The electronic broadcast of a medical interview, or a video tele-consultation (VTC), challenges many of our traditional concepts of privacy and confidentiality. The nature of a doctor-patient relationship changes dramatically when the open airwaves carry the personal histories, images, and concerns of a patient. Discussions of telemedicine often allude to inherent ethical concerns yet there are no established guidelines for the ethical conduct of a VTC

Delaplain, C B

Lindborg, C E

Norton, S A

English

eVols at University of Hawaii at Manoa

Consent and Privacy in Telemedicine Scott A. Norton MAJ, MC* C. Eric Lindborg MD** Calvin B. Delaplain LTC, MC*** The electronic broadcast of a medical interview, or a videotele-consultation (VTC), challenges many of our traditional concepts of privacy and confidentiality. The nature of a doctor-patient rela-tionship changes dramatically when the open airwaves carry the personal histories, images, and concerns of a patient. Discussions of telemedicine often allude to inherent ethical concerns yet there are no established guidelines for the ethical conduct of a VTC. Introduction During the past year, we have conducted more than 70 VTCs' and have paid attention to aspects of VTCs that pose ethical chal-lenges. Without claiming any special expertise in medical ethics, we describe in this article our efforts to preserve private, confiden-tial relationships between patient and physician during a VTC. Confidentiality Patients who appear on VTCs must be informed that aspects of the relationship with their physician have changed (Fig 1). The physician maintains his responsibility to keep patient information confidential but the customary total privacy and confidentiality of the medical setting cannot be guaranteed. The patient's image and medical history are conveyed not only to the consulting physician but, by necessity, to several individuals outside the traditional medical team. The broadcast procedure requires technical staff at both ends and frequently we have observers interested, not in the particular patient, but in the practice of telemedicine. In small communities, it is possible that the patient knows the nonmedical personnel socially, compounding the sense ofloss of privacy. Furthermore, transmission over the airwaves or by direct link is not secure-ie, others can intentionally or unintentionally gain access to the broadcast. Some centers now scramble their broad-casts electronically to ensure confidentiality. The military's tech-nical personnel often have security clearances and are accus-tomed to handling sensitive information. In general, however, the implicit code of ethics of professional video-broadcasters should be an assurance of confidentiality. Intimacy Most patients and physicians want warm professional relation-ships with each other; therefore, important for the consultant to appear as personable over the video as he or she might be in a face-to-face setting. Bright lights, technical contraptions, and extraneous personnel can diminish this feeling; we advise conveying to the patient an image of the consultant alone, free of background clutter and motion. Keeping the consultant's studio free of distracting clut-ter helps convey the impression that the consultant's sole purpose is to evaluate that patient, adding to the sense of intimacy. * ** 340 Telemedicine Committee, Tripier Army Medical Center, Honolulu, HI 96859. and the Kwajalein Hospital, USAKA, APO AP 96555. Address correspondence to Dr. Norton. STATEMENT OF UNDERSTANDING FOR VIDEOTELECONSUL TATIONS I understand the following: 1. Details of my medical history, examinations, X-rays, and tests will be discussed with off-island specialists. 2. Limited physical examination may take place during the VTC. 3. Nonmedical technical personnel may be in the VTC studio to aid in video trans-mission. 4. Other medical or nonmedical personnel may be off-screen at the consultant's VTC studio as observers or technical assistants. 5. Video recordings may be taken of the VTC and may be viewed by various per-sonnel for training and administrative purposes. Noting all of the above, I understand that participation in the medical VTC constitutes a waiver of the usual rights to doctor-patient privacy. I further understand that I have the right to: 1. Request that USAKA's VTC physician omit specific details of the history of examination that are personally sensitive to me. 2. Limit any physical examination proposed during the VTC. 3. Request that nonmedical USAKA personnel leave the VTC studio at any time. 4. Request that all USAKA personnel leave the VTC studio to allow a private con-sultation with off-site specialists. 