TELEMEDICINE AT NIMHANS

INTRODUCTION TO TELEMEDICINE

The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities. In simple words, telemedicine facilitates the provision of medical aid from a distance. It is an effective solution for providing specialty healthcare in the form of improved access and reduced cost to the rural patients and the reduced professional isolation of the rural doctors. Telemedicine can enable ordinary primary care doctors to perform the function of specialist doctor’s tasks under the supervision of the specialist through telemedicine.

Telemedicine is an effective interface between Information Technology and Medical Science. The Telemedicine system consists of simple hardware and software at both the Patient and Specialist doctor ends with some of the Diagnostic Equipments like ECG, X-ray and pathology Microscope/Camera provided at the patient end.

They are connected through a Very Small Aperture Terminal (VSAT) system and controlled by the Network Hub Station of ISRO. The patient data, medical images and other information pertaining to the patients can be sent to the specialist doctors, either in      advance or on a real time basis through the satellite link in the form of Digital Data Packets. These packets are received at the specialist centre, the images and other information  is reconstructed so that the specialist doctor can study the data, perform diagnosis, interact with the patient and suggest the appropriate treatment during a Video Conference with the patient end. Telemedicine facility thus enables the specialist doctor and the patient separated by thousands of kilometers to see visually and talk to each other. This enables the specialist doctor to assess the physical and psychological state of the patient and suggest treatment.

ADVANTAGE OF TELEMEDICINE

One of the major advantages of Telemedicine technology has been

a) saving money

b)saving time and

c) effort to the rural patients, as they are not required to travel long distances for obtaining consultation and treatment.

d) specialist consultation

APPLICATION OF TELEMEDICINE

Application of telemedicine is much more valuable in case of

  1. emergency, when time is a critical factor in the outcome of the diseases
  2. during disaster situation, a specialist can provide his services through telemedicine in disaster affected area
  3. post operation (Post Surgery) follow up since the patient is not required to travel unnecessarily and hence saving money and time.
  4. providing training for primary health doctors
  5. monitoring national health programs
  6. providing medical care in custodial settings such as prison, juvenile home, rehabilitation centers etc.

In this way, the systematic application of Information and Communication Technologies to the practice of healthcare has changed the medical practice and training.

NIMHANS TELEMEDICINE

The Indian Space Research Organisation (ISRO) has implemented the Karnataka Telemedicine Project, to bring multi-specialty healthcare, to a significant section of the rural population of the state of Karnataka, India. Technology wise, this network would be state-of-the-art and unique. This network would also serve as a model for the utilization of “Healthsat” proposed for launch in the future. 

In this phase the state-of-the-art “Server/Browser-based, Multi-point-to-Multi-point” type of Telemedicine System/Network (provided by TeleVital) is put into operation. This Multi-Specialty Network has a network consisting of a pool of specialty hospitals. Under this network specialty hospital for Psychiatry, Neurology, Neuro-surgery, Cardiology, Oncology, Gynaecology, Nephrology, etc provides telemedicine service to various district hospital across Karnataka.

This new era of consultation was initiated by Indian Space Research Organisation (ISRO) in the form of a Telemedicine Pilot Project in the year 2001. Later, National Institute of Mental Health Sciences (NIMHANS), Bangalore also adopted this novel initiative in 2005 to provide for the rural patients through tele-consultation.

This collaboration between National Institute of Mental Health Sciences (NIMHANS), Bangalore and Indian Space Research Organisation (ISRO) has successfully linked many hospitals across India and almost all District hospitals across Karnataka to provide tele-consultation. Thus, connectivity between non-specialist doctor at remote end (District Hospital) and the specialist doctors at NIMHANS centers has been effectively established.

Types of telemedicine consultation from technical aspects

Asynchronous teleconsultation (store and forward) – in which Specialist and Client center work independently; physician ordering consultation prepares patient’s medical test results and after interpreting them, forwards them to a specialist. At this stage, it is possible to arrive at an initial diagnosis with the request for its verification. After receiving test results, specialist makes a diagnosis, which is forwarded, to the physician who requested it. Electronic mail seems to be the most appropriate way of conducting teleconsultation in this case.

Synchronous teleconsultations (live/real time tele-video conference) – in which Specialist and Client center communicate simultaneously in a joint session using video-conference. Synchronous ones significantly improve the quality of consultation: depending on the capabilities of the system, participants may use voice calls, chat, video call or interactive pointer which may point to significant areas of interest.

NIMHANS telemedicine is using both Asynchronous tele-consultation (store and forward) and Synchronous tele-consultations (live/real time tele-video conference).

Types Of Tele Consultations From Personnel Involved

Tele consultation can occur between

i. two doctors (primary care doctor and specialist at the tertiary care)

ii. doctor and a para-medical personnel, (between a specialist and para-medical staff such as nurse, pharmacist, care-giver etc)

iii.  doctor and a patient

iv. NIMHANS, tele-consultation is between two doctors (i.e. primary care doctor and specialist at the tertiary care).

