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|Year : 2019
: 61 | Issue : 10 | Page
|The dawn of eMental health professional
Mohan Sunil Kumar1, Sharmitha Krishnamurthy2, Mahesh R Gowda3, Nitya Dhruve1
1 Clinical Division, Augmenta Health (P) Ltd., Bengaluru, Karnataka, India
2 Division of Public Health, Augmenta Health (P) Ltd., Bengaluru, Karnataka, India
3 Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
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|Date of Web Publication||8-Apr-2019|
| Abstract|| |
The widespread reach and ease of use make technology a handy tool for today's practicing mental health professional (MHP), especially in light of the Mental Healthcare Act (MHCA) 2017, the essence of which safeguards the rights of patients while squarely placing the onus on MHPs. In order to keep up with the changing times, it is imperative for the MHP to be aware of the potential of technology to not only aid delivery but also ease the burden of care while being MHCA-compliant. In addition, the article calls for a more proactive role of the MHP in driving change in terms of leveraging technology in mental health settings. It looks at how certain tools can be incorporated across a range of scenarios right from wellness applications and facilitating medical adherence to aiding crisis intervention and extending quality care services in remotes areas. The article briefly outlines a framework involving various stakeholders at different levels as well as the channels in which the technology can be leveraged while keeping the patients' rights front and center. The potential barriers that an “e-ready” MHP can expect and directions for moving ahead are discussed, keeping a critical eye on the lacunae in using technology.
Keywords: Digital age mental health care framework, e-mental health, eMental health professional, Mental Healthcare Act 2017
|How to cite this article:|
Kumar MS, Krishnamurthy S, Gowda MR, Dhruve N. The dawn of eMental health professional. Indian J Psychiatry 2019;61, Suppl S4:730-4
| Introduction|| |
Technology has swamped every aspect of human life; healthcare is by no means an exception. Health care in general and mental health care in specific is complex, often involving a nexus of stakeholders. With no room to err, there is an absolute need for robust technological systems to assist in delivering optimal quality health care. The availability of high-speed 5G networks and cost-effective hand-held digital devices offset the challenge of rapidly increasing high patient volumes, making it imperative for smart use of technology. Technology and its applications are becoming a ubiquitous component of mental care system. As with the frequently used adage, “old wine in a new bottle,” combining the traditional psychotherapeutic modalities with the technological innovations of the 21st century will enhance both the quality and reach of the services rendered alongside professional excellence and personal satisfaction.
In India, the MHCA 2017 was passed on April 07, 2017 and came into force from May 29, 2018 to ensure that the autonomy and rights of those diagnosed with mental illnesses are respected and that they remain protected against any form of discrimination and receive high-quality treatment and care delivered through responsive healthcare services. This, in effect, for the treating mental health professionals (MHP), is a task- and time-intensive constructive challenge. With a multitude of deadlines to be met, the MHCA 2017 has contributed to the increase in MHP responsibilities and in turn made them proportionally vulnerable to liabilities. Leveraging technology for the delivery of mental healthcare could aid in combating this challenge with rigor. Combining with the power of technology, the opportunities for a mental healthcare professional who is willing to explore newer avenues of delivering mental healthcare that is accessible, affordable, acceptable, and adaptable are bountiful.
The objective of this brief article is to enable mental health practitioners cut across all sections of practice to be both aware and appreciative of the available technological aids; their functioning; benefits and risks associated; and strategies to engage them in optimum, proactive use in mental healthcare. This shall enable them to seamlessly weave technological advances into the fabric of clinical practice while acknowledging the need for their evaluation and standardization.
Any product, website, organization, or program mentioned herein is neither to include the endorsement of its content nor the decision not to mention any entity or product excludes an endorsement.
| An Emental Health Professional in the Making|| |
In the era of legal and ethical uncertainties, with the availability of newer platforms of technology, a question that commonly resonates in all practicing mental healthcare professionals is “How much can I leverage technology in my mental health practice?” The response is “As much as you want. Cloud does not limit.” Owing to their perceptions and opinions about the use of technology, some practitioners may find the urge to stay safe from the clutches of the risks associated with the use of technology. However, the unrelenting economic forces, third-party payers favoring professionals who leverage technology for their clinical services, and the end users eagerly waiting to utilize the therapeutic benefits of the technology are driving the need to adopt technological innovations. Thus, for the clinician, it is an option to be a part of the team directing the development of the health technologies or be the end-user of the technology directed to be used. Hence, it is strongly suggested to have a broad working knowledge of the available technologies to enable one to make informed decisions in the best interest of the patients and maintaining one's professional integrity. With the paucity of evidence-based applications, it is suggested that the service providers use this golden opportunity to scientifically research and document the safety and effectiveness of their use in their respective clinical settings.
