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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

 
Build a Strong Privacy Management Program for Your Clinic With These 5 Critical Modules

Build a Strong Privacy Management Program for Your Clinic With These 5 Critical Modules

Struggling to Learn Your Role As A Privacy Officer?

In many small healthcare practices, the privacy officer is also the clinic manager, healthcare provider, IT technician, or business owner. It’s no surprise that new privacy officers feel overwhelmed trying to balance competing responsibilities.

Without a clear plan, you may find that you

  • Panic when a patient asks for their information for access or correction.
  • Scramble when new employees and healthcare providers join your clinic . . .and suddenly realize that you never got around to providing privacy and cybersecurity awareness training.
  • Hope that your practice will not be tapped on the shoulder for a practice review by your college or the OIPC.
  • Ignore privacy breach and hope no one else notices.
  • Avoid difficult decisions with your owners / staff who insist on doing things their way – even when it is not privacy compliant.
  • Never get ‘review privacy impact assessment’ and ‘review privacy policies and procedures’ off of your to-do list.
  • Avoid discussing privacy and security with your EMR and computer networks managed service providers because you are unsure of what questions to ask and what types of answers you should receive.

If you don’t have a written privacy management program and action plan, you are missing the systems that prevent small issues from becoming privacy and security incidents.

The good news? Organizations with an active privacy officer and privacy management program are less likely to experience breaches and report better staff engagement and patient trust.

Privacy Is Good For Business

Strong privacy practices aren’t just about legal compliance. Policies, procedures, and systems improve communication, reduce risk, and support better decision-making.

A practical privacy management program creates accountability for the collection, use, and disclosure of health information, while demonstrating compliance to regulators and professional colleges.

Based on my experience, the five critical modules of a privacy management program are:

  1. Know Your Obligations
  2. Train
  3. Privacy Breach Management
  4. Document your Privacy Management Program
  5. Access and Disclosure

Module 1—Know your Obligations

Accountability starts with your healthcare provider(s)—also known as “custodians.” They are legally responsible for the privacy, confidentiality, and security of personal health information (PHI).

Custodians can delegate day-to-day tasks to a privacy officer, often the clinic or practice manager in smaller settings. Business owners also have obligations for employee and customer information. Together, the healthcare provider, business owner, and privacy officer form a trifecta of authority responsible for privacy compliance.

Knowing your obligations means:

  • Establishing clear roles and accountability
  • Identifying all types of personal and health information in your practice
  • Understanding how privacy legislation applies to your operations

Training for custodians and privacy officers is often required to build confidence and competence in these responsibilities.

Module 2 – Training

Privacy training is essential and must be consistent across your organization. Every staff member—new and experienced—should complete privacy awareness and cybersecurity training, and you should document attendance.

Effective training includes both formal and informal opportunities:

  • Formal: orientation programs, annual refreshers, and documented privacy awareness training
  • Informal: short reminders in staff meetings, activities tied to events like Data Privacy Day or Cybersecurity Awareness Month

Don’t overlook staff moving into new roles—promotions are an ideal time for targeted training about new responsibilities, such as authorizing users or supervising others.

Module 3 – Privacy Breach Management Plan

Every practice needs a written privacy breach management procedure. The privacy officer should ensure staff know how to recognize and report a breach, and custodians must be notified promptly.

Your plan should cover:

  • How to contain and investigate suspected breaches
  • Sanctions for non-compliance
  • Notification to patients and regulators when required

The privacy officer will manage mandatory privacy breach notification requirements under the health privacy legislation like the Alberta Health Information Act (HIA), Ontario Personal Health and Information Protection Act (PHIPA) and the Personal Information Protection of Electronic Documents Act (PIPEDA) and other province’s legislation.

Module 4 – Document: The Backbone of Privacy Compliance

Privacy training is essential and must be consistent across your organization. Every staff member—new and experienced—should complete privacy awareness and cybersecurity training, and you should document attendance.

