RECENT predictive modelling (here, here and here) has suggested the need to urgently increase mental health service capacity in response to the COVID-19 pandemic. Physical distancing, social isolation and fear of contagion are being compounded by distress caused by loss of education, employment and the economic disruption (here and here).
Pre-COVID-19, the World Economic Forum had already called for the rapid deployment of digitally enhanced mental health care as a means to deal with demand issues. Such system transformation requires the Australian Government to immediately prioritise and adopt key policies that promote online access to mental health care, equity, innovation and ongoing and world-leading research and development.
Given the predicted and already emerging adverse impacts (such as community surveys of increased anxiety and depression, and increased calls to emergency help lines and, more recently, increased presentations of young people with self-harm to emergency departments in Victoria) of the COVID-19 pandemic on Australia’s mental health (here, here and here), there is now an urgent need to connect many people for the first time with effective mental health care. This is particularly evident for younger Australians, women in casual or part-time employment, middle-aged or older individuals facing permanent job loss, those confronting family breakdown, those living in rural and regional communities, and those who can least afford to pay the significant out-of-pocket costs associated with high quality mental health care (here, here and here).
Internationally, there is now considerable emphasis on the potential for health information technologies to deliver online access to mental health care, enhance the delivery of traditional in-clinic services and provide additional community support. While various reports are again highlighting the major deficiencies of traditional clinic-based services (here and here), Australia has been a leader in the development of innovative digital mental health care solutions (eg, moodgym, eheadspace, MindSpot, This Way Up, ReachOut.com and Project Synergy). These innovations extend well beyond developing simple mobile apps for common forms of anxiety or depression. The main game now is the delivery, at scale, of effective digitally enabled and coordinated mental health care. Recent predictive modelling (here, here and here) has indicated the extent to which such care has a real capacity to ameliorate the most devastating mental health effects of the COVID-19 pandemic (eg, increased rates in youth suicide, surge in demand for specialist services etc) and, beyond the pandemic, to facilitate a more robust and dynamic mental health system for the future.
These opportunities, however, are dependent on the Australian Government quickly adopting key national policies that seriously promote online access to mental health care, equity, innovation and ongoing and world-leading research and development (Table 1). These priorities have emerged during our extensive stakeholder consultations and linked health service implementation studies, as part of the Australian Government Department of Health-funded initiative Project Synergy (2017–2020). As there are many issues yet to be resolved by sustained engagement with users (including consumers, family and carers, health professionals and service providers), and supported by robust impact evaluation, the challenge is to create an environment where digital innovations do not elicit hostile public and professional feedback.
Instead, we need to foster an environment that is responsive to new innovations and able to rapidly manoeuvre in a way that embraces changes to health service delivery which offer improved efficiencies and effectiveness.
These key national policy priorities can be grouped into those that:
- are designed to make Australia an attractive test site for both national and international developments in digital mental health care (priorities 1, 3, 4, 6, 9);
- enhance user’s experience of digital mental health care (priorities 1, 4, 5, 7, 10); and
- add real value to the Australian health care system, by promoting accountability, smart infrastructure investments and rapid improvements in regional and national governance (priorities 2, 7–9).
Addressing such priorities could finally help us realise the type of person-centred care our mental health system has been trying to deliver for years.
Table 1: Key challenges and national policy priorities to promote world-leading digital mental health care
|National policy priority
|Need for transfer of relevant personal and health information (data) between internet-based services (interoperability)
Effective data transfer (while respecting privacy and ensuring security) maximises access to all relevant information to support high quality self-care and clinical decision making
|Ensure open application program interfaces (APIs) are a requirement of all digital mental health care solutions (and other related internet-based services) funded by the Australian Government
|Highly variable delivery of telecommunications capability
|Conceptualise digital infrastructure as key health infrastructure and fund regional systems appropriately
|Limitations of existing Australian Privacy Principles (Privacy Act 1988) and data security standards
|Development of national standards for privacy and data security that are relevant to digital mental health care solutions. For example, using ISO standards 9001 (quality management system – plan, do, check, act) and the 27000 series (privacy, confidentiality and information technology, technical and cybersecurity issues)
|Need to promote trust between all users (consumers, health professionals, service providers) to promote effective and efficient transfer of relevant personal and health information (data)
|Consumer controls over degrees of data sharing with and between health professionals and/or service providers (eg, on–off permission systems, four-digit passcodes for immediate transfer of data)
|Need for equitable access to Internet-based services
|i. Australian Government funding of digital mental health solutions via appropriately credentialed organisations at low or no cost to consumers
ii. Ensure digital mental health solutions are provided in a non-discriminatory accessible manner (W3C, at least “A level” compliance)
|iii. Consideration of “digital navigators” to support consumer, health professional and/or service provider deficits in digital literacy
|Need to recast traditional medico- legal considerations to fit 21st- century digital health solutions
|Pre-emptive detailing of best practice approaches, supported by Medicare-style descriptors that are suitable for digital mental health care solutions
|Need for relevant service delivery models of care that enshrine collaborative partnerships between consumers and their health professionals or service providers
|Support for active digital “user interfaces” that share personal and health information (data) directly and transparently between consumers and their health professionals or service providers. This may require a combination of top-down and bottom-up approaches to ensure effective and wide adoption
|Need to drive continuous and productive mental health services reform through outcomes-based data
|Ensure digital mental health care solutions use real-time, multilevel measures of service performance indicator data (consumers, health professionals, service providers, policy and regulators) for ongoing quality improvement
|Missed opportunities to benefit from the world of digital health innovations
|Enhancing the attractiveness of Australia as a test site for new digital mental health care developments, linked health service research trials as well as linkage to health outcome datasets
|Need to differentiate digital health innovations from electronic medical records. Among many clinicians and service users, it is wrongly assumed that the primary goal is creating an archival report rather than a real-time tool to inform clinical decision making and self-care strategies
|Promote real-time digital mental health care solutions as clinical tools for consumers as well as their health professionals or service providers that are not simply extensions of, or access to, archival medical records
Making Australia an attractive test site
Here, the principal challenge is to balance the necessary regulatory aspects of digital mental health care with the desire to promote innovation, investment and sustained implementation. An overzealous and, at times, paternalistic preoccupation with protecting a consumer’s privacy, system security and personal and health information (data) transfer may quickly stop any serious national developments and prevent integration or interaction with smart international developments.
