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AI Scribes in Canada

AI Scribes in Canada

 

AI Scribe in Canada

A lot has changed recently on new AI scribe initiatives in Canada.

A lot has changed recently with AI scribe initiatives in Canada. Here’s a quick update and resources to help your clinic make informed decisions.

What is AI?

Artificial intelligence (AI) is an advanced form of information processing that helps automate or enhance tasks. In healthcare, AI doesn’t replace providers—it supports them. Clinicians still guide its use, review outputs, and make informed decisions.

AI can reduce administrative burden and help address physician burnout. Importantly, it should not be used to increase patient volumes. Instead, it is a tool to enhance care and support the physician’s role.

AI tools typically combine hardware, software, and data. Even familiar tools like Microsoft Copilot or ChatGPT follow this model. In healthcare, software is often applied to patient data, which means privacy and transparency are critical.

What Is an AI Scribe?

“AI Scribe” is a broad term for tools that help generate clinical notes. Common workflows include:

  • Dictation: provider speaks, and AI formats the note.
  • Live Listening (also called Ambient Listening): AI listens during a patient visit and drafts the note based on the conversation.
  • Advanced features: some tools analyze lab trends, suggest diagnoses, or remind providers about follow-ups.

See my article Thinking About Using AI Scribe in Your Healthcare Practice? for additional background.

Why AI Governance Matters

Each clinic must manage how personal health information (PHI) is collected, used, accessed, and disclosed—especially when introducing new technology.

An AI governance framework provides a structured approach to address risks, ethics, and compliance. Think back to when computers first arrived in clinics: there was hype, confusion, and risk. Eventually, we built vendor vetting processes, training, and structured implementation. The same is true today with AI.

Key principles:

  • Create written procedures for evaluating vendors.
  • Set clear expectations: employees should not independently adopt AI tools.
  • Encourage open discussion and collaborative decision-making.

AI Governance and Accountability Framework

Just as it was never appropriate for individuals to bring their own computers from home to manage patient records, it is not appropriate for clinicians or staff to adopt AI tools on their own.

Introducing AI into a clinic requires a collaborative, structured approach. An AI governance framework helps organizations manage risks, ethics, and compliance requirements, including new or emerging risks.

Every clinic should have written procedures that:

  • Set clear expectations for evaluating and selecting vendors.
  • Prohibit staff from independently implementing AI tools.
  • Encourage open discussion and a culture of accountability when considering new technologies.

Without this oversight, indiscriminate use of AI can compromise the accuracy, integrity, and security of personal health information (PHI) — and create risks for the entire organization.

Implementation: Not Plug and Play

AI adoption requires planning. Assign responsibility and accountability for implementation and monitoring. Include your privacy officer in this role.

Your plan should include:

  • Staff training and awareness
  • Confidentiality and end-user agreements
  • Cybersecurity and technical safeguards

Do You Need a Privacy Impact Assessment (PIA)?

Yes! If an AI system introduces new collections, uses, or disclosures of PHI, a PIA is required.

Custodians must ensure PHI is protected against theft, loss, and unauthorized use or disclosure, and that records are securely retained, transferred, and disposed of. This includes ensuring vendors have sufficient safeguards in place.

Recent Resources

Here are a few current references to support your decision-making:

Canada Health Infoway announced in May 2025 a program offering one-year fully funded one-year licenses for eligible primary care providers across Canada. Visit Canada Health Infoway to register for updates and eligibility notifications.

Artificial Intelligence (AI) Scribe Privacy Impact Assessment Guidance developed by the Office of the Information and Privacy Commissioner (OIPC) of Alberta.  September 22, 22025.

Canada Health Infoway Supports AI Scribe Implementation in Alberta with Reference to OIPC Privacy Guidance – September 22, 2025

Contractual Safeguards – Ontario MD Guidance – AI Scribes

Vendor of Record list, Supply Ontario – This list features qualified solutions that meet the needs of clinicians

AMA Artificial Intelligence Principles and Policy, February 7, 2025

Need help getting started with your AI privacy and implementation plan?

      • Explore our blog posts on AI and privacy.
      • Join the Practice Management Success membership for training, templates, and discussions.
      • Or ask me directly about PIA consultation services to support your clinic’s AI implementation.
 
 

When we know better, we can do better…

Jean Eaton is constructively obsessive about privacy, confidentiality, and security especially when it comes to the handling of personal health information. If you would like to discuss how I can help your practice, just send me an email. I am here to help you.