Effective training includes both formal and informal opportunities:

  • Formal: orientation programs, annual refreshers, and documented privacy awareness training
  • Informal: short reminders in staff meetings, activities tied to events like Data Privacy Day or Cybersecurity Awareness Month

Don’t overlook staff moving into new roles—promotions are an ideal time for targeted training about new responsibilities, such as authorizing users or supervising others.

Module 5 – Access and Disclosure: Ensuring Patient Rights

Patients and employees have the right to access and correct their information. Release of information (ROI) policies and procedures are essential.

Your ROI plan should:

  • Define clear steps for handling requests
  • Train staff on how to respond appropriately
  • Align with legislation and college standards of practice

Doing this well helps you avoid complaints and breaches, improves efficiency, and strengthens patient trust.

Bringing It All Together

Being a privacy officer doesn’t have to feel overwhelming. With a structured privacy management program built on these five modules, you’ll have the systems to protect patients, support your staff, and strengthen your business.

If you’re a privacy officer in a healthcare practice and want practical strategies you can apply right away, join the upcoming Practical Privacy Officer Strategies training.

Training starts October 9, 2025

Register here https://informationmanagers.ca/ppo

Not sure if this is for you?

Send me an email and ask me! I’m happy to mentor you and help you assess your practice management and privacy compliance priorities.

Do You Want To Be A Confident Healthcare Privacy Officer?

Do You Want To Be A Confident Healthcare Privacy Officer?

Understanding the Role: What Is a Privacy Officer?

A privacy officer is a key employee in a healthcare organization who is named by the healthcare provider (custodian) and assigned the responsibility to oversee all activities related to the implementation of, and adherence to, the organization’s privacy practices, and to ensure operational procedures are in compliance with relevant privacy laws. The Privacy Officer monitors employees and systems about how information is collected, used, and disclosed and access to identifying information.

A privacy officer may be known by other titles like privacy compliance officer or a security officer.

If your healthcare business involves the collection, use, and disclosure of your clients’ and patients’ personal health information, a privacy officer is necessary in order to meet legislated requirements.

Consequences of Operating Without a Privacy Officer

Healthcare practices without a privacy officer often experience confusion about how patients’ personal health information should be collected, used, and disclosed. Patients may complain about lack of access to their personal health information. Without a named privacy officer to assume the responsibility to implement and monitor reasonable administrative, technical, and physical safeguards you are more likely to experience privacy and security incidents, privacy breaches, investigations, fines, and charges under the privacy legislation!

Case Studies: Real-world Implications of Privacy Officer Absence

In 2019, the British Columbia Office of the Information and Privacy Commissioner (OIPC) conducted a privacy audit of 22 medical clinics. OIPC auditors examined 22 clinics and found gaps in privacy management programs at several clinics, including the absence of a designated privacy officer, a lack of funding and resources for privacy and a failure to ensure that privacy practices keep up with technological advances.

Here’s another example. A complaint was made against a medical clinic with an employee suspected of accessing health information for an unauthorized purpose. The Alberta OIPC investigated and revealed confusion around the roles and responsibilities of privacy compliance among the custodians and the privacy officer. The OIPC determined that the custodian was in contravention of the regulation which requires custodians to ensure that their affiliates are aware of and adhere to the all of the custodian’s administrative, technical, and physical safeguards with respect to health information. 

Say No to Snooping: The Need for Privacy Enforcement

Employees are not aware of privacy requirements and engage in snooping into personal health information. Consequences of employee snooping include firing, charges under the Health Information Act and court ordered fines, jail time, probation, community service and more.

say not so snooping animation of thief taking papers from folder

Roles and Responsibilities of a Healthcare Privacy Officer

So, what does a privacy officer do? The roles and responsibilities of a privacy officer in a typical healthcare practices include the following:

  • Identify privacy compliance issues for the business.
  • Ensure privacy and security policies and procedures are developed and keep them up to date.
  • Ensure that everyone working at your clinic and your vendors are aware of their privacy obligations.
  • Monitor your clinic’s ongoing compliance with privacy legislation like the Health Information Act (HIA) in Alberta.
  • Provide advice and interpretation of related legislation for the business.
  • Respond to requests for access and corrections to personal information.
  • Ensure the security and protection of personal information in the custody or control of the business.
  • Act as the primary point of privacy and access contact for staff, patients, vendors, regulators and other stakeholders.
 

