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Why You Need Policies and Procedures

Posted on March 15, 2022 by Jean Eaton in Blog

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

Fines for not having policies and proceduresYou 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? 

Why Do You Need Health Information Policies and Procedures?

Healthcare Policies And Procedures: Essential in EVERY Practice

New! Health Information Policy and Procedure Manuals

Privacy Impact Assessments (PIA)

 

Alberta, clinic, custodian, health, Health Information Act, healthcare, HIA, medical, physicians, PIPA, Policies and procedures, privacy, Privacy Impact Assessment, reasonable safeguards

Do You Know Where Your Policies And Procedures Are?

Posted on November 15, 2021 by Jean Eaton in Blog

Do You Know Where Your Policies and Procedures Are?

This is a cautionary tale.

And it could save you a lot of embarrassment – even legal issues.

The way a healthcare provider collects, uses and discloses personal health information (PHI) is critical to an efficient healthcare practice.

It’s also required by legislation and professional college regulations and standards.

Policies and procedures must be in writing, available to employees, and monitored to ensure that they are followed. Otherwise, you face all sorts of risks, including privacy breaches and other legal problems.

Policies and procedures must be in writing, available to employees, and monitored to ensure that they are followed. #Policies Click to Tweet

Don't let this happen to you!

Everyone in a healthcare practice — including front office staff, wellness practitioners and physicians and other custodians — must be aware of and follow these policies and procedures.

These policies and procedures also become the foundation of your privacy impact assessment (PIA).

That’s why, in this Privacy Breach Nugget, we’ll review a privacy breach investigation report from Alberta's Office of the Information and Privacy Commissioner (OIPC). Whether you have a new practice, or an existing practice, we have a number of services and resources designed to help you manage your practice in a way that not only meets legal requirements, but is streamlined and efficient, and keep your information secure.

What Happened

This report started with an employee suspected of accessing health information for an unauthorized purpose.

It started with at the clinic with a conflict between the employees and the employer.

An employee (Employee A) was on leave from her position at the clinic. Her access to the electronic medical record (EMR) was suspended during her leave.

Employee A wanted to access patient information to support her dispute with management. Over two months, Employee A used Employee B’s credentials to access patient records.

This action is in contravention of the Health Information Act (HIA) sections 27 and 28.

This is where this case becomes even more convoluted and, in fact, a better case study of what not to do.

Employee Dispute

Understanding the Health Information Act

The Health Information Act (HIA) requires the custodian (the physician, in this case) to take reasonable steps to maintain administrative, technical, and physical safeguards to protect patient privacy as required by sections 60 and 63 of the HIA, and section 8 of the Health Information Regulation.

In November 2013, the clinic submitted a privacy impact assessment (PIA) to the OIPC prior to its implementation of an electronic medical record (EMR).

The PIA included written policies and procedures.

The letter to the OIPC accompanying the PIA was signed by two physicians, as well as Employee A who was the privacy officer at that time.

The physician named in the investigative report is not the current custodian at the clinic. The physician was hired in 2015 and therefore not a member of the clinic in 2013 and not involved in the initial PIA submission.

During the investigation, both employees indicated that the policies and procedures to protect patient privacy were in a binder in the clinic, but it was never used or shared with the staff.

Oaths of confidentiality may have been previously signed by the employees, but the documents could not be produced during the investigation.

Section 8 (6) of the Regulation states the ‘custodian must ensure its affiliates are aware of and adhere to all of the custodians administrative, technical, and physical safeguards in respect of health information.’

It’s common practice for clinics to require employees to sign confidentiality agreements and ensure that they receive patient privacy awareness training with regular updates.

But in this investigation, the employees said they never received privacy awareness training.

Show Me Policy and Procedure Checklist

Access To Patient Information

The employees also stated it was common practice at this clinic for individuals to not log off of their EMR account on the computers at the reception desks. It was common practice for other employees to access an open session to quickly perform a task in the EMR.

The investigator concluded that the physician was in contravention of the HIA section 63(1) which requires custodians to establish or adopt policies and procedures that would facilitate the implementation of the Act and regulations.

These specific findings were made:

  • The custodian failed to ensure the clinic employees were made aware of and adhered to the safeguards put in place to protect health information in contradiction contravention of section 8(6) of the regulation.
  • The custodian was in contravention of section 8(6) of the regulation which requires custodians to ensure that their affiliates are aware of and adhere to all of the custodian’s administrative, technical, and physical safeguards with respect to health information. It’s important to note any collection use or disclosure of health information by an affiliate of a custodian is considered to be the collection, use, and disclosure by the custodian.
  • The custodian failed to ensure the employee and the other clinic staff adhered to technical safeguards as required by section 60 of the HIA and section 8(6) of the regulations.

Privacy Breach Nuggets You Need to Know

Privacy breaches are in the news every day. The more you know how breaches can affect you allows you to be more proactive to prevent privacy breach pain.

Get Your Privacy Documents In Order

To protect yourself and your practice from patient privacy breaches (and massive fines, see the conclusion to this article), follow these steps.