- Smartphone-based applications have a potential role to play in the end-to-end solutions across complete clinical care delivery-administrative, assessment, clinical notes, diagnosis to treatment and follow-up. In routine clinical practice, application-based instant access to updated treatment guidelines  for screening and management of mental health conditions that are scientifically valid and have sound evidence base can equip the service provider with the ease of access, and the service users with a better understanding of the treatment regimen to enable them with the power to make informed decisions with regard to their own treatment
- Smart wearable technology, including smartwatches, fitness trackers (from companies such as Fitbit, Apple, Nike, and Jawbone), intelligent eyeglasses, mood trackers, and sleep trackers, which use accelerometers, already routinely used by the common man, are powerful tools to access and assess behavioral and physiological data in real-time. With the added advantage of the users having to use them remotely for an extended time, without having to interact with other technological systems, makes it user-friendly and accessible. Mobile sensors-wearables and applications can help collect all important data about steps accrued, sleep, biological functions, and other sedentary and activity parameters. The cost-effectiveness and ease of use make it look like an important monitoring system to improve patient outcomes. The smartphone technology has made mobile friendly biofeedback therapeutic interventions, a possibility. Providing the users a platform to share and compare their data with others also enables them to understand their health-related behaviors better. An opportunity for self-reflection to facilitate improvement or change can be extremely useful in individuals who remain alone or with the poor social system. Adapting, synchronizing and standardizing these tools for effective utilization in the routine treatment care settings will be a challenge
- Smart homes with smarter technologies (commonly referred to as home automation or domotics) are a habitat that uses Internet-connected devices that enables remote monitoring and management of lighting and heating systems. They utilize environmental sensing and integrated computing technologies such as Natural Language Processing (NLP), Machine Learning (ML), and Artificial Intelligence (AI) and hence, have a great potential for newer interactive behavioral treatment modalities 
- Using ambient persuasive technologies to help lifestyle modification will be a game changer. For example, a mirror which changes the patient's avatar based on the number of cigarettes smoked or not could give immediate aversive feedback for the individual to work on a healthy lifestyle; or a sensor-based chair alarm to monitor time spent sitting; or automated floor cleaning robots (e.g., Robovac) that are connected to Wi-Fi, allows to remotely control the operation from a smartphone or tablet, and collects data as they clean, can provide significant insights into one's daily living pattern and lifestyle
- Speech recognition and speech processing tools that commonly deploy NLP allow handheld devices to interact by verbal communication with the service users available in electronic devices. Most widely used speech recognition tools include Alexa (Amazon), Siri (Apple), Google Assistant (Google), and Cortana (Microsoft) which use inbuilt microphones for the detection of speech, including questions, commands, dictations, reminders, and subsequent text transcription by Automatic Speech Recognition. They can play a role in history taking, translation, and faster documentation. Audio and video recording of consenting, unlocking personal data, and understanding psychopathology from speech samples are potential areas for further exploration. With the usage of ML for frequent tweaks and adaptation to the user's language and accent, the search preferences are automatically absorbed to return personalized search results later. The management of Electronic Medical Records by designing personalized QR coded digital health portfolios, which can both record and track health metrics and information of the patients and share them across different health settings, can enhance accessibility and availability
- The potential use of technology as a safety net is commendable. Speech recognition tools can be deployed in immediate crisis intervention areas, including that of suicide prevention. For example, certain phrases are filtered and flagged for imminent threat or danger, including those containing the potential for self-harm or suicide (e.g., “Help me kill myself,” “What is the easiest, pain-free way to kill myself?”), and the user will be automatically connected to suicide helplines or nearest crisis intervention outlets. Advanced automated home systems like Alexa can be trained to pick heated conversations in homes, clinics, or hospitals and further can connect for immediate assistance or help
- With growing autonomy and individual living, treatment adherence is an important challenge to be tackled. Using the concept of Internet of Things (IoT) in digitalized pillboxes, smart pills, and pill trackers may significantly contribute to an increase in quality of care. Growing trends in research indicate that in future, 90% of the major healthcare organizations globally would have adopted IoT technology which will be quintessential to all major healthcare initiatives taken up
- Augmented reality exposure therapy  has indeed become a reality, and evidence in favor of its effectiveness is slowly garnering attention. The improved quality and ability to deliver it on handheld devices suggests that it shall remain an important implement in the hands of a digital age MHP