Introducing Practical Privacy Office Strategies Training

I want to help you become a confident healthcare privacy officer. And a guide (or a Jeannie ) to help you is a good thing.

Practical Privacy Officer Strategies will help you to assess your current PIA and privacy management program and plan your privacy compliance activities for the next year!

Practical Privacy Officer Strategies will help you to assess your current PIA and privacy management program and plan your privacy compliance activities for the next year!
5 Modules with Live 1-hour training and on-line mentoring will help you to build systems to monitor the routine tasks that will protect privacy and alert you to potential problems before they become privacy and security incidents.
 
How the training will be delivered:
  • Pre-recorded core training in each of the 5 modules. You watch the 1 hour video before the live coaching call.
  • Live 1 hour coaching call with practical case study, discussion, and accountability in each of the 5 modules.
  • Actionable plan with templates, tools, and resources to use what you learned.
  • Every module includes both WHY you need the information and HOW you should use the information.
 
Find Out More!
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)

Privacy Principles Applies After Death

Privacy Principles Applies After Death

 

Privacy Principles Applies After Death

Are your staff looking at medical records when they shouldn’t be?

Many people have the mistaken impression they can look at a patient’s medical records as long as they don’t tell anyone else.

It’s not okay.

We continue to see examples of snooping where both seasoned and new healthcare providers and support staff don’t realize that looking at patient’s health information—even with good intentions—is a serious privacy violation.

As privacy lawyer Kate Dewhirst puts it

  • Privacy = Don’t look
  • Confidentiality = Don’t tell

Despite years of experience, many healthcare professionals still need a refresher on the basics. Privacy awareness training remains essential.

In this article, I am sharing an example of the Ontario’s Information Privacy Commissioner (IPC). This case involves a privacy complaint submitted by the family of a deceased individual. It’s a good reminder that whether you’re running a brand-new clinic or managing an established practice, it’s critical to understand your legal responsibilities and have systems in place to protect patient information.

What Happened

In 2014, a physician accessed a deceased patient’s health records while acting in his role as a coroner. The patient was also a family member. Soon after, the family alleged that the physician continued to access the individual’s personal health information (PHI) contrary to Ontario’s Personal Health Information Protection Act (PHIPA).

The family submitted a complaint to the hospital. Initially, the hospital’s response did not satisfy the family. The family filed a complaint to the Information and Privacy Commissioner (IPC) of Ontario.

The IPC started a complaint investigation.

privacy principles after death privacy breach incident scenario diagram

Privacy Complaint Investigation

Under PHIPA, the hospital is a health information custodian and the physician is an agent of the hospital.

During the IPC investigation, the physician admitted he “accessed the health information in response to his concern about the individual’s well-being.”

“I know now that proceeding in this way was misguided and wrong.” He would never disclose the information to anyone; that would be a violation of patient privacy and a breach of doctor – patient confidentiality.

He acknowledged he misunderstood the difference between:

• Privacy: The general right of every individual (living or deceased) to limit access to their health information.
• Confidentiality: The duty to not share that information once accessed.
• Circle of care / Need to know: You must only access information required to provide care at that moment.

4 Step Response Plan

When you have a privacy breach, follow these four steps to manage the privacy breach incident.

Step 1 – Spot and Stop the Breach

The family’s complaint prompted the hospital to begin the first step to spot and stop the breach.

Step 2 – Evaluate the Risks

An initial risk assessment was conducted, and after the IPC got involved, the hospital re-opened the investigation. They completed a comprehensive review and used audit log reporting tools to trace access.

Step 3 – Notify

The hospital eventually informed the family of the privacy breach—but the notification wasn’t timely. A more thorough and timely response could have helped address the family’s concerns more effectively.