  1. Find your policies and procedures and review them with all staff and custodians. Make sure you document that this has been done.
  2. Review and update your privacy awareness training and ensure all staff, including custodians, have completed this recently. Make sure you have this documented, including certificates of attendance if available.
  3. Oath of confidentiality documents should be signed by all of all clinic staff and custodians and maintained in a secure location.
  4. Review your privacy impact assessment and ensure all of your current custodians have read this and understand it. Visit this post for more information to help you determine if you need a PIA amendment.

Monitor

This incident occurred in 2016. The OIPC office did not recommend any additional sanctions against the clinic, physicians, or employees.

To get templates of policies and procedures for your healthcare practice, be sure to sign up for the Practice Management Success Membership

New Amendments To The HIA

This case might have turned out differently today.

New amendments, as of 2018, provide a provision for fines under the HIA ranging from $2,000 to $200,000.

The public — and our patients — expect and trust us to make sure that their personal health information is kept secure and confidential.

It’s our responsibility to make sure we have these administrative, technical, and physical safeguards in place and are maintained in a consistent fashion.

When you've done the hard work to implement your patient privacy policies and procedures and your privacy impact assessment, make sure you continue your journey and keep these documents up-to-date and current. To help you, sign up for the Practice Management Success Membership.

There are many patient privacy breaches in the news each day, and you never know when it could happen to you.

The more you know about the breaches and how they can affect you allows you to be more proactive to prevent privacy breach pain. If you need to prepare your privacy breach management plan, start your on-line training 4-Step Response Plan right away!

If you need templates of policies and procedures for your healthcare practice, be sure to sign up for the Practice Management Success Membership. These tips, tools, templates, and training will help you save time and money to develop and maintain policies and procedures in your healthcare practice.

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

Click Here To Register for the FREE Training Video "Can You Spot the Privacy Breach?"

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

Why Do You Need Health Information Policies and Procedures?

Healthcare Policies And Procedures: Essential in EVERY Practice

New! Health Information Policy and Procedure Manuals

When Do You Need a PIA Amendment?

When is a Privacy Breach a Privacy Breach?


References and Resources

Alberta Office of the Information and Privacy Commissioner. Investigation Report H2019-IR-01 Investigation into alleged unauthorized accesses and disclosures of health information at Consort and District Medical Society Clinic. May 21, 2019. https://www.oipc.ab.ca/media/996888/H2019-IR-01.pdf

Alberta, clinic, custodian, health, Health Information Act, healthcare, HIA, medical, Patient privacy, physicians, Policies and procedures, Prevent privacy breaches, privacy, privacy breach, Privacy Impact Assessment, reasonable safeguards, templates

Pharmacist Convicted and Fined Under the HIA

Posted on February 1, 2021 by Meghan in Blog

Pharmacist Convicted and Fined Under the HIA

What Happened

An Edmonton pharmacist was in a vehicle accident. The pharmacist subsequently accessed and used the health information of the individual involved in the accident in an attempt to persuade the individual from submitting an insurance claim for the vehicle accident.

The individual submitted a complaint to OIPC in April 2018 and an investigation was launched.

Penalties

The pharmacist appeared in court on Friday January 15, 2021. He was convicted of an offence under the Health Information Act (HIA). He was ordered to pay a $5,000 fine, plus a $1,000 victim fine surcharge for using health information in contravention of the HIA.

This Could Happen To You

Are you prepared? If you have a privacy breach like this in your practice, be prepared to implement the 4 Step Response Plan.

pharmacist convicted fined

Understanding the Health Information Act

It is an offence under HIA to knowingly use health information in contravention of the act (section 107(2)(a)).

What Happens When A Privacy Breach Is Reported To The OIPC

When a privacy breach is reported to the OIPC, the OIPC will review the report and consider the custodian’s determination if a reasonable risk to the patient(s) was present. The OIPC will review the report and consider:

  • agree (or not) with the determination of risk of harm
  • was the patient notified appropriately
  • is there an offence under the HIA
  • is an investigation warranted?

If an investigation is indicated, the OIPC will conduct the investigation and report their findings to the Crown prosecutors at Alberta Justice. The Crown will determine if it continues to press charges under the HIA.

Privacy Breaches – What You Need to Know

1. Provide privacy awareness training for each employee and healthcare provider at orientation and regularly throughout the employment.

2. Collect the employee’s oath of confidentiality, including an acknowledgement that the employee understands the principles of only accessing and using the health information necessary to perform their job.

3. Monitor your users’ access to health information to quickly identify when a suspicious privacy incident occurs. The sooner you identify a privacy breach, the sooner you can limit the risk.

4. Implement your sanction policy when needed. Your sanctions policy clearly identifies the sanctions when an employee or healthcare provider is liable of an offence under the HIA.

5. Report a privacy breach to your custodians and healthcare providers, the Office of the Information and Privacy Commissioner, and the Minister of Alberta Health and the individuals affected by the breach.

 

4 Step Response Plan

The more you know about how breaches can affect you allows you to be more proactive to prevent privacy breach pain and protect the privacy, confidentiality, and security of your patients’ information.

