Name:
Dr. Deanna Chin, Dr. Si Ying (Sherry) Liu, Dr. Kavita Patel
Address:
Phone: 905.247.6605
Fax: 289.452.2888
Website: https://www.glenfamilydoctors.ca/
The Physician or Nurse Practitioner (“the Provider”) has offered to provide the following means of virtual care (“the Services”), and the use of AI-powered medical documentation tools:
Videoconferencing (Zoom Health, OTN, or other platform offered by clinic)
Website
Patient communication portal offered by clinic
AI-powered medical documentation/scribe
I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected Services more fully described in the Appendices to this consent form. I understand and accept the risks outlined in the Appendices to this consent form, associated with the use of the Services when interacting with the Provider and the Provider’ staff. I consent to the conditions and will follow the instructions outlined in the Appendices, as well as any other conditions that the Provider may impose in relation to patients using the Services.
I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for virtual care and AI powered technology tools, it is possible that interacting with the Provider or the Provider’s staff using the Services may not be encrypted. Despite this, I agree to interact with the Provider or the Provider’s staff using these Services with a full understanding of the risk.
I acknowledge that either I or the Provider may, at any time, withdraw the option of using the Services upon providing written notice. Any questions I had have been answered.
Patient name: ____________________________________________
Patient address: ____________________________________________
Patient home phone: ____________________________________________
Patient mobile phone: ____________________________________________
Patient email (if applicable): ____________________________________________
Patient signature: Witness signature:
_______________________ _______________________
Date: Date:
_______________________ _______________________
Risks of using virtual care tools
The Provider will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use virtual care tools). However, because of the risks outlined below, the Provider cannot guarantee the security and confidentiality of all virtual care tools:
Use of virtual care tools to discuss sensitive information can increase the risk of such information being intercepted by third parties.
Despite reasonable efforts to protect the privacy and security of information communicated through virtual care platforms, it is not possible to completely secure the information.
Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
Virtual care tools can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
Communications through virtual care tools can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Provider or the patient.
Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
Communications through virtual care tools may be disclosed in accordance with a duty to report or a court order.
Some videoconferencing platforms may be more open to interception than other forms of videoconferencing.
If the email or text is used as a virtual care tool, the following are additional risks:
Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.
Conditions of using the Services
While the Provider will attempt to review and respond in a timely fashion to electronic communications such as emails, text messages, and instant messages, the Provider cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.
If your electronic communication requires or invites a response from the Provider and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
Virtual care is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the Provider’s electronic communication and for scheduling appointments where warranted.
Electronic communications or recordings of virtual encounters concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications and recordings.
The Provider may forward electronic communications or recordings to staff and those involved in the delivery and administration of your care. The Provider might use one or more of the Services to communicate with those involved in your care. The Provider will not forward electronic communications or recordings to third parties, including family members, without your prior written consent, except as authorized or required by law.
The Provider will use their professional discretion as to when to use or not use the Services to communicate sensitive medical information
You agree to inform the Provider of any types of information you do not want sent via the Services (e.g. Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, Substance abuse). You can add to or modify the list at any time by notifying the Provider in writing.
Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes.
The Provider is not responsible for information loss due to technical failures associated with your software or internet service provider.
Instructions for using the Services:
To use the Services, you must:
Reasonably limit or avoid using an employer’s or other third party’s computer. Conduct virtual care encounters in a private setting and using a secure device, where possible. Obtain the Provider’s consent prior to making any recording of the virtual care encounter.
Inform the Provider of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.
If the Services include email, instant messaging and/or text messaging, the following applies:
Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message.
Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the Provider.
Ensure the Provider is aware when you receive an electronic communication from the Provider, such as by a reply message or allowing “read receipts” to be sent.
Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
Withdraw consent only by email or written communication to the Provider.
If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Provider’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.
This document is designed to provide you with information about AI-Powered Medical Documentation Technology we intend to use during your medical consultation and care, and to seek your informed consent to its use.
Description of AI-Powered Medical Documentation Technology:
It assists healthcare professionals in data collection and note-taking, generating clinical notes and letters, which in turn aids in patient care. The application can process information provided in various forms, such as text, audio, and live patient conversations and generate notes for your doctor. It may also involve a conversation with an autonomous doctor assistant (ADA), which is strictly used for note-taking and collection of health information by your healthcare provider.
Purpose of Use:
The use of AI-Powered Medical Documentation Technology is intended to improve the efficiency and accuracy of medical documentation, thereby freeing more time for your healthcare provider to focus on your care.
Data Processing, Confidentiality, and Security:
While AI-Powered Medical Documentation Technology assists in the process of note-taking and chart generation, it's important to note that the system may process sensitive health information provided during your consultation. The information processed by AI-Powered Medical Documentation Technology is strictly used for the purpose of your ongoing medical care and is subject to strict data privacy regulations to ensure your information remains confidential.
No personal health data submitted via the AI-Powered Medical Documentation Technology application is used to train or improve any AI model. The data sent through the application is fully HIPAA and PIPEDA compliant. Any data transfer is secure and encrypted.
The AI-Powered Medical Documentation Technology application communicates with the AI model over encryption grade security ensuring that all data requests and responses are encrypted.
The third-party technologies include, but are not limited to, Microsoft Azure’s OpenAI and/or Anthropic’s Claude. These third party services may be utilized (independent of our own self-hosted service) depending on provider location, content-filtering policies, or data-storage policies in compliance with PIPEDA, provincial Canadian, and HIPAA based privacy regulations.
Fragments of your transcribed text may be used to further train or enhance Large Language Models.
Potential Risks:
While AI-Powered Medical Documentation Technology is designed to improve the efficiency of your medical care, there are potential risks associated with its use. These include, but are not limited to, inadvertent errors in transcription or interpretation of your health information, and potential, though highly unlikely, breaches of data security.