Step 4 – Prevent the Breach From Happening Again

Following the breach, the hospital implemented several improvements:

  • Introduced a new auditing program that enhances its ability to detect unauthorized access.
  • Updated its Privacy and Confidentiality Policy, which applies to all agents of the hospital.
  • Launched mandatory annual electronic privacy training program for all staff, volunteers and learners. Physicians must complete this training as part of the annual reappointment process.
  • Strengthened the privacy warning on its electronic system, which warns users that unauthorized use of personal health information may result in disciplinary action.

privacy principles after death sanctions

The hospital’s Medical Advisory Committee also recommended disciplinary actions:

  • A three-month suspension of the physician’s hospital privileges
  • Three years of enhanced monitoring of his access to patient records
  • A requirement to present at Grand Rounds on privacy topics upon his return

The IPC concluded that the disciplinary consequences for the physician were sufficient in the circumstances.

Privacy Breach Nuggets You Need to Know

Privacy breaches are in the news every day. Here’s how you can be proactive to prevent privacy breach pain.

  • Go beyond policies—model good practices
  • Use real-life examples in staff meetings
  • Incorporate gamification and ongoing discussions to engage your team

Privacy awareness is everyone’s responsibility. Make sure your staff know what’s expected, what’s at risk, and what to do if something goes wrong.

If you need to start or update your privacy awareness training program, check out the on-line education Privacy Awareness in Healthcare: Essentials.

When we know better, we can do better…

I’ve helped hundreds of healthcare practices prevent privacy breach pain like this. If you would like to discuss how I can help your practice, just send me an email. I am here to help you protect your practice.

PRIVACY BREACH NUGGETS are provided to help you add a ‘nugget’ to your privacy education program. Share these with your staff and patients as a newsletter, poster, or staff meeting.

Jean L. Eaton, Your Practical Privacy Coach

References and Resources

Dewhirst, Kate. After Death: Who Can Access The Records Of A Patient After Death? May 7, 2019. https://katedewhirst.com/blog/2019/05/07/after-death-who-can-access-the-records-of-a-patient-after-death/

Ontario Information and Privacy Commissioner IPC Investigation Report PHIPA DECISION 74 HC15-4 Sault Area Hospital August 10, 2018.

Does AI Take Your Data? AI and Data Privacy

Does AI Take Your Data? AI and Data Privacy

 

Does AI Take Your Data? AI and Data Privacy

Generative AI, including platforms like ChatGPT, DALL-E, Google Gemini, Apple Intelligence, has revolutionized our relationship with technology. Maybe these tools have completely changed how you work and engage with the internet. There seems to be endless ways to use these platforms, many of which are called large language models (LLMs). These chatbots can assist with brainstorming, writing, and even coding—but they also can be significant risks when used carelessly. One of the biggest concerns? Employees inadvertently exposing sensitive company information.

The National Cybersecurity Alliance 2024 Oh Behave report found that 65% of us are concerned about AI-related cybercrime, and most people (55%) haven’t received any training about using AI securely. For AI Fools Week, let’s change that! #AIFools

First and foremost, when you’re using an AI tool, think about what you’re sharing and how it could be used.

Generative AI

 

Think intelligent about AI

AI models process and store data differently than traditional software. Public AI platforms often retain input data for training purposes, meaning that anything you share could be used to refine future responses—or worse, inadvertently exposed to other users.

Here are the major risks of entering sensitive data into public AI platforms:

  • Exposure of private company data – Proprietary company data, such as project details, strategies, software code, and unpublished research, could be retained and influence future AI outputs.
  • Confidential customer information – Personal data or client records should never be entered, as this could lead to privacy violations and legal repercussions.

Many AI platforms allow you to toggle off the use of what you enter for training data, but you shouldn’t trust that as an ultimate failsafe. Think of AI platforms as social media: if you wouldn’t post it, don’t enter it into AI.