This is one of the many training sessions available in the e-course 4 Step Response Plan – Prevent Privacy Breach Pain

In the e-course, I mentor you and provide you with tips, tools, templates and training to help you complete your Privacy Breach Management Plan and respond to a privacy breach with confidence.

Find out more and register for the course using the button below!

Click Here To Register for the 4 Step Response Plan online course

References

AB OIPC, (https://www.oipc.ab.ca/news-and-events/news-releases/2021/pharmacist-fined-for-breaching-health-information.aspx), January  2021.

Edmonton Journal https://edmontonjournal.com/news/local-news/edmonton-pharmacist-fined-after-post-collision-snooping-of-health-info-threatening-other-driver-privacy-commissioner)  January 2021

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

Not sure what is considered a privacy breach? See When is a Privacy Breach a Privacy Breach?

 

Do you have a privacy breach awareness program in place in your healthcare practice?

Spotting a privacy breach is the first step to stopping a privacy breach.

You Can Use This Privacy Breach Example to Review and Improve Your Practice.

Jean EatonWhen 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

4 Step Response Plan, Alberta, clinic, conviction, health, Health Information Act, healthcare, HIA, incident response, pharmacist, privacy breach

What Is a pORA?

Posted on January 6, 2021 by Meghan in Blog

What Is A pORA?

The Provincial Organizational Readiness Assessment (pORA) document is a risk assessment tool that describes the technical, administrative, and physical security controls necessary to meet the minimum-security standards required by legislation and by Alberta Health.

When we provide our personal and sensitive information to a healthcare provider, we want assurances that the confidential information will be respected. We expect that our information will only be shared with people who need to know the information to provide health services to us. Alberta's Health Information Act (HIA) requires healthcare providers (custodians) to put appropriate safeguards in place to protect the privacy, confidentiality, and security of health information.

A completed pORA is one of the pre-requisites for community sites to access the Alberta Netcare Portal.

Alberta Netcare, known as the provincial Electronic Health Record (EHR), is a secure and confidential electronic system. It is accessible to health professionals and contains Albertans’ personal health information. This is also known as the Alberta Netcare Portal or ANP.

A pORA asks questions similar to the questions in a privacy impact assessment and is frequently completed at the same time as a Privacy Impact Assessment (PIA) when a new clinic is preparing to open. It's easy to get them confused, but they are separate documents and have separate purposes.

PIA

A Privacy Impact Assessment is a process that assists healthcare providers (custodians) to review the impact that an implementation of a new administrative practice, information system, or change to existing practices or systems relating to the collection, use and disclosure of individually identifying health information, may have on individual privacy. This includes how the clinic will ensure appropriate safeguards to ALL information sharing practices, including the use of Alberta Netcare.

  • In Alberta, a PIA must be submitted by the custodian to the Office of the Information and Privacy Commissioner (OIPC) for review and acceptance.

pORA

This comprehensive risk assessment is required by Alberta Health to verify that a community healthcare provider custodian meets minimum security standards, before accessing provincial health information. It is one of the core requirements for access to the ANP and assists the custodian in meeting their legislative requirements and protect the privacy, confidentiality, and security of health information.

  • The pORA is submitted by the custodian to Alberta Netcare prior to access to Alberta Netcare Portal.
  • Prior to being granted access to Alberta Netcare Portal, the custodian must also have a PIA accepted by the OIPC.

We know that technology and office practices change over time. It is an expectation that the healthcare provider custodian will review their PIA, pORA, and supporting policies and procedures regularly, at least annually. Alberta Netcare requires that within two years from the date of approval of the pORA that its contents be thoroughly reviewed to ensure the information is correct and up-to-date.

For more information about pORA, see Alberta Netcare. Frequently Asked Questions. Provincial Organization Readiness Assessment. February 2020. 

 

Watch the FAQ video here!

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

Do You Need An Expedited Netcare Privacy Impact Assessment?

 

Alberta, Alberta Netcare, Alberta Netcare Portal, ANP, Health Information Act, HIA, Netcare, p-ORA, pORA, Privacy Impact Assessment, Provincial Organizational Readiness Assessment

Add Custodians To Your PIA

Posted on December 28, 2020 by Meghan in Blog

Add Custodians To Your PIA

Congratulations! You have expanded your practice and recruited a new healthcare provider to your team. Now you also need to add a custodian your PIA.

To do this, you need to orientate the provider to your practice including the policies and procedures to protect the privacy, confidentiality, and security of the personal health information and inform the Office of the Information and Privacy Commissioner (OIPC).

When the new healthcare provider is a member of a regulated health profession as defined by the health privacy legislation in Alberta, the Health Information Act (HIA), the provider also has responsibilities as a custodian.

HIA Definitions:

Custodian

A health service provider; specifically, a member of the following regulated health professions: Optometrists, Opticians, Chiropractors, Midwives, Podiatrists, Denturists, Dentists and dental hygienists, Registered nurses, Pharmacists, and Physicians (and others).

Affiliate

An employee of a custodian or as designated by the custodian, for example medical office assistant, receptionist.

