-therapy.
    Note:
    a) I understand that “teletherapy” includes consultation, treatment, health education and therapy. The modes utilized can be text (emails, messages), audio (telephone conversations) and video (conferencing).
    b) The ethics and laws that protect the confidentiality of medical information also apply to information shared during teletherapy.
    c) Presence of patient is highly advisable during the tele-therapy. This is as per the Telemedicine Practice Guidelines-2020 and Mental Healthcare Act, 2017
    d) I accept that teletherapy does not provide emergency services. If symptoms worsen or become severe and/or side effects of the medication and/or emergency care is required, I will proceed to the nearest hospital emergency room for in-person consultation
    e) The session reporting proforma will be kept in my file at the institute/hospital/clinic
    f) Neither of the party (patient or psychiatrist) will not do audio or video recording, without prior
    explicit consent
    g) The Telemedicine Practice Guidelines have stated (Code 4.1.1.2) that the patient will be
    responsible for the accuracy of the information shared with the doctor
    h) Homework assignment and compliance is an integral part of the teletherapy and I will do my
    best to adhere to it
    Patient’s Signature:……………………………………………. Date:…………………
    Family member’s Signature ……………………………………Date……………….. (if applicable)
    40|Page
    NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-4
    Formal Authorization Letter to Represent for Telepsychiatry Consultation
    41|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-4
    Formal authorization letter for representation
    I Mr/Ms/Mrs__________________________ S/o__________________________________ would like to state that, I have understood the information provided regarding telemedicine. I hereby give my informed consent for the use of telepsychiatry consultation in my mental health care. At present, I am located at ____________________________
    I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
    I hereby authorize Mr/Ms/Mrs________________________S/o _ _and related to me as _____________________________ (relationship) to represent me. He/she will represent and participate in my mental healthcare through telemedicine in the course of my diagnosis and treatment. I understand and accept that there are risks and benefits in assigning a representative for my mental healthcare.
    Signature of patient’s Representative ___________ Date: _
    Signature of patient___________________________________
    Date: __
    42|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-5
    Telepsychiatry Prescription
    (Psychiatrist will keep a copy of the prescription in the patient’s file at the institute/hospital/clinic)
    43|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Hospital / Clinic Name
    Name:…………………………………………………………………………………………Age:…………Gender:…………. Father/Mother’s Name…………………………………………………………………..Patient ID…………………………… Address:………………………………………………………………………………………………………………………………. Date……………….Time…………….Duration of Consultation…………………..mode of consult……………………… Teleconsulting Mobile No…………………………………………………Email ID…………………………………………..
    Ht:………….Wt:…………LMP:………..
    Registered Medical Practitioner’s Name……………………………………………………………………………….
    Qualification……………………………………………………………………. Reg No………………………………. Address……………………………………………………………………………………………………………………. Mobile No…………………………………………………………….Email ID………………………………………..
    Chief Complaints:
    Relevant Points from History:
    Examination/Lab Findings:
    Suggested Investigations:
    Diagnosis/Provisional Diagnosis:
    (Please consider using ICD or DSM code, to maintain the confidentiality of the diagnosis)
    a) Name of the Medicine in Capital Letter (Generic Name) dose, frequency & duration
    b) Name of the Medicine in Capital Letter (Generic Name) dose, frequency & duration
    Special Instructions
    This Prescription is generated on a telemedicine consultation RMP Signature and Stamp
    44|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-6
    The Board of Governors in Supersession of MCI Modification in Medicine List in Telemedicine Practice Guidelines
    45|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    Appendix-6
    46|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
    References
  3. Medical Council of India. Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. 25th March 2020. Available at https://www.mciindia.org/CMS/wp- content/uploads/2019/10/Public_Notice_for_TMG_Website_Notice-merged.pdf Accessed on 5th May 2020
  4. Medical Council of India. Frequently Asked Questions [FAQs] on Telemedicine Practice Guidelines. April 2020. Available at https://mciindia.org/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNew s/Final_FAQ-TELEMEDICINE%20%206-4-2020..pdf Accessed on 5th May 2020
  5. Medical Council of India. Modification in medicine list in Telemedicine Practice Guidelines. Public Notice Circular No: MCO-211(2)/2019(Ethics)/201874 dated 11.04.2020 https://www.mohfw.gov.in/pdf/ModificationinMedicineListinTelemedicinePracticeGuidelines.p df Accessed on 5th May 2020
  6. Mental Health Care Act, 2017. Published by Ministry of law and Justice. Government of India. 7th April 2017. Available at http://egazette.nic.in/WriteReadData/2017/175248.pdf Accessed on 5th May 2020
  7. Mental healthcare (State Mental Health Authority) Rules, 2018. Published by Ministry of Health and Family Welfare, Government of India. 29th May 2018. Available at https://www.latestlaws.com/wp-content/uploads/2019/03/Mental-Healthcare-State-Mental- Health-Authority-Rules-2018.pdf Accessed on 5th May 2020
  8. Medical Council of India. Code of Medical Ethics Regulation, 2002. Available at https://www.mciindia.org/CMS/wp-content/uploads/2017/10/Ethics-Regulations-2002.pdf Accessed on 5th May 2020.