Check Before You Use AI At Work

Before integrating AI tools into your workflow, take these critical steps:

  1. Review company AI policies – Many organizations now have policies governing AI use. Check whether your company allows employees to use AI and under what conditions.
  2. See if your company has a private AI platform – Many businesses, especially large corporations, now have internal AI tools that offer greater security and prevent data from being shared with third-party services.
  3. Understand data retention and privacy policies – If you use public AI platforms, review their terms of service to understand how your data is stored and used. Specifically look at their data retention and data use policies.

How To Protect Your Data While Using AI

If you’re going to use AI, use it safely!

  • Stick to secure, company-approved AI tools at work – If your organization provides an internal AI solution, use it instead of public alternatives. If your workplace isn’t there yet, check with your supervisor about what you should do.
  • Think before you click – Treat AI interactions like public forums. Don’t enter information into a chatbot if you wouldn’t share it in a press release or post it on social media.
  • Use vague or generic inputs – Instead of inputting confidential information, use general, nonspecific questions as your prompt.
  • Protect your AI account with strong passwords and MFA – Protect your AI accounts like all your other ones: use a unique, complex, and long password (at least 16 characters). Enable multi-factor authentication (MFA), which will add another solid layer of protection.

Increase your AI IQ

Generative AI is powerful! But you are wise. Use AI intelligently, especially when sensitive data is involved. By being mindful of what you share, following company policies, and prioritizing security, you can benefit from AI without putting your company at risk.

You May Also Be Interested In

Is AI the Right Fit for Your Clinic? Key Considerations Before You Implement

 

 
Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

Medical Secretary Fined for Unauthorized Access And Disclosure

Privacy Breach Nugget
Ever wonder how privacy breaches happen—and what you can do to stop them? Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s unpack today’s case and explore what went wrong, what worked, and how you can apply these insights to protect patient information.

What Happened

In 2020, a medical secretary working at the University of Alberta Hospital in Edmonton, Alberta, accessed the health information of 17 individuals without any legitimate job-related reason.

The individuals whose information was accessed had personal relationships with the secretary. She went a step further by disclosing sensitive health information about two of them—including infectious disease details—to others who had no reason to know this information.

One of the individuals experienced harassment through text messages as a direct result of this disclosure.

Managing the Breach

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

unauthorized breach

Step 1 – Spot and Stop

When a privacy incident is suspected, the first priority is to stop the unauthorized access. It would be appropriate to immediately suspend the employee’s access to health information systems like ConnectCare and Netcare.

If you suspect a privacy breach, don’t wait—report it to your Privacy Officer and Custodian right away.

Step 2 – Investigate

Alberta Health Services (AHS) completed an internal investigation including auditing the employee’s system activity.

The investigation assessed the “real risk of significant harm” (RROSH). This case is a stark reminder of how improper access and disclosure of health information can lead to serious harm.

Step 3 – Notify

In Alberta, custodians like physicians and healthcare organizations are legally required to notify:

• The Office of the Information and Privacy Commissioner (OIPC). (See Guide to Reporting Privacy Breaches)
• The Alberta Minister of Health.
• The affected patients whose personal health information was improperly accessed or disclosed.

Additional notifications may include law enforcement, insurers, or other stakeholders depending on the situation.

Step 4 –Prevent the Breach from Happening Again

Proactive prevention is key to prevent breaches like this. Here’s how:

• Conduct regular privacy training to keep privacy awareness top of mind.
• Maintain a privacy incident log to spot trends and address recurring issues.
• Implement and enforce privacy-monitoring practices to detect and deter snooping.

Diane McLeod, Alberta’s Privacy Commissioner, highlighted an “alarming rise” in snooping incidents in health information systems. The OIPC’s 2023-2024 Annual Report revealed 14 potential breaches of the Health Information Act investigated by the Commissioner’s office, with hundreds more reported.

Commissioner’s Investigation

The OIPC has implemented a process to focus on high-priority breaches. Following its investigation, the Commissioner recommended charges under the Health Information Act (HIA).

Court’s Decision

In February 2025, the court sentenced the medical secretary, Kayla Satre, to a $2,000 fine for unauthorized access to health information, violating the HIA.

However, the Crown Attorney withdrew charges related to the unauthorized disclosure of health information.