5. Stop participation in the VTC at any time. Signatures of counseling physician: Witness: Patient or ParenVSponsor/Guardian: Date and time: Figure 1: Information and consent form used by the Kwajalein Hospital, Kwajalein, Republic of the Marshall Islands. Most patients at this hospital are American citizens working for the U.S. Department of Defense or its contract agencies. VTC =video teleconsultation; USAKA = United States Army Kwajalein Atoll. We recommend that the consultant's studio resemble a typical physician's office. We are fortunate that our studio allows the consultant to sit behind a solid wooden table. The table is clear except for a nameplate, paper, and pen. When patients are involved in the unfamiliar process of tele-medicine, they are reas-sured to view the consultant the same as in a traditional setting. A nameplate listing the consultant's name, degree, and spe-cialty adds credibility, familiarity, and helps the patient remem-ber the name of a specialist whom they have never met in person. Similarly, the consultant must try to address the patient using only the first name, in an attempt to prevent a depersonalized relationship, yet preserving some anonimity. Privacy Although the patient has waived the usual rights to privacy (Fig 1), a properly conducted VTC should nevertheless be a pri-vate session. That is, it should be free from disruption, intrusion, and should avoid a fishbowl atmosphere. First, the image broadcast to the patient should show only the consultant. It is disruptive and unnecessary for people to stray HAw An MEDICAL JouRNAL-VoL. 52, No. 12-DECEMBER 1993 into the camera's field behind the consul-tant. The patient must be informed that there could be people off-camera in the consul-tant's studio who are observing the session. Nevertheless, the patient can expect that the consultant is the only individual interested in the medical details of the case. If an observer off camera at the consultant's end needs to be called-on for an additional opinion, the patient should be so informed at the start of the conference. For example, the patient's television screen will show only the intended consultant who may say, "Mrs. Remote and Dr. Distant, also joining me here is Dr. Jones, another orthopedic surgeon. He's sitting off-camera now, but I might ask for his opinion on your diagnosis and care." Failure to notify the patient of a another consultant viewing the session does not vio-late the consent but is contrary to the implicit understanding that others in the studios are indeed disinterested. Similarly, the consultant must know if there are persons at the patient's video-stu-dio who could inhibit truthful answering of the questions. Twice, our physicians have learned after a VTC that patient's family members were off-camera in the distant stu-dio, leading to concerns that perhaps some questions, eg, the sexual history, might not have been answered truthfully because of the family's presence. If the physical examination requires par-tial disrobing, it comforts the patient to have an off-camera changing area, gowns, and some privacy screens in the camera field. Informed Consent To embody the principles discussed, we developed guidelines to use in counseling patients before their VTCs. Furthermore, we prepared a written Statement of Understand-ing for the counseling session and to serve as its record (Fig 1 ). Conclusion We strive to establish a relationship between the patient and the video-consultant that closely resembles the traditional patient-physician role. Sensitivity to issues of privacy and confidentiali-ty-and full disclosure of the inherent difficul-ties-enables patients to feel more comfortable with their VTC and avoids unpleasant moments and depersonalized care. We hope it enhances the effectiveness of telemedicine and increases confi-dence in it on the part of the patients as well as that of both the consulting and attending physicians. Our treatise is limited to few of the many ethical concerns of telemedicine. We encourage further endeavors in this field. The opinions and assertions contained in this article are those of the authors and are not to be construed as those of the Department of Defense. References I Delaplain CB, Lindborg CE, Norton SA, Hastings JE. Tripier pioneers telemedicine across the Pacific. Hawaii Med J. 1993. Retirement Plans • Investment Management Consulting • Life and Disability Insurance • mel r. hertz MBA, CFP Charitable Remainder Trusts Certified Financial Planner Pacific Tower, Suite 2800 100 1 Bishop Street Honolulu, Hawaii 96813 (808) 599-4504 ~ Offond Tluau IFG Net-t s.c..tllieo, Inc. OFGI, Mornb.. NASIJ •rxl SIPC. F0>onclol l't..,illl ~ ~ Aoooo-..1 FlnMCUI P , Inc. IAFPI, R.,U..... lrlw,.,..,. Ad.>.- ,..., t lwtr I• • .._;Mnld princ•pol oliFG ond • Nl -.I ~laM ol iU Jlili- AlP, bc,ch ol..ftld. - adww-. lilllld wilh ...,_., - ---------------------------------------------------CLINICAL INVESTIGATORS NEEDED IN VARIOU SPECIALITIES INCLUDING: RHEUMATOLOGY 0 COLOGY DERMATOLOGY OPHTIIALMOLOGY GERO TOLOGY GYNECOLOGY ALLERGY and others MANA IN TITUTE/HAWAll OSTEOPORO I CENTER Contact: LAURIE L. KOIKE 592 ... 2655 HAWAII MEDICAL JouRNAL-VoL. 52, No. 12-DECEMBER 1993 341 

Consent and privacy in telemedicine.

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Consent and privacy in telemedicine.

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