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Why “Demonstrable Accountability” Matters

Why “Demonstrable Accountability” Matters

Why “Demonstrable Accountability” Matters

Does Your Privacy Program Have ‘Demonstrable Accountability’?

The first Ontario decision to include an Administrative Monetary Penalty (AMP) under the Personal Health Information Protection Act (PHIPA) shows how serious the consequences can be when personal health information (PHI) is used for an unauthorized secondary purpose.

Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s dive into what went wrong, what worked, and how you can apply these insights to strengthen your privacy program.

What Happened

This case includes the Windsor Regional Hospital, Chatham-Kent Hospital Alliance, Erie Shores Healthcare, WE Kidz Pediatrics, and Dr. Omar Afandi.

Between April 20 and May 7, 2024, Dr. Afandi accessed the shared electronic health record (EHR) system of CKHA’s Women’s and Children’s Program. He used it to identify newborns so he could contact their parents to offer circumcision services at his private practice, WE Kidz Pediatrics.

Several parents reported receiving these unsolicited calls and complained to the hospitals. Dr. Afandi later stated he did not realize these accesses were unauthorized under PHIPA.

Managing the Breach

We can analyze the hospitals’ and clinic’s response using the 4-Step Response Plan.

Step 1 – Spot and Stop

The breach was reported by patients who received unsolicited contact from the physician.

The Chief of Staff wrote to Dr. Afandi on May 15, 2024, advising that his actions constituted an unauthorized collection and use of PHI and inviting him to withdraw his reappointment application with the hospital.

Step 2 – Investigate

The hospital conducted an internal investigation and notified the Information and Privacy Commissioner (IPC).

Records showed that Dr. Afandi had completed Privacy, Security, and Confidentiality training in October 2020 and had signed a confidentiality agreement with WRH. He also confirmed he reviewed WRH’s privacy module again when he reapplied in April 2024.

Step 3 – Notify

The hospitals reported the breach to the IPC on May 31, 2024, and to the College of Physicians and Surgeons of Ontario on June 1, 2024.

Notification letters were sent to potentially affected families the week of July 2, 2024, describing the incident, the PHI involved, and corrective actions. A hotline was provided for questions.

Step 4 –Prevent the Breach from Happening Again

AMP powers to address a privacy breach signal a new era of active enforcement in Ontario’s health privacy landscape.

Administrative Monetary Penalties (AMPs) came into effect under PHIPA on January 1, 2024. This update to the legislation gives the Information and Privacy Commissioner (IPC) authority to issue AMPs of up to $50,000 for individuals and $500,000 for organizations in cases of PHIPA non-compliance.

In this case, the Commissioner exercised those new powers and fined:

  • Dr. Afandi (individual) – $5,000
  • WE Kidz Pediatrics (clinic as custodian) – $7,500

Both were penalized for unauthorized access and use of PHI for personal gain.

The IPC found that WE Kidz opened without a compliant privacy program — a key factor in the penalty decision. 

WE Kidz was also required to complete privacy training and develop formal privacy policies and procedures. The Commissioner also recommended that WRH improve its record-keeping and monitoring to better demonstrate compliance in future audits.

Commissioner’s Investigation

The IPC emphasized the importance of “demonstrable accountability.”

“Demonstrable accountability” refers to a repeatable and evidence-based system of data governance whereby organizations can show regulators and individuals how they meet their legal and professional responsibilities in practice.

In the data regulatory context, the concept has evolved beyond basic checklist compliance. It now requires organizations to prove that their accountability mechanisms are active and effective — that safeguards are working as intended to reasonably protect personal health information.

In other words, demonstrable accountability means being able to measure, document, and demonstrate that privacy protections are in place, maintained, and effective — not just written in a policy.

Being able to demonstrate compliance is a regulatory expectation under PHIPA — and it’s the key to avoiding costly penalties.

Demonstrable Accountability infographic Information Managers Ltd.

Under Section 10 of PHIPA, custodians must have information practices describing how they collect, use, disclose, retain, and safeguard PHI — and they must comply with those practices in day-to-day operations.

Take-Aways

✅ “Demonstrable accountability” means having evidence that your privacy program is working — not just written policies on a shelf.

✅ Maintain dated policies, training checklists, and signed confidentiality agreements for every team member.

