Informed Consent-Telemedicine
INSTRUCTIONS
This document explains the purpose of telemedicine ? also known as ?telehealth? and referred herein, collectively, as ?telemedicine? ? and outlines the benefits and risks of telemedicine.
It is important that you read the whole document carefully. Please initial each page. Doing so means you have read the page. Signing the consent agreement means that you agree to a telemedicine session with your doctor or one of the doctor?s assistants (i.e. nurse practitioner, physician assistant, etc.).
GENERAL INFORMATION
Telemedicine is the distribution of health-related services and information via electronic and telecommunication technologies, such as computers and mobile devices, to access and manage health care services remotely. Telemedicine may include technologies you use from home or that your doctor uses to improve or support health care services. Telemedicine allows out-of-office patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. Examples of telemedicine include videoconferencing, teleconferencing, transmission of images, ehealth including patient portals, and remote monitoring of vital signs.
ALTERNATIVE METHODS OF MEDICAL CARE BESIDES TELEMEDICINE
In-person care is an alternative method of medical care to telemedicine.
BENEFITS OF TELEMEDICINE
The benefits of telemedicine include the following
? Make health care accessible to people who live in rural or isolated communities.
? Provide long distance clinical care.
? Make services more readily available or convenient for people with limited mobility, time or transportation options.
? Obtain expertise of specialists.
? Improve communication and coordination of care among members of a health care team and patient.
? Provide support for self-management of health care.
? Quick and efficient medical evaluation and management.
RISKS OF TELEMEDICINE
As with any medical care options, there are potential risks associated with the use of telemedicine. These risks include, but may
not be limited to:
? Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision
making by the physician and assistant(s);
? Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
? Security protocols could fail, causing a potential breach of privacy and/or inadvertent disclosure of personal identifying
information and/or protected health information;
? Lack of access to complete medical records may result in adverse drug interactions, allergic reactions or other judgment
errors;
? Overuse of medical care;
? Unnecessary or overlapping care.
CONSENT FOR THE USE OF TELEMEDICINE
1. I understand that the purpose of telemedicine is to provide health care services.
2. I permit my doctor and the doctor?s assistants to use telemedicine in my care.
3. I understand that telemedicine means using phone and/or video to communicate with my health care team instead of seeing
my team in person (face-to-face).
4. I understand that reasonable efforts will be made to protect my privacy, though there may be risk of inadvertent disclosure
of my personal identifying information and/or protected health information.
5. I understand that I can ask questions and discontinue the use of telemedicine at any time I choose.
6. I understand that telemedicine does not replace other types of medical assessment and care. If I am not improving and have
serious health concerns, I will seek immediate medical attention at an emergency facility.
7. ALL OF MY QUESTIONS REGARDING TELEMEDICINE WERE ANSWERED, AND THE FOLLOWING WAS EXPLAINED
TO ME IN A WAY THAT I UNDERSTAND:
a. THE CONCEPT OF TELEMEDICINE
b. RISKS AND BENEFITS OF THE USE OF TELEMEDICINE
c. ALTERNATIVE METHODS OF MEDICAL CARE
I CONSENT TO THE USE OF TELEMEDICINE IN MY MEDICAL CARE AND THE ITEMS THAT ARE LISTED ABOVE (1-7). I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS.
Electronic Signature