The incoming custodian must ensure that the reasonable safeguards to project the administrative, technical, and physical safeguards of the personal health information are implemented in the practice. This includes ensuring that they have reviewed the current privacy impact assessment (PIA).

The lead custodian also has an obligation under the Alberta Health Information Act (HIA) to inform the Office of the Information and Privacy Commissioner (OIPC) when there are changes to the organization management of the clinic.

 

How To Add Custodians To Your PIA

In Alberta, the lead custodian in a clinic must update their PIA regularly and inform the OIPC when there are significant changes to their PIA.

One common trigger for informing the OIPC  is the addition of a custodian to the practice. Often, this PIA amendment can be as simple as a letter to the OIPC.

  1. The lead custodian or privacy officer will prepare an amendment to the previously submitted Privacy Impact Assessment when new custodians join the practice. Often a letter to the OIPC signed by the lead custodian is sufficient.
  2. The PIA amendment must include how the custodian has been made aware of the current PIA and how they are meeting their requirements to enter into an agreement with information managers as defined in the Health Information Act section 66.
  3. The lead custodian will submit the PIA amendment to the OIPC for acceptance.
  4. The new custodian must acknowledge that they have been informed of the Health Information Privacy and Security Policies and Procedures and the submitted PIA and agree to follow these practices. The new custodian will sign the letter to the OIPC and attach it to the PIA amendment from the lead custodian (in step #1 above) to the OIPC for acceptance.

 

Routine Onboarding Of New Employees

Before the new custodian is granted access to patient health information, your computer network, and your electronic medical record (EMR), you need to ensure that new custodians are aware of your Health Information Privacy and Security Policies and Procedures, PIAs, and information manager agreements, including the information management agreements with Alberta Netcare Portal, patient records management, EMR vendor, billing vendor, and/or others.

You should have a written policy and procedure ‘When a New Physician / Custodian Joins Your Practice’ to guide you when onboarding new custodians. The procedure should include the forms below and template letters to the OIPC. These templates are also available to members of Practice Management Success.

Add custodians to your PIA
Do You Need Help With Your PIA?

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Alberta, amendment, custodian, dental, Health Information Act, medical clinic, OIPC, PIA, Privacy Impact Assessment

Do You Need An Expedited Netcare Privacy Impact Assessment?

Posted on November 6, 2020 by Meghan in Blog

What Is An Expedited Netcare Privacy Impact Assessment (PIA)?

A privacy impact assessment is a requirement of the Health Information Act (HIA) in Alberta. Alberta Netcare Portal (ANP) is a data repository of health information of Alberta residents. Many healthcare providers request access to the ANP to quickly access lab test results, text reports, and health insurance information to assist them to provide continuing care and treatment to their patients.

We know that privacy and security of health information is critical to the continued accuracy and completeness of health information for all patients. Alberta Health is the custodian of the ANP data repository. To ensure that everyone with access to the ANP also has accepted reasonable standards to protect the privacy, confidentiality, and security of health information, Alberta Health requires each healthcare provider to demonstrate that they have met these reasonable standards before being granted access to the ANP.

Community based healthcare providers who work in independent practices are also known as ‘custodians' as defined in the HIA. The custodians must submit a PIA to the Office of the Information and Privacy Commissioner (OIPC) for their review and acceptance. This PIA demonstrates the custodians' commitment to protect the privacy, confidentiality, and security of health information. Alberta Health and the OIPC have agreed to a streamlined process for healthcare providers and custodians to prepare, submit, and accept the ANP PIA so that healthcare providers can request access to the ANP.

We also know that technology and business practices change over time. It is a good business practice to review your PIA annually and update your risk assessment and mitigation strategies as needed. Updating your Health Information Privacy and Security Policies and Procedures and your PIA and submitting these to the OIPC is recommended best practice and a pre-requisite for continued access to the ANP.

Is It Time To Amend Your Privacy Impact Assessment?

Maybe you want to:

  • add a new digital health app or patient portal to make it easier for patients to book appointments with you, or
  • get access to Alberta Netcare Portal, or the CII or CPAR projects,
  • expedited Netcare Privacy Impact Assessment,
  • use the internet to get telehealth on-line consultations for your patients,
  • update your participating custodians and privacy officer, and
  • regular review to ensure that you are continuing to meet the requirements of the Health Information Act (HIA).

A PIA is a practical business tool in your healthcare practice.

A PIA is an important tool that you can use to help you with project management.

It will help you anticipate risks to the project before it starts and avoid serious problems, and wasted time and money.

The PIA process requires you to have written policies and procedures so that you can implement the project effectively and train your staff consistently.

Sometimes a PIA is a requirement of legislation. But it is always a best practice whenever you implement a project that includes personal health information.

I'd Like To Help You!

I’d like to help you with your Privacy Impact Assessment amendment. Click the button below for the next complimentary workshop!

Sign up for the complimentary workshop HERE!

If you are starting your new practice and need your first Privacy Impact Assessment, see our available consultation options here.

About Jean L. Eaton

Jean Eaton, BA Admin (Healthcare), CHIM, CC is the Practical Privacy Coach and Practice Management Mentor of Information Managers Ltd.