- Virtual coaches and therapists shall fill the most crucial gap in treatment-the time between two consultations with professionals. With the growing ability to personalize care and incorporate AI components and the ability for monitoring by a professional team, these kinds of virtual coaches and therapists shall be not only an alternative but also a supportive strategy in patient care
- Global Positioning System (GPS) aids in the location of a service user in a wide geographic space, using cellular triangulation. GPS-enabled trackers can play a pivotal role in tracking the whereabouts of a service user. One potential application includes tracking and reconnecting back with a dementia patient who might wander away due to the illness. Another is in the space of addiction management where a location that previously was a cue to succumbing to temptation can be recognized in advance, and automated alerts can be utilized to stay vigilant and use an alternate path
- Given that social media is becoming a vital component of an individual's life, there are possible ML and artificial algorithms which can identify individuals in distress while they are posting varied content, and tweak the support available to them. These are promising interventions to be considered in the areas of suicide prevention
- Developing chatbots and therapist avatars could be alternatives to be considered due to the rising demand for MHP services. Virtual consults at home, at primary health centers, and at other important nodal points will enable the MHPs to reach the unreached
- Community medical professionals could be supported, guided, and mentored in their work to reduce the mental health burden at the community level. Sensitizing the community at large and developing integrative communities is quite possible with education and support. Community-based educational technologies in the form of incorporating multimedia videos, games, AI, and interactive learning modules would help us to customize, individualize, and design culturally sensitive information material. Handheld community assessment tools enabled on phones shall help the community workers with early identification and making referrals.
| The Digital Age Mental Health Care Framework: 360° Impact of Technology on Mental Healthcare|| |
Considering the possible technological innovations and applications outlined above, a hypothetical “Digital Age Mental Health Care Framework” for optimum leveraging of technology has been developed [Figure 1]. The concentric circles highlight the various components that make up the digital age mental healthcare. The core of the framework is to ensure confidentiality, autonomy, and rights of the individual patients, a “no compromise” aspect while leveraging technology. The immediate inner circle of the framework indicates the movers of technology. The outer circle represents the various channels used for leveraging technology.
| MHCA 2017 Era - an Act Spiked With Deadlines|| |
Admission reporting, discharge reporting, and supported admission reporting are the broader sections with deadlines, nonadherence to which can incite serious consequences. In ensuring compliance to MHCA 2017, a few areas where the support of technology can be of utmost benefit include (not limited to):
- The statutory deadlines of the MHCA 2017 mandate the need to have robust yet flexible, responsive automated fool proof health information management systems, which can adequately collect data, authentically self-interpret basic details through pattern matching, and automatically pop up reminders to prompt the team to act in a time-appropriate manner
- Myriad of forms with repeated data entry points surmounting a clinician's desk warrants one-touch sync of all online submissions. High-quality synchronization and integration of the data enable administrative and clinical information to be compiled and analyzed, providing an opportunity for ML and newer insights
- Modern technology can be a great value addition for both clinical and assisted care settings, helping mental healthcare practitioners across settings in reducing variability in delivery and thereby improving outcomes. Quick and easy search mechanisms for faster data retrieval, powerfully automated reminders, access to basic medical records, and ongoing dissemination of evidence-based updates on healthcare information would help keep the momentum going
- ”Big data” plays a vital role in the mental healthcare as well at the level of the individual patient in the form of data from insurance company profiles, diagnostic information, psychological assessments, wearable trackers, or smartphone applications, which can all be leveraged in the provision of highly customized personalized care
- Leveraging technology for the planning of advance directives (AD) is nondebatable. In the AD made by a person under Section 5, individuals have the ability and right to express, well in advance, their preferences on treatment care they are willing to undergo. They have the option to identify a trusted, legally empowered representative to make mental healthcare decisions on their behalf. Complex decisions can be chunked down into more manageable components. With changing preferences in the changing times, digitalizing the process of AD can enable individuals to revisit and update their planning documentation in real time. Documentation of verbal statements through digital video recording, online monitoring of the concordance between the desired care and the actual care received by stakeholder will ensure legal compliance.