Beneficiary of the tele-consultation

Tele-consultation is method in which a specialist assisting the primary care physician/ district hospital doctor in rendering a diagnosis, treatment and rehabilitation. This service is available only for government institute/hospitals. This may involve the use of live interactive video or the use of store and forward transmission of diagnostic images, vital signs and/or video clips along with patient data for later review.

NIMHANS  tele-consultation is between two doctors, in which NIMHANS specialist assisting the primary care physician/ district hospital doctor in rendering a diagnosis, treatment and rehabilitation.

To be specific, patients who are getting benefit from tele-consultation are

  1. Patients visiting District Hospital (Government) in Karnataka
  2. Regional Rehabilitation Center, Bangalore
  3. Bangalore Central Prison patients, Bangalore
This technology is leveraged to provide mental health and neurological care. The main aim is to reach the unreached.  

Telemedicine Practice Guidelines -2020

The Indian Government has published Telemedicine Practice Guidelines on March 25, 2020. These guidelines finally clarify India’s position on the legality of teleconsultation. It is now perfectly legal to provide teleconsultation by registered medical practitioners in line with the requirements of the Telemedicine Guidelines.

The Board of Governors (BoG) issued guidelines, outlining that telemedicine provides safety of patients, as well as health workers safety especially in situations where there is risk of contagious infections and it can be conducted without exposing staff to viruses or infections in the times of such outbreaks. The BoG has taken over the powers and functions of the MCI pending passage of the National Medical Commission Bill that seeks to replace the council with a freshly constituted regulatory body.

Telepsychiatry Operational Guidelines -2020

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 Disabilities Act 2016, Narcotic Drugs and Psychotropic Substances Act 1985, Drugs and Cosmetics Act, 1940 and Information and Technology Act 2000.

Telemedicine Society of India & Indian Psychiatric Society in association with National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru (an institution of National importance), undertook this effort to bring in the Telepsychiatry Operational Guidelines. 

Clinical Schedules for Primary Care Psychiatry: Version 2.3 (COVID-19)

This schedule is prepared for the clinical use of Primary Care Physicians (PCPs) to screen during this Corona Virus outbreak and aftermath of the outbreak.

This contains guidelines for screening, referral, early diagnosis, first line treatment and routine follow-up of an ADULT patients with psychiatric disorders at routine OUT-PATIENT primary health care or GPs clinics. 

The contents of this schedules are an adopted version of psychiatric classification, diagnostic criterias, & treatment guidelines for wider utilization by GPs of India.

Click for downloading the CSP

CSP 2.3 (COVID-19) (May 2020)

Guidelines for Tele - Psychiatric Social Work Practice

In the modern era, technology has brought changes in Psychiatric Social Work practice and has greatly expanded Psychiatric Social Workers’ ability to assist people in need. The use of technological tools in Psychiatric Social Work practice may be offered stand-alone or in conjunction with in-person Psychiatric Social Work services. Contemporary Psychiatric Social Workers can provide services to individual clients, groups, and communities by using online/telephonic/video/self-guided web-based services. Psychiatric Social Work Practice using telecommunication technology includes the use of email, text messaging, video conferencing, online chat, or internet phone calls. The following standards are provided for five main Psychiatric Social Work services, which are: (1) Working with individuals, (2) Working with families, (3) Working with groups, (4) Crisis management and (5) Working with communities. Each practice standard provides Psychiatric Social Workers with general guidance on how to use technological tools ethically and maintain the professional boundary. The standards and their interpretations are intended to set a minimum score of excellence for professional practice when psychiatric social workers use technology and to provide a framework to address possible benefits, challenges, and risks that arise when using these tools.


Guidelines for Tele-psychotherapy Services for Clinical Psychologists - 2020

The COVID-19 pandemic has resulted in disruption of continued psychological services for our clients and as a barrier for persons seeking to engage with professional psychotherapy services. In this context, the Department of Clinical Psychology at NIMHANS, has taken the initiative to formulate Guidelines for Tele-psychotherapy Services, with sample consent forms, to be use by qualified clinical psychologists, as recognized by the Rehabilitation Council of India (RCI) and the Mental Health Care Act, 2017. 

These guidelines aim to standardization of competent and ethical tele-psychotherapy services in our country to benefit clients in need, while safeguarding their interests. Version 1.0 of these guidelines were formulated after referring to a range of national and international practice guidelines for tele-psychology and tele-psychiatry. The contextual realities of the practice of psychotherapy in India have been considered in the preparation of these guidelines. The draft version of the guidelines was reviewed by faculty members in the Department of Clinical Psychology, and subsequently by a panel of senior Clinical Psychology professionals including former heads and psychotherapy coordinators from the department, the President of the Indian Association of Clinical Psychologists (IACP), as well as the Head of Telemedicine at NIMHANS