Jean is constructively obsessive about privacy, confidentiality, and security in healthcare.

She is an experienced leader in health information management. She has worked with multi-disciplinary health care service professionals in primary, acute, and tertiary care facilities across Canada.

Jean has successfully assisted primary care physicians, chiropractics, dentists, pharmacists, primary care networks, and other health care providers across Canada to develop privacy impact assessments (PIA) and office policies and procedures and training regarding the collection, use, and disclosure of health information.

You May Also Be Interested In:

 

“What is a Privacy Impact Assessment?”

Read the article and watch the short video now to take a look at what is a PIA, what will a PIA do for you, when you need a PIA, and what is the PIA process.

You can also listen to the Practice Management Nuggets podcast episode here.  

 

“How Long Does it Take to do a New Privacy Impact Assessment?”

Ideally, you should start the Privacy Impact Assessment process 3- 6 months prior to your go-live date. Find out more by reading the article.

Alberta, amendment, expedited Netcare, PIA, privacy consultant, Privacy Impact Assessment

Protect Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments – A Complete Step-by-Step Course

Posted on October 28, 2020 by Jean Eaton in Services, Training

Do you need a Privacy Impact Assessment?

Or do you need to amend an existing PIA?

Privacy Impact Assessments are just one of the requirements you need in order to fulfill your obligations in Alberta’s Health Information Act (HIA) and other legislation and are an important aspect of developing privacy best practices in your office.

And a little help along the way is always a good thing.

Practical Privacy Coach, Jean  L. Eaton of Information Managers, is constructively obsessive about privacy, confidentiality, and security when it comes to the handling of personal and health information, particularly in primary health care settings. Jean has helped hundreds of healthcare providers, vendors, and health and social service delivery organizations and associations complete their Privacy Impact Assessment which have been successfully accepted by organizations' management and regulators. Jean has customized and delivered privacy training programs for privacy officers, records management professionals, implementation teams, and healthcare providers across Canada and the US.

Now you can have access to five modules to help you learn everything you need in order to complete your own PIA.

     

**** New PIA Amendment Track ****

Each module includes a video training, as well as templates, tools, resources and case studies to build on in each lesson. You can use this scenario to guide you through the PIA process in healthcare. If you work in healthcare or privacy or records management and need to do a PIA, this e-course is for you.

 

You need a Privacy Impact Assessment (PIA) when

  • You  are opening a new clinic or establishing a new health services program.
  • You are changing administrative procedures or technology equipment, services, or vendors
  • You are changing how you collect and use personal information,
  • You are implementing or changing an Electronic Medical Records (EMR)
  • You are sharing health information with another healthcare provider, organization, Primary Care Network or other health program.
  • You want to prevent a privacy breach,
  • You have a Privacy Impact Assessment that was written more than 2 years ago (It is time to review and update this!)

 

If you are a healthcare provider, practice manager, and you need your first Privacy Impact Assessment, this e-course is for you

Are you in a group or solo practice with direct patient care, for example:

  • Physician
  • Pharmacist
  • Registered nurse
  • Optometrist or optician
  • Chiropractor
  • Physiotherapist
  • Midwife
  • Podiatrist
  • Dentist, dental hygienist or denturist
  • Audiologist
  • Mental health practicitioner
  • Laboratory, x-ray, and imaging technician
  • Paramedic

A PIA should be as common place to a healthcare practice as a business plan is to a business. BUT most healthcare practices don’t know this and often don’t know that a PIA is  usually part of their professional college requirements and often even a legislated requirement! Prevent malicious errors, omissions or attacks that could result in fines and even jail time for the business, healthcare provider, employee, or vendor by completing a PIA.

If your Privacy Impact Assessment was written more than 2 years ago this online on-demand course is for you!

The Clinic Manager and Physician Lead and Privacy Officer  must ensure its content is updated to reflect the current state of administrative, physical and technical controls.

BONUS! Checklist to update your PIA to meet recent changes to Alberta's Netcare Portal. If your practice has completed a PIA and now you need to update the PIA, you receive a checklist of items that you need to consider to refresh your PIA.

 

If you a vendor that supports healthcare practices this e-course is for you!

BONUS! One hour tele-consult with Jean, “Create a branded Privacy Impact Assessment Readiness Package”. Jean will work individually with you to review your documentation and coach you on how to prepare the package to give to healthcare practices.

BONUS! Vendor PIA live webinar includes Vendor non-disclosure agreement, Information Manager Agreement, GAP Analysis, Computer Network Narrative templates.

 

Jean has helped hundreds of physicians, chiropractors, pharmacists, and other healthcare providers complete their Privacy Impact Assessment. She has visited hundreds of practices across Canada. But time and geography limit my ability to visit each healthcare practice that needs a PIA. That's why I developed this on-line interactive course to help you learn everything you need in order to review, amend, or create your own PIA. Each module includes a video training as well as templates, tools, resources and two common case studies to build on each week. You can use these scenarios to guide you through the PIA process.