Take-Aways

Snooping is the unauthorized access to health information. This remains a persistent issue in healthcare. Here’s what you can do:

• Educate and remind your team regularly about the importance of patient privacy.
• Monitor system access proactively to detect and stop unauthorized activity.
• Share real-world examples like this one to drive home the importance of privacy compliance.

Protecting patient information isn’t just about compliance—it’s about trust. Share this example with your team and make privacy a daily priority!

Reference and Resources

Office of the Information and Privacy Commissioner of Alberta. Former Alberta Health Services employee fined for unauthorized disclosure of health information, February 6, 2025. https://oipc.ab.ca/former-alberta-health-services-employee-fined-for-unauthorized-disclosure-of-health-information/

You May Also Be Interested In

3rd Largest Fine Ever Under the HIA – Blog post on the unauthorized use of health information that led to costly fines
Practical Privacy Officer Strategies – Training for clinic manages and privacy officers includes how to respond to a privacy breach and prevention strategies.
Tips to Prevent Employee Snooping – A Key Component of Your Privacy Practice Management Program: A Hands-On Guide to Protect Your Healthcare Practice from Privacy Beaches
3 Parts to Every Privacy Awareness Training Plan

3 Parts to Every Privacy Awareness Training Plan

Reasonable Safeguards – the Myth

You may have heard the myth that the Health Information Act (HIA) is a big scary thing that will interrupt your routine, rob you of countless billable hours, impact all of your staff, turn your office inside out, and change the way that you run your entire business!

Myth Buster

The HIA provides structure and framework for reasonable safeguards that apply to any healthcare business.

One of the requirements of reasonable safeguards includes having a privacy awareness training plan.

Click the >> arrow to play the video

Privacy Awareness Training

Your Privacy Awareness Training Plan should include learning objectives throughout the year, including

  • Orientation – Standardized training curriculum provided to everyone in you healthcare practice at the time of employment. This is often included during a new employee’s orientation period.
  • Specific – Privacy training that is more detailed and specific to the roles and responsibilities of that individual’s job in your healthcare practice. There may also be specific training when new software, technology, or procedures are introduced anytime throughout the employment.
  • Reward – Keep privacy awareness top of mind all year long. Recognize and reward when individuals follow privacy principles that also add value to your client satisfaction or business efficiency.

It is reasonable to expect regular privacy awareness training, especially at orientation, and a formal review annually.

What a Privacy Awareness Training Plan Can Do For You

When you implement regular privacy awareness training, you will see:

  • Privacy and security expectations clearly communicated among your team.
  • Team members demonstrate their commitment to privacy, confidentiality, security of personal health information.
  • Efficient practices that protect the privacy and save you time and money
  • Team members confidently and correctly handle personal health information using reasonable safeguards

Are You a Myth-Buster?

You can be a myth-buster, too, and implement privacy awareness training in your healthcare practice.

You can easily implement reasonable safeguards and meet HIA requirements to ensure privacy, confidentiality, and security of health information that saves you time, frustration and money.

If you need a little help, I have written a practical privacy awareness training course designed for the community health care practice. This is ideal for orientation of new employees and a refresher for the rest of us.

Privacy Awareness in Healthcare: Essentials

Understand basic health care privacy principles and how to handle personal information, use safeguards, and recognize and report a privacy breach.

Ideal for community-based health care professionals and staff, direct care providers, or anyone working with a health care, dental, or social services organization.

An effective privacy compliance program promotes organizational adherence to the Health Information Act (HIA), Personal Information Protection Act (PIPA) Alberta, Personal Health Information Protection Act (PHIPA) Ontario and the Personal Information Protection of Electronic Documents Act (PIPEDA) requirements. A compliance program is your first line of defense to promote the prevention of criminal conduct, and enforce government rules and regulations, while providing quality care to patients. All three training products help protect practices against privacy and security breaches, improper payments, fraud and abuse, and other potential liability areas through education.

Canadian Health Care Privacy Training Solutions

Corridor’s online training makes it easy for health care organizations to comply with provincial and federal legislation that mandates regular privacy training for all health care providers, staff, and vendors.