Jean L. Eaton
Your Practical Privacy Coach
INFORMATION MANAGERS

 
If You Collect PHI, You Need a Data Inventory

If You Collect PHI, You Need a Data Inventory

If You Collect PHI, You Need a Data Inventory

You Can’t Safeguard What You Can’t Find

Do you know where all the personal health information (PHI) in your practice lives?

When you collect PHI, you are responsible to ensure the security, privacy, and confidentiality of that information. The first step is knowing where the PHI resides.

A data inventory is a foundational privacy and security tool. It is a detailed list of all the PHI that you collect, what data is included, where it is kept, and who has access to it.

A well-maintained data inventory supports informed decisions about budgeting, risk analysis, and incident response. If you don’t have a data inventory yet, use these tips to help you prepare one now. An annual review is an expected reasonable safeguard to protect PHI and stay compliant.

Why Custodians Need a Complete Picture of PHI Locations

When a healthcare provider collects PHI, they take on an explicit responsibility to the individual who shared their information. Patients trust you with their sensitive data—and you must demonstrate that you will respect and protect it.

Reasonable safeguards are not just good practice—they are mandated by professional standards and provincial privacy legislation such as Alberta’s Health Information Act (HIA) and Ontario’s Personal Health Information Protection Act (PHIPA).

The healthcare provider (sometimes called a custodian) is ultimately responsible for the safekeeping of PHI. Their privacy officer often is responsible to ensure that privacy and security documentation is up to date and communicated throughout the organization.

PHI doesn’t only exist in your EMR. It lives in many places, such as:

  • Electronic Medical Records (EMRs)
  • Billing systems
  • Email inboxes
  • Paper records
  • Third-party apps (e.g., transcription, booking tools)
  • Staff smartphones (texts, voicemails, photos)

Remember: If you don’t know where it is, you can’t protect it—and you certainly can’t include it in your breach response plan.

Your Data Inventory: The “No Data Left Behind” Checklist

 

A data inventory doesn’t have to be complicated. Include members of your care team and admin support as you build this list. Start with this simple framework:

A. Identify All Systems and Locations

List all the places where PHI is stored, whether short-term or long-term:

• EMR or practice management system
• Billing submissions (e.g., provincial insurance, private insurance, patient payments)
• Medical devices (e.g., ECG machines, dental imaging)
• Scanners, fax machines, copiers
• Email systems
• Cloud storage (e.g., Google Drive, Dropbox)
• Staff’s personal devices (if BYOD)
• Third-party service providers
• Archived/off-site backups
• Paper charts and historical records

B. Track Who Has Access

For each location, identify who has access:

• Internal staff (by role or function)
• IT support
• Contracted vendors (e.g., EMR vendors, managed service providers, billing services, transcriptionists)
• Consultants
• Software integrations

C. Review What Kind of Data Is Stored

Be detailed and include data elements for each category:

• Demographic data
• Clinical notes
• Referrals
• Lab results, diagnostic images
• Billing or insurance information
• Communication records (e.g., emails, messages, voicemails)

D. Record How Long You Need to Keep It

Know your legal and professional patient records retention requirements:

• Generally: 10 years past the last contact, or 10 years after the patient reaches the age of majority.
• Be cautious: deleting data too soon or holding on to it too long can both carry risk.

Annual Inventory Review: Contracts and Data Access Change

Things change—vendors go out of business, new platforms are introduced, and team members come and go. That’s why an annual review is essential.

Use this opportunity to:

• Update your list of active software and service providers
• Review and confirm that vendor contracts include proper privacy safeguards (e.g., Information Management Agreements)
• Remove access from former employees and terminated accounts
• Re-assess your data flow maps and user permissions

A current, complete inventory is also essential for PIAs (Privacy Impact Assessments), risk assessments, and effective breach response.

Bonus Tip: Get Your Team Involved

Your staff may know about data sources you’ve forgotten—like a temporary tool used during vacation coverage or a shared spreadsheet with legacy data.

Include your team in the conversation:

  • Host a “Where is our data?” lunch-and-learn or team meeting
  • Use privacy awareness week as a trigger to review and update your inventory
  • Encourage a culture of shared responsibility for PHI protection

It’s Time to Create Your Data Inventory

You can’t safeguard what you can’t see. Now is the perfect time to create—or update—your clinic’s data inventory.

Need help getting started? Join our Practice Management Success Membership for templates, training, and step-by-step guidance. You’ll gain access to practical tools that support your privacy compliance every day.