You know your practice better than anybody else. If you had the right tools, at the time most convenient for you and a mentor to help you, you can develop good office practices, meet legislated and college requirements, and successfully complete your Privacy Impact Assessment requirements.

Using a Webinar on-line interactive program, you will get great content and mentoring from Jean Eaton and once a month during the Q&A live training webinars. Learn the PIA process with these modules.

The modules include:

Module 1:

PIA to Protect Your Practice, Your Assets, and Your Patients

 

Module 2:

Information Flows–-the Foundation of Your PIA

 

Module 3:

Risk Analysis and Mitigation Strategies

 

Module 4:

PIA Format - Pulling it All Together

 

Module 5:

Complete Your PIA Submission

BONUS Module 6:

Create a Branded Privacy Impact Assessment Readiness Package

The replays, tools, and resources will be available to you right away.

If you are new to this field, I suggest that you first register for Privacy Awareness in Healthcare: Essentials to master the key definitions and concepts.

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Privacy Awareness in Healthcare: Essentials

 

Protect Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments –

A Complete Step-by-Step Course

5 Core Modules, Templates, Training, and Tools to Get Your PIA Done!

Monthly Live Q&A Training Webinars

$450.00 (plus GST)

Purchase e-course

 

You will get

  • Learning Resource Guide for EACH module – how-to explanations, templates, and resource lists
  • Checklists to help you plan your PIA
  • MindMap of the entire PIA process
  • PIA project plan timeline templates
  • Checklists of  personal and health information privacy and security policies that you need in your practice
  • Many examples of projects in medical, dental, chiropractic and more practices including new PIA project and PIA amendments.
  • Explanation and real-life examples of key terms that you need to know and include in your PIA
  • Strategies and templates of risk management assessments that you can customize
  • This E-course might qualify for CPE credits, too!

 

BONUS!  Monthly live Q&A webinar training with Jean to help you get un-stuck with your PIA.

BONUS! Checklist to update your PIA to meet recent changes to Alberta's Netcare Portal.

BONUS! Private discussion group with other registered participants of this course to network and support each other on your PIA journey and continue to help you after this course closes.

BONUS! Regular updates of privacy resources and templates that you can use.

 

If you hired a consultant to do the work of the PIA process for you it may cost you as much as $3,000!

And then…when the consultant is done, they take their knowledge out the door with them.

Invest only $450 in this course and you'll have what you need to do your first PIA project today…and every project in the future!

Jean Introduction Ecourse PIA (1)


I had the pleasure of working alongside Jean to develop a PIA for my Dental Office. I could not have completed this document without her. She was there to help me every step of the way. Her online course made it easy to communicate with her as well as having so many resources to use that were so helpful. Each Module had videos to watch that explained step by step what needed to be done. The PIA document is a lot of information to put together and if it's not enough information on its own, you also need to develop a policy and procedures manual. Jean has developed an amazing resource for this manual that was very user friendly and made a 300 page manual a lot more attainable than creating it on your own. I highly recommend taking Jean's PIA course and having her help throughout the process!”

~~Lindsey Cave, Office Manager, Orion Dental Group

 

What people are saying about our PIA e-courses and in-person workshops:

Q: What did you learn from this workshop?

Participant's Responses:

  • Understanding of need / use of Information Management Agreement's and an ‘Evaluation” agreement.
  • Lots – when / how to make amendments.
  • Compliance / requirements of PIA and their purpose.
  • PIA information; agreements, updating.

 

Q: What do you feel was the biggest benefit to attending this workshop?

Participant's Responses:

  • Understanding a PIA.
  • Having a better understanding of PIA's and everything included in requirements.
  • Gain a better overview of my PIA and what I need to add; organizational strategy.
  • Clear vision of work to be done.

“When Jean told us about the Protest Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments E-course and explained how the course will help us better understand the Health Information Act, our responsibilities as healthcare providers and our relationship with our vendors and partners, I signed up right away! Thanks again – it is no doubt that we have hitched our wagon to a shining star.”
~~Bill Stowe, Business Manager Synergy Respiratory & Cardiac Care

“This was my first ever time I had to work on a PIA and I was a little nervous about doing it efficiently – but you really made it as simple and straight forward as possible. Thank you for being available for my questions when I had them. I would easily recommend Privacy Impact Assessments to Protect Your Practice course for anyone to do their own PIA's! Thank you so much!”
~~Karen Sarabura, Clinic Manager and Privacy Officer, CGA Medical Imaging, Alberta

“I attended the Privacy Impact Assessment Walk-through workshop (for ARMA members). Jean shared resources and on-going networking opportunities. The biggest benefit to me is to know that there is help out there in moving forward with our Privacy Impact Assessment responsibilities.”
~~Ellen Sauvé, Parkland County

Comments from other E-course participants:

“Learning about how all the information gathering systems interact was the most valuable part of this workshop”

“Excellent presenter – variety of learning opportunities.”