Select the training that best fits your needs:

NEW! Privacy Awareness in Healthcare Training: Dental Practices – Alberta

Dentists and dental practices in Alberta are required to have an ongoing privacy program to ensure the protection of private records and patient information. The appropriate collection, use, and disclosure of personal information is critical to maintaining privacy for patients that choose to trust in your practice. Accomplishing this important goal demands an up-to-date training strategy.

Privacy Awareness in Health Care Training – Canada

Includes detailed resources for each province and territory with key terminology and links to applicable privacy legislation. Resources are provided for our ten provinces: Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Nova Scotia, Ontario, Prince Edward Island, Quebec, Saskatchewan, and three territories: Northwest Territories, Nunavut and Yukon. This new product is ideal for both organizations and vendors who provide health care services or have health care clients in more than one province.

Privacy Awareness in Health Care Training – Alberta 

Includes the mandatory privacy breach notification amendments to the Health Information Act (HIA).

Privacy Awareness in Health Care Training – Ontario

Specifically covers all legislation and rules specific to the province of Ontario including the Personal Health Information Protection Act (PHIPA).

Refresher: Privacy Awareness in Health Care – Alberta

A quiz-based review of Corridor’s full Privacy Awareness course. The Refresher starts with an initial quiz to assess knowledge on the topics and information covered in the full course. Based on the quiz results, one or more of eight Refresher topic quizzes must be completed, each focusing on a specific subject area. The Refresher also includes access to the original course content.

 

Privacy Awareness in Healthcare: Essentials

Grab your on-line course from Information Managers and Corridor Interactive

for just $30 per individual 3 month subscription now!

Click Here to Grab Your On-Line Privacy Awareness Course Now!
3rd Largest Fine Ever Under the HIA

3rd Largest Fine Ever Under the HIA

3rd Largest Fine Ever Under the HIA

Ever wonder how privacy breaches happen—and what you can do to stop them? Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s dive into today’s case and explore what went wrong, what worked, and how you can apply these insights to protect patient information.

What Happened

An employee who had access to personal health information (PHI) had unauthorized use and altered the PHI. The employer discovered the unauthorized access and conducted an internal investigation. Subsequently, the employer reported the privacy breach to the Office of the Information and Privacy Commissioner as required under the Alberta Health Information Act (HIA).

The Alberta OIPC charged an individual with falsifying COVID-19 immunization records of nearly 200 people from September to November 2021 while they were employed in an administrative support staff role at Alberta Health Services (AHS). The false information was entered into the health information system which feeds into the Alberta Health Immunization record system.

Commissioner’s Investigation

The OIPC opened an offence investigation in June 2023. in March 2024, the OIPC recommended charges under the HIA.

In December 2024, Justice Mah of the Alberta Court of Justice sentenced Hind Mahmoud Dabash to a fine of $12,000 for the offence of knowingly using and creating health information in contravention of the HIA.

The other charge, of knowingly gaining access to the health information of 199 members of the public, was withdrawn.

Take-Aways

The custodian, AHS, was able to monitor and investigate the users’ actions in the electronic medical record systems. This capability is a requirement of health information systems and is a deterrent to individuals to access and alter PHI.

This case is unusual because the employee altered or changed the results of the immunization records which could have resulted in inaccurate diagnosis and treatment decisions for the individual and their families and contacts.

Regular privacy awareness training and monitoring of user activity audit log and supervision are essential steps to prevent and detect the unauthorized use of health information.

Reference

Alberta OIPC News Release December 19, 2024.  https://oipc.ab.ca/court-case-concludes-in-sentencing-for-offence-under-health-information-act/ 

You May Also Be Interested In

Practical Privacy Officer Strategies – Training for clinic manages and privacy officers includes how to respond to a privacy breach and prevention strategies. 
Tips to Prevent Employee Snooping – A Key Component of Your Privacy Practice Management Program: A Hands-On Guide to Protect Your Healthcare Practice from Privacy Beaches