| Barriers and Roadblocks to Leveraging Technology|| |
Despite the progressive MHCA, leveraging technology shall remain a challenge until the major barriers and roadblocks as outlined below are removed:
- A need for higher standards of protection have been increasingly felt over the years, especially when it comes to sensitive health information, specifically mental health information. The collection, receipt, storage, handling, and transfer of Sensitive Personal Data or Information in electronic form is subject to the Information Technology Rules 2011. From a healthcare perspective, this includes information relating to physical, physiological and mental health conditions; sexual orientation; and medical records and history. As implementation of MHCA leads to a multi-tiered system of various stakeholders, developing databases with tiered and privileged access shall remain the key to satisfy the professional, legal, ethical, and administrative needs. Considering the sanctity of the data collected and the need to ensure utmost privacy and protection, customization of the complex services offered is the key 
- The MHCA 2017 in itself has remained silent about the potential use of technology and has not provided any framework to be considered for leveraging technology. The emphasis on paper records in the MHCA 2017, is a regressive step. The fact that telemedicine or e-medicine remains at infancy stages in India shall negatively impact the speed of technological adaptation in the area of mental healthcare
- Challenges of convincing the key stakeholders; need for investment on infrastructure; selection of need-based, right vendors in the digital ecosystem; strategic use of workforce and training; willingness to incorporate technology and update continuously; robust backup plan for unforeseen circumstances; developing protocols for workflow; and Finally, falling in line with multiple laws, i.e., those governing the medical profession, the doctor–patient relationship, and information technology
- The regulatory framework needs also to be sensitive and updated with this expansive growth to overlook, guide and regulate the framework under which the mental healthcare systems are developed. The challenge in front of them is humungous in terms of the need for extensive knowledge and expertise. Considering the rapidity of change and growth, these authorities shall be running against time for all the decisions and regulations
- By circumventing these challenges and investing in robust technology that put the patient at the center of care, mental healthcare sector should lead other specialties in this rapidly changing continuum by being an early adopter and innovator in leveraging technology, because facilitation of an MHCA-compliant practice can lay down critical pointers for successful digital transformation.
| Concluding Remarks|| |
However, powerful, personalized, point-to-target care, and cost-effective it may seem, the need for more evidence-based research, including the gold standard randomized control trials for safe and effective use of technology in the mental healthcare settings, is the need of the hour. One cannot be oblivious of the fact that any form of generalized, untested technological aid may do more harm than good. With this precautionary note, leveraging the modern technological tools is just not a “want” but a “need” to enable one to have a robust MHCA-compliant practice. This means not only ensuring legal compliance but also ubiquitous deployment of technologically feasible systems for effective implementation, monitoring and evaluation of the legal compliance to ensure that all involved key stakeholders are equally benefited from technological advances of the 21st century. Technology integration and leveraging shall remain a cornerstone to make mental healthcare accessible, available, and affordable. An MHP-driven needs assessment and development or adaptation of useful technological breakthrough shall remain pivotal to the provision of quality mental healthcare and service. Not only that, there is a need to work with professionals who bring their technical expertise, resulting in optimal and quality services for the end-user. The quote “We are changing the world with technology” by Bill Gates makes us reframe it to the present context as “The key to a foolproof future for a digital age MHP is leveraging the effective use of existing technology.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Mohan Sunil Kumar
Augmenta Health (P) Ltd., #108, St Johns Road, Sivanachetty Garden P. O., Bengaluru - 560 042, Karnataka
Source of Support: None, Conflict of Interest: None