“Jean is an excellent speaker and I enjoyed the audio seminar you gave today and I learned a lot from your seminar.”
~~Annette T (AHIMA webinar, Three Mistakes in Managing a Privacy Breach”)

“Jean Eaton is one of those ‘critical suppliers' you keep in your email contacts list, no matter what company you manage. She really knows her stuff and delivers prompt, accurate information on time. Her courses are interesting, informative, and I like the opportunity to meet with classmates who have similar challenges.”
~~Kevin Morris, Shape MD, Team Leader/Office Manager

 

Buy e-course

In-Person Workshops Are Now Available 

Are you a hands-on kinda person?

Are you more likely to get things done when you schedule your time for a working meeting?

Would you like help to kick-start your PIA amendment and review with other like-minded clinic managers and privacy officers?

PIA Amendment Workshops are available. Send a request to me and let's set up a workshop near you! You also get full access to the on-line course to support you after the workshop.

 

 

Not sure if the E-course is for you?

Jean will answer your questions in the free webinar, 

 

Prevent Big Fines (or Worse!) for Your Healthcare Practice

How to Plan a Privacy Impact Assessment for Your Healthcare Practice

with Jean L. Eaton
Replay Recorded Live

This webinar is for Privacy Officers, Clinic Managers, Practice Managers and anyone else responsible for doing a PIA.

You will learn what is getting in your way of getting your PIA done!

In this free webinar, you will learn:

  • 5 Manageable Steps of every PIA
  • 3 Biggest Myths about PIA’s that is preventing you from completing your PIA
  • Questions Privacy Officers, Clinic Managers, Practice Managers and Healthcare providers should ask about PIA’s but don’t
  • Biggest fears about doing a PIA and how you can kick it to the curb so that you can finally get it done

Join us for the webinar so that you can plan your PIA for your healthcare practice!

Sign me up for this FREE webinar

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Please provide your email address below and you will be re-directed to the webinar replay right away.

Check your email in-box to confirm your registration!


 Along with your webinar registration, you will also benefit from the occasional Privacy Nugget tips by email of similar privacy resources and articles that you can use right away!

 

Alberta, amendment, breach, employee training, ePIA, ePrivacy, Health Information Act, healthcare, HIA, PIA, PIA process, Practical Privacy Coach, Privacy Impact Assessment, privacy officer training, templates

3 Parts to Every Privacy Awareness Training Plan

Posted on June 15, 2020 by Jean Eaton in Blog, Clinic Manager / Privacy Officer, Employee, Established Practice, New Practice, Services

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.

     
Privacy Awareness Training

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!
Alberta, Canada, Corridor Interactive, dental, Health Information Act, Ontario, Personal Health Information Protection Act (PHIPA), PHIPA, PIPEDA, privacy awareness training, reasonable safeguards

When Do You Need a PIA Amendment?

Posted on July 23, 2019 by Jean Eaton in Blog

A Privacy Impact Assessment Is Good For Business

A privacy impact assessment (PIA) is part of a regular business process if you collect, use, or disclose personal health information in your healthcare practice. When you have a previous PIA that has been prepared, submitted to the Office of the Information and Privacy Commissioner (OIPC) and it has been accepted for use–well, that is not the end of your PIA journey.

You need to ensure that you are updating and amending your PIA as your practice matures and as you make administrative and technical changes to the procedures in your practice.

You need a PIA Amendment when you have a previously accepted PIA and any one of these common triggers below.

You Have a PIA That Was Written More Than 2 Years Ago

It is time to review and update this!

Under Section 8(3) of Alberta’s Health Information Regulation, custodians must periodically review the safeguards they have in place to protect health information privacy. This means that custodians need to regularly review the privacy risk mitigation plans set out in PIAs to ensure they continue to protect against reasonably foreseeable risks to the privacy of health information. The submission of your PIA to the Office of the Information and Privacy Commissioner (OIPC) is mandatory and must precede implementation of your new system or practice.

Change in Health Information Act (HIA) Legislation and Regulations

The HIA has undergone significant amendments in 2006, 2010, most recently in August 2018. Make sure that you have updated your privacy breach management program and include mandatory privacy breach notification to the (OIPC) and the Minister of Health (MOH). Again, ensure that your team training has been updated so that they know how to spot, stop, and report a privacy breach. (See Mandatory Privacy Breach Notification)

Changes In Your Electronic Medical Record or Computer Network

You have the same EMR database, but maybe the configuration has changed. For example, a change from a local to an application service provider (ASP) or cloud-based data centre or Software as a Service (SAS) model would trigger a PIA amendment.

Another trigger is a change in your computer network vendor or changes in wireless networking, remote access, or implementing mobile devices.

PIA amendment EMR computer network

Change in Participating Physicians / Privacy Officer

Since your original PIA, you may have new custodians, including physicians, registered nurses, chiropractors, and other health professionals named in the HIA that have joined or left your practice. Your Privacy Officer may have changed, too. Your amendment should include an up-to-date listing of custodians and privacy officers.

New Users / Information Sharing

There have been many recent information sharing initiatives in healthcare. You might now plan to participate in evaluation projects, patient panel management, or other community initiatives. Make sure that you have your PIA amendment and information manager agreements completed, too. (See – The Top 3 Agreements Your Healthcare Practice MUST Have (and Why).