When we know better, we can do better…

Jean Eaton is constructively obsessive about privacy, confidentiality, and security especially when it comes to the handling of personal health information. If you would like to discuss how I can help your practice, just send me an email. I am here to help you.

Jean L. Eaton
Your Practical Privacy Coach
INFORMATION MANAGERS

Thinking About Using AI Scribe in Your Healthcare Practice?

Thinking About Using AI Scribe in Your Healthcare Practice?

Thinking About Using AI Scribe

What is AI?

AI (artificial intelligence) is an advanced form of information processing to help automate or enhance tasks. In healthcare, AI doesn’t replace providers—it supports them. Clinicians still need to guide its use, review outputs, and make informed decisions.

AI tools typically involve hardware, software, and your data. Even common tools like Microsoft Copilot or ChatGPT rely on this structure. In healthcare, you are often purchasing software and applying it to your patient data—so privacy and transparency are critical.

What Is AI Scribe?

“AI Scribe” is a broad term for tools that help generate clinical notes. Common workflows include:

  • Dictation: The provider speaks, and AI formats the note.
  • Live Listening: The AI listens during a patient visit and drafts the note based on the conversation.

Some advanced tools go further—analyzing lab trends, suggesting diagnoses, or reminding providers about follow-ups. For example, an AI integrated into your EMR may prompt you to include trending lab values in the note.

The AI can “listen” to the patient encounter and summarize it, preparing a draft clinic note for the provider to review.

What Are the Benefits?

AI scribe tools can reduce documentation time by up to 40%, allowing for:

  • Less administrative burden
  • More time with patients
  • Reduced provider burnout

Supporting data:

  • Ontario’s Ministry of Health reports significant time savings.
  • Canada Health Infoway highlights administrative efficiency gains.
  • Alberta’s OIPC HIA Engagement Survey (2024) found public support—with a strong emphasis on transparency.

Do You Need Patient Consent?

Some technology providers argue that patient consent isn’t required—just like we don’t ask patients to approve our use of an EMR system. However, informing patients is essential, especially if the AI listens to or analyzes conversations.

For example, if the provider speaks observations aloud (e.g., “You appear pale and sweaty”) for the AI to capture, patients should understand that this is part of the documentation process.

Inform Patients When We Use AI Tools

As part of your AI implementation plan, consider how you will inform individuals. You might use:

  • A poster in the clinic
  • A verbal explanation at the visit start
  • A statement in your privacy notice

The key is to make a thoughtful, documented decision—and apply it consistently.
Your risk assessment and associated policies will form the foundation of your Privacy Impact Assessment (PIA).

Implementation: It’s Not Plug and Play

AI tools require careful planning. Follow these steps to support successful implementation:

  1. Understand Your Workflow – Know what works and what needs improvement.
  2. Benchmark – Collect data to measure impact.
  3. Choose a Vendor – Use Canada Health Infoway’s pre-qualified vendor list (https://aiscribe.infoway-inforoute.ca).
  4. Do a Risk Assessment & PIA – Ensure compliance with privacy legislation.
  5. Start Small – Pilot the tool first before full rollout.
  6. Analyze Results – Check what’s working.
  7. Roll Out Broadly – Expand based on success.
  8. Monitor Continuously – Evaluate, adjust, and improve as needed.

Who Benefits Most From AI Scribe?

According to the eHealth Centre of Excellence, family physicians and primary care providers benefit most—especially those not already using dictation tools. AI scribe tools are ideal for routine, episodic care with clear documentation needs.

Funding Opportunity

Canada Health Infoway is offering one-year fully funded one-year licenses for eligible primary care providers across Canada including:

  • Family physicians
  • Nurse practitioners
  • Nurses in remote communities
  • Pediatricians providing community-based care

Visit (https://aiscribe.infoway-inforoute.ca) to register for updates and eligibility notifications.

Final Thoughts

AI scribe tools aren’t one-size-fits-all. But with thoughtful planning, clear communication, and proper implementation, the benefits can be significant: more efficient workflows, improved care, and reduced clinician burnout. This improves patient access to healthcare, too!

Need help getting started with your AI privacy and implementation plan?