By contrast, transparency (at the consumer, health professional, service, and system levels) should be placed very high on the list of priorities along with the promotion of individual autonomy, choice and agency. In the wider world, consumers are exercising their choices every day about how far or freely they release their personal information. It is often assumed that mental health is a “special” case and that those with mental health problems do not wish to share their data openly with (and between) their various health providers. While privacy and security are key principles, much co-design work with those with lived experiences of mental ill-health (primary service users, family members and carers) has endorsed the importance of real-time data sharing to improve the quality of clinical care provided (here, and LaMonica et al, in press).
Enhancing user’s experience of digital mental health care
Many users of current digital health programs, particularly electronic medical records and linked administrative systems, perceive them to be:
- poorly designed for mobile use;
- not directly relevant to the actual health care needs of consumers;
- not used in real time to improve care;
- not capable of reporting key performance indicators of service safety and quality;
- not sophisticated enough to capture personal health needs or the complexity of a mental health journey;
- too complex for those with limited capacity to interact with these systems; and
- not designed to foster genuine or transparent consumer and health professional collaborative partnerships in care (here and here).
Continuous improvement in these areas needs to be fostered by the participation of all users in the active and ongoing design and systematic evaluation of new and innovative digital mental health care solutions.
An important part of continuous improvement may also involve the re-evaluation of existing solutions that currently act as barriers to the implementation and use of new digital solutions that are better suited for modern mental health care and actually enhance the overall user experience.
Adding real value to the Australian health care system
Many service providers and organisations as well as system administrators perceive digital innovations as simply adding another layer of complexity, time or cost to already poorly resourced and traditional clinic-based mental health services (here and here). The value proposition, both social and economic, of this type of transformation, locally, regionally and nationally, needs to be clearly articulated and actively supported by changes to policy and practice. These must address key performance indicators (also here and here):
- enhanced access to high quality and more personalised mental health care;
- greater responsiveness to the multiple dimensions of a consumer’s needs;
- improved equity;
- greater transparency;
- more credible consumer, health professional and service provider accountability;
- greater clinical safety;
- improved coordination of care within and between health professionals and services; and
- enhanced strategic investments (eg, telecommunications capability).
Mental health care in Australia, as elsewhere in the developing and developed world, is never likely to respond effectively to population-level demand for services or consumer desire for ready access to high quality services without uptake of digital innovations. The sheer size and scope of the problems and the need to provide genuine high quality, ongoing and multidisciplinary care exceeds the capabilities of most health systems, even in highly developed countries (here and here). The pace at which this happens, the cost to consumers of the experience, the equity of the distribution of 21st-century and international best practice, are all likely to depend on the extent to which the Australian Government capitalises rapidly on our current strategic advantage.
Ms Tracey Davenport was the Director of Research, Ethics, Governance and Analytics at The University of Sydney’s Brain and Mind Centre. She is now the Director (Research and Evaluation), Design and Strategy Division at the Australian Digital Health Agency.
Associate Profesor Jo-An Atkinson is the Head of Systems Modelling, Simulation and Data Science; and Co-Director of the Mental Wealth Initiative at the Brain and Mind Centre, The University of Sydney. She is also the Managing Director of Computer Simulation and Advanced Research Technologies (CSART) Ltd.
Dr Haley LaMonica is a Senior Research Fellow at the Brain and Mind Centre, The University of Sydney; she is also a Senior Clinical Neuropsychologist and the Head of eHealth at the Healthy Brain Ageing Clinic at The University of Sydney.
Dr Frank Iorfino is an early career researcher and is a Research Fellow at the Brain and Mind Centre, The University of Sydney. Dr Iorfino has led numerous research studies, including the development of prototype technologies which aim to support quality improvements in mental health service delivery.
Professor Ian Hickie is Co-Director, Health ad Policy at the Brain and Mind Centre, University of Sydney. Professor Hickie has a 5% equity share in Innowell Pty Ltd, a joint venture company of the University of Sydney and PwC, focused on development of digital mental health solutions.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.