✅ Replace “professional deference” with consistent expectations — all healthcare providers must complete privacy training and demonstrate understanding.

✅ Document and review your privacy program annually to ensure that safeguards and practices are effective in real life.

✅ Unauthorized secondary use of PHI — even for legitimate healthcare services — is a serious breach and can result in financial penalties.

Need Help Training Your Privacy Team?

Join the Practice Management Success Membership to access privacy awareness training, templates, and resources to strengthen your privacy management program.

Reference

Information Privacy Commissioner of Ontario. PHIPA Decision 298. August 28, 2025. https://www.ipc.on.ca/en/decisions/latest-decisions/phipa-decision-298

 

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Privacy Breach Nugget: Why Documentation Matters in Privacy Breach Investigations

Privacy Breach Nugget: Why Documentation Matters in Privacy Breach Investigations

Investigation Tips Following the NWT Health Authority Incident

When employees make mistakes that result in a privacy breach, the custodian is held responsible to ensure that appropriate investigations are performed. This includes appropriate documentation of the privacy breach incident and sanctions when indicated.

The NWT Information and Privacy Commissioner (IPC) opened an investigation into the Northwest Territories Health and Social Services Authority (NTHSSA) after a reported privacy breach in 2024. This review aimed to assess whether the health authority had adequate safeguards in place to investigate and prevent similar future incidents.

Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s dive into what went wrong, what worked, and how you can apply these insights to strengthen your privacy program.

What Happened

In April 2024, a patient filed a complaint with the nurse-in-charge at a health centre in the Northwest Territories. The complaint alleged that a clerk had inappropriately shared the patient’s personal health information with a family member during a casual conversation.

The nurse-in-charge apologized to the patient and escalated the issue to the regional manager. The clerk denied disclosing the health information, but the health authority concluded the incident had indeed occurred.

The Commissioner emphasized that there was no ill intent, stating:

“The interaction between the clerk and the sister was spontaneous and indicates a simple lapse in judgment.”

Managing the Breach

The NTHSSA’s management of the privacy breach can be examined using the 4 Step Response Plan.

Step 1 – Spot and Stop

The privacy breach was identified by the patient and reported to the nurse in charge and escalated to the regional manager.

Step 2 – Investigate

An investigation was initiated. While the clerk denied the allegation, the health authority determined a breach had occurred.

However, the Commissioner noted a serious concern: the investigation was poorly documented. If notes were taken, they could not be located or produced during the review.

Step 3 – Notify

The patient and NTHSSA (the custodian) was aware of the breach. No further notification was required.

Step 4 – Prevent the Breach from Happening Again

The health authority directed the clerk to:

  • Complete updated privacy training
  • Review the oath of office
  • Review patient confidentiality policies

No further disciplinary action was taken.

Commissioner’s Investigation

The IPC made several key recommendations:

  • Equip investigators: Ensure staff who investigate privacy breaches are properly trained and supported to conduct effective, timely, and well-documented investigations.
  • Enforce sanctions: Ensure managers understand the range of disciplinary options available and are aware of their obligation to apply reasonable disciplinary measures when warranted.
  • Annual privacy training: Reinforce the Mandatory Training Policy by ensuring all employees complete refresher privacy training every year.
  • Use real examples: Incorporate this privacy breach as a case study in future privacy training to help employees understand their obligations—at work and outside of work.

Take-Aways

Annual privacy training is not enough.

Training must include real-world, job-relevant examples and emphasize how privacy rules apply in everyday situations.

When employees make mistakes, it’s the custodian’s responsibility to lead an appropriate and well-documented investigation—not just revisit outdated training.

A strong privacy culture includes tools, training, and clarity. Equip your investigators, privacy officers, and managers with the skills they need to respond appropriately.

For more on how to manage privacy-related employee errors, listen to the podcast:

Managing Employees When They Make Mistakes – Episode #105

Need Help Training Your Privacy Team?

Ask me about Practical Privacy Officer Strategies training to strengthen your internal investigation process and build a more resilient workplace.

Reference

NWT IPC File Number: 24-950-6 on April 4, 2025Northwest Territories Health and Social Services Authority (Re), 2025 NTIPC 97 (CanLII), <https://canlii.ca/t/kc0s6>, retrieved on 2025-06-09

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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