Practice Management Success members have access to additional tools, including:

  • AI Privacy Checklists
  • Sample Risk Assessments
  • On-demand Q and A with Jean replays:
    • AI in Healthcare – AB Engagement Survey (Mar 11, 2025)
    • AI Implementation Toolkit (Nov 12, 2024)
    • Is AI the Right Choice for Your Clinic? Key Questions Before Using AI Transcription Tools (Jul 9, 2024)

When we know better, we can do better…

Jean Eaton is constructively obsessive about privacy, confidentiality, and security especially when it comes to the handling of personal health information. If you would like to discuss how I can help your practice, just send me an email. I am here to help you.

Jean L. Eaton
Your Practical Privacy Coach
INFORMATION MANAGERS

Why You Need Policies and Procedures

Why You Need Policies and Procedures

 

Why You Need Health Information Policies and Procedures

Maybe you’ve heard you need written policies and procedures for your health information, but you’re left asking yourself why it’s so important?

The truth is, without written policies and procedures, you open a healthcare practice up to a whole host of problems, including major legal issues.

In fact, every business needs good practices that apply to your:

  • Information that you collect from patients/clients
  • Website
  • Email
  • Business practices including electronic (or paper) patient records, and computer network
  • Financial information
  • Billing, collection, and payment processing

Within the healthcare industry, there are additional legislation requirements that require specific written health information policies and procedures.

The Health Information Act (HIA) and the Personal Information Privacy Act (PIPA)

As we mentioned, when a custodian collects health information, you must follow the Health Information Act (HIA) in Alberta.

Like most other private businesses in Alberta, private healthcare practices must also comply with the Personal Information Privacy Act (PIPA).

The colleges of regulated health professionals (like the Alberta Dental Association and College (ADAC) and the College of Physicians and Surgeons of Alberta (CPSA), require dentists and physicians to meet the standards of practice which includes compliance to HIA and PIPA legislation.

In addition, the college has other standards of practice that you must meet, including policies and procedures for the collection, use, disclosure, and access of health information.

So, let’s explore further why written policies and procedures are so essential, as well as what can happen without them, and why healthcare practices may not think they need them in the first place.

Benefits of Policies and Procedures

One of the most critical benefits of having policies and procedures in place is that they’re good for business.

Here’s how:

  • They contribute to consistent, efficient workflow.
  • You can figure it out once, write the procedure, tweak it to make it better, and then repeat the same procedure again and again.
  • They help you make better business decisions, like buying supplies, choosing services, and selecting vendors.
  • They help support your accreditation efforts.
  • On-boarding employees the right way with no missed steps is much easier with policies and procedures in place.

If you’re looking for even more proof of the benefits of having written procedures, it can also help you avoid:

  • Internal disputes within your team and external disputes with your patients and clients
  • Re-work and re-training employees
  • Poor customer service
  • Poor reputation
  • Fines and penalties

Fines And Penalties For Not Having Written Policies And Procedures

You might be wondering why you would face fines and penalties for not having written policies and procedures in the first place.

The HIA requires the custodian – which includes the physician, pharmacist, dentist or dental hygienist – to take reasonable safeguards to protect the privacy and confidentiality of patients’ health information.

Having written policies and procedures is a common, expected, and reasonable safeguard.

Let’s say you have a privacy breach in your practice or an error (like sending a fax to the wrong number or you are a victim of a phishing or ransomware attack).

You can learn more about what makes a privacy breach a privacy breach here.

If you can’t demonstrate that you had the appropriate reasonable safeguards, like written policies and procedures in place, you are guilty of an offence under the law.

It’s illegal not to have policies and procedures when you collect health information.

If you are guilty of this offence, you are liable for a fine of a minimum of $2,000 and not more than $500,000. (HIA section 107(7)).

3 Policies and Procedures Myths

One reason some healthcare practices fail to have written policies and procedures is because they believe they don’t need them.

Often, this is because they’ve fallen prey to the common myths about policies and procedures.

There are 3 of the common myths that stop healthcare providers and their clinic managers from creating written policies and procedures:

  1. It’s Too Hard

While it does take some skill to write clear, easy to read, and easy to understand policies and procedures, it doesn’t have to be heard. In fact, you can even purchase templates to make this easier.

  1. It Takes Too Much Time

Writing policies and procedures does take some time.

But investing the time to create policies and procedures pays off by preventing suffering from inconsistent or broken procedures, using or disclosing health information in error, and having to pay fines, penalties, public relations nightmares, or spending the time required to run a privacy or security investigation.