  9. Math SB, Manjunatha N, Kumar CN, Gowda GS, Philip S, Enara A, Gowda M. Sale of medicines by Registered Medical Practitioners at their clinics: Legal and ethical issues. Indian J Psychiatry. 2019 Apr;61(Suppl 4):S786-S790.
  10. Gowda GS, Kulkarni K, Bagewadi V, Rps S, Manjunatha BR, Shashidhara HN, Basavaraju V, Manjunatha N, Moirangthem S, Kumar CN, Math SB. A study on collaborative telepsychiatric consultations to outpatients of district hospitals of Karnataka, India. Asian J Psychiatr. 2018 Oct;37:161-166.
  11. Manjunatha N, Agarwal PP, Shashidhara HN, Palakode M, Raj EA, Mary Kapanee AR, Nattala P, Kumar CN, Sudhir P, Thirthalli J, Bharath S, Sekar K, Varghese M. First 2 Years of Experience of “Residential Care” at “Sakalawara Rehabilitation Services,” National Institute of Mental Health and Neurosciences, Bengaluru, India. Indian J Psychol Med. 2017 Nov- Dec;39(6):750-755.
  12. Gowda GS, Kulkarni K, Bagewadi V, RPS S, Manjunatha BR, Shashidhara HN, Basavaraju V, Manjunatha N, Moirangthem S, Kumar CN, Math SB.A study on collaborative telepsychiatric consultations to outpatients of district hospitals of Karnataka, India. Asian J Psychiatr. 2018 Oct;37:161-166.
    47|Page NIMHANS, IPS& TSI- 2020 TELEPSYCHIATRY OPERATIONAL GUIDELINES
  13. Kulkarni K, Shyam RPS, Bagewadi VI, Gowda GS, Manjunatha BR, Shashidhara HN, Basavaraju V, Manjunatha N, Moirangthem S, Kumar CN, Math SB. A study of collaborative tele-psychiatric consultations for a rehabilitation centre managed by an Indian public primary health centre. Indian Journal of Medical Research (Press)
  14. Das S, Manjunatha N, Kumar CN, Math SB, Thirthalli J. Tele-psychiatric after care clinic for the continuity of care: A pilot study from an academic hospital. Asian J Psychiatr. 2020 Feb;48:101886. doi: 10.1016/j.ajp.2019.101886. Epub 2019 Nov 23.
  15. Malathesh BC, Gowda GS, Kumar CN, Narayana M, Math SB. Response to: Rethinking online mental health services in China during the COVID-19 epidemic. Asian J Psychiatr. 2020 Apr 17;51:102105. doi: 10.1016/j.ajp.2020.102105. [Epub ahead of print]
  16. Manjunatha N, Kumar CN, Math SB. Coronavirus disease 2019 pandemic: Time to optimize the potential of telepsychiatric aftercare clinic to ensure the continuity of care. Indian J Psychiatry 2020; 62:320-321
  17. Math SB, Nagendrappa S, Mukku SSR, Harshitha NR, Manjunatha N, Kumar CN, Sivakumar PT, Thirthalli J. Video consultations from an Indian academic hospital: First 3 years of experiences from Telepsychiatric After Care Clinic. National Medical Journal of India. (press)
  18. Manjunatha N, Kumar CN, Math SB. Virtual Physical Examination in Video Consultations: A valid inspection component of physical examination? National Medical Journal of India (Press)
  19. Agarwal PP, Manjunatha N, Gowda GS, Kumar MNG, Shanthaveeranna N, Kumar CN, Math SB.Collaborative Tele-Neuropsychiatry Consultation Services for Patients in Central Prisons. J Neurosci Rural Pract. 2019 Jan-Mar;10(1):101-105.
  20. Mukku SSR, Manjunatha N, Kumar CN, Sivakumar PT, Math SB. A Video based Tele After Care Clinic: An Early Experiences from an Indian geriatric psychiatry service. Indian Journal of Psychiatry (press)
  21. Math SB, Gowda GS, Basavaraju V, Manjunatha N, Kumar CN, Enara A, Gowda M, Thirthalli J. Cost estimation for the implementation of the Mental Healthcare Act 2017.Indian J Psychiatry. 2019 Apr;61(Suppl 4):S650-S659.
    20.American Telemedicine Association. Practice guidelines for videoconferencing-based telemental health. Available at https://www.e-psychiatry.com/pro/practice-guidelines-for- videoconferencing-based-telemental-health.pdf Accessed on 5th May 2020
  22. The American Psychiatric Association & The American Telemedicine Association. Best Practices in Videoconferencing-Based Telemental Health, April 2018. Available at https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Telepsychiatry/APA-ATA- Best-Practices-in-Videoconferencing-Based-Telemental-Health.pdf Accessed on 5th May 2020
    48|Page NIMHANS, IPS& TSI- 2020 Every challenge is an opportunity in disguise. Telemedicine presents an enormous opportunity to take mental healthcare to the doorsteps. Telemedicine is going to be a Paradigm shift in India’s healthcare system. Telemedicine is not a Doctor versus Technology saga; it’s in fact, Doctor with Technological synergy to reach the unreached. Telemedicine is not an alternative; it is a healthcare destination. It is all about “Right to Access Healthcare”. Resilience is to utilize all this information and digital technology innovation to provide quality care to our patients.
    NIMHANS Publication No. 170

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