  1. It’s A Waste Of Time

Here are a few good reasons that prove writing policies and procedures is not a waste of time:

  • Practical privacy policies and procedures will create a more efficient practice and help you make better business decisions.
  • The policies and procedures become the foundation of your privacy impact assessment.
  • Policies and procedures are pre-requisites for other initiatives, like access to Netcare or other community integration initiatives, and privacy impact assessment (PIA). Click here to learn more about PIAs.
  • You must have them as part of your legislative compliance.
  • It’s the law. Not having policies and procedures regarding the collection, use, disclosure, and access of health information is illegal.

As you can see, written policies and procedures help ensure consistent office procedures and good communication between team members in your healthcare practice.

In addition to those good reasons, you must have good written policies and procedures about how you collect, use, disclose, and provide access to health information to avoid legal problems, fees, penalties, and other problems.

 

Not Sure Which Policies and Procedures That You Need?

Show Me Policy And Procedure Checklist
 

Did you enjoy this article? If you’d like to look at similar posts, visit these links:

Do You Know Where Your Policies and Procedures Are? 

Privacy Impact Assessments (PIA)

Policy and Procedure Checklist book image
Leaving a Group Practice? Know Your Responsibilities for Patient Records

Leaving a Group Practice? Know Your Responsibilities for Patient Records

 

Leaving a Group Practice? Know Your Responsibilities for Patient Records

You’ve been part of a group practice for some time.

Now, you’re preparing to open your own clinic, relocate to another area, or step away from practice altogether. Whatever your next move, it’s important to understand your responsibilities when it comes to patient health records.

Here’s what you need to know to leave well—and stay compliant.

Understanding Your Rights and Responsibilities

When you leave a group practice, you still have important obligations tied to patient records. These include:

  • Record access, security, and retention – You’re responsible for the health records you’ve collected while in practice.
  • Right of continuing access – You have the right to access the records of patients you’ve cared for, even after leaving, to respond to inquiries for access, disclosure, complaints, or investigations.
  • Continuity of care – You’re responsible for ensuring appropriate access to patient records to support ongoing care.
  • Duty to inform – Patients should be made aware of your departure and how their records will be managed.
  • Respect existing agreements – This includes any contracts or group practice policies in place, such as Information Management Agreements (IMAs) or Information Sharing Agreements (ISAs).

Resources to Guide You

Before finalizing your departure, review the following documents and standards:

  • Your contract – especially termination clauses
  • Information Management Agreements (IMAs) – with both the group practice and EMR providers
  • Information Sharing Agreements (ISAs)
  • Privacy and security policies – especially those related to closing or relocating a practice
  • Professional college standards – around recordkeeping and patient notification
  • Provincial health privacy legislation – such as Alberta’s Health Information Act or Ontario’s PHIPA

These documents can help clarify who retains custody of the records, what access rights you have, and how to ensure continuity of care for your patients.

What Are Your Plans?

Your responsibilities will vary depending on your next step:
If You’re Relocating (and Patients May Follow)
You may want to request a copy of relevant patient records for continuity of care. To do this:

  • Review your IMA – Is there a cost to receive a copy of your patient records?
  • Talk to your EMR vendor – Is data export or transfer supported? What is the cost?
  • Ensure data quality assurance – Will the records be intact and complete?
  • Prepare a new Privacy Impact Assessment (PIA) for your new location, including data migration

If You’re Leaving Practice or Relocating Far Away
You may choose to leave records with the current group practice. In that case:

  • Make sure you have a written agreement outlining who is responsible for access, storage, and disclosures.
  • Update your IMA to authorize the group to manage patient inquiries on your behalf.
  • Keep in touch with group practice so that they can reach you in case you’re needed to support access to patient records or respond to complaints. You also want to know if the group practice changes significantly.
  • Don’t abandon your records. Even if you’re no longer practicing, you’re still responsible for their safekeeping

The group practice must also agree to manage your patient records on your behalf. Don’t make assumptions—get it in writing!

It Takes Time

It takes time

You didn’t start your practice overnight. It will take time to successfully plan and implement the transition of patient records when you leave the group practice.

Leaving a group practice is a significant professional step—and handling patient records properly is part of doing it right.

With the right planning, communication, and documentation, you can support your patients, protect yourself, and move forward with peace of mind.

Want Extra Support To Navigate Your Transition?

These resources include practical templates, checklists, and expert guidance to help you leave your current practice confidently and in compliance.

✅ Download the Practice Management Success Tips – Closing or Moving Your Healthcare Practice

✅ Get your copy of The Top 3 Agreements Your Healthcare Practice MUST Have (and Why)