A quick word of caution: if your new information sharing project includes data matching–the creation of new information by combining two or more sets of data—requires custodians to prepare a privacy impact assessment before performing data matching involving health information (HIA sections 70, 71). The custodian that carries out the data matching is responsible for preparing the Privacy Impact Assessment.

PIA amendment new users

Communicating With Patients

If you are adding new technology to keep in touch with patients for appointment reminders, on-line appointment booking, secure email or patient portals, these will trigger a PIA amendment or, perhaps, a project specific PIA. Make sure that your policies and procedures are up to date, too. (See – Can You Use Text Message With Your Patients? )

PIA Amendment Communicating with patients

Alberta Netcare Portal (ANP) / Community Integration Initiative (CII) / CPAR

ANP updated their PIA in 2016 and, therefore, you need to make sure that your corresponding policies and procedures and training have been updated, too. Remember – when you agreed to participate in ANP, you promised that you would review your threat risk analysis (TRA) and update your Provincial Organization Readiness Assessment (p-ORA) when changes occur and at least every two years.

If you want to participate in new initiatives like CII and CPAR, you need to review and update both your PIA and your p-ORA, too.

Maturing Practice

You have learned and grown since your original Privacy Impact Assessment submission. Have you implemented everything that you said that you would? Can you demonstrate that your teams have received privacy and security awareness training? Have you reviewed your Health Information Management Privacy and Security policies and procedures in the last two years?

Keeping up to date without any other significant changes to your practice may not trigger a Privacy Impact Assessment amendment. Make sure that you document your careful review so that you are prepared for your next Privacy Impact Assessment submission.

Important Business Decisions

Creating and reviewing your PIA regularly can help you to spot errors or gaps between the way that you do the work in the clinic and the way that you said that you were going to implement in your clinic.

The questions that we ask during the PIA process are important. The time that you take now to identify the potential risks and prevent those incidents from happening may save you time, money, reputation and even jail time in the future.

You Know Your Practice Better Than Anyone Else

When you have a coach to guide you through the PIA amendment process, provide you with templates, and give you feedback on your work in regular live training webinars, join me in the on-line step-by-step course, Protect Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments.

Protect Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments

Find out more here: Protect Your Practice, Your Assets, and Your Patients with Privacy Impact Assessments or send me an email.

Practice Management Nuggets Podcast

This topic is included in our Practice Management Nuggets podcast! Be sure to tune in to the podcast episode

When Do You Need a PIA Amendment? | Episode #078

Listen to the Podcast
#PrivacyImpactAssessment, #ProtectYourPractice, Alberta, clinic, health care, Health Information Act, healthcare, HIA, how to do a pia, medical, Netcare, PIA, Privacy Impact Assessment, privacy impact assessment amendment, training

When is a Privacy Breach a Privacy Breach?

Posted on July 13, 2019 by Jean Eaton in Blog

The biggest mistake in managing a privacy breach is not recognizing the privacy breach.

The second biggest mistake is not knowing what to do about it.

The recent publicity about the privacy breach in Alberta when a laptop with health information was stolen and came to the public's attention several months later is not the first news item of its kind.  In fact, this happens frequently in healthcare, retail, government departments and other industries.  This doesn't make it any easier to swallow and certainly doesn't make it right.  But this is an opportunity for you, healthcare provider or practice manager, and vendor to make sure that you have good practices in place to manage your next privacy breach.

Health information is recognized as being particularly sensitive and important to the person that the information is about.  It is so important, in fact, that a new breed of legislation was developed to set out specific rules to ensure that the health information has robust safeguards (administrative, technical, and physical) to keep the health information confidential and secure.  In Alberta, the Health Information Act (HIA) was proclaimed in 2001 to help custodians (people or organizations who collect, use, and disclose health information) ensure that they have identified the risks to breach of health information and how to prevent those risks.  The legislation also ensures that the people who the health information is about have access to their personal health information.

In August 2018, amendments to the HIA were proclaimed that make it mandatory to report a privacy breach that could result in harm to the Office of the Information and Privacy Commissioner (OIPC).

Privacy breaches come in all types and sizes.  One of the most common forms of a privacy breach is when a clinic or healthcare provider intends to send a report to another healthcare provider for continuing care and treatment but it is sent to the wrong physician.  Or, the referral request went to the correct physician but included extra information about another patient that was not part of the referral.

What Is Considered a Privacy Breach?

A privacy breach is an unauthorized access to or unauthorized collection, use, disclosure , loss, or disposal of personal or health information.

To each of us, our own personal health information is important.  As a healthcare industry, we need to ensure that we recognize this and acknowledge that each privacy breach is important to the person the information is about.  We need to make sure that we minimize the risk of the information being used inappropriately or maliciously.  We need to acknowledge to ourselves and to our patients and clients that we are human and that sometimes we do make mistakes and we will strive to do better.

A ‘small' breach of one person one time might have a big impact to the individuals involved.

A ‘big' breach of a lost laptop might have a bigger magnitude affecting many individuals.

When a breach also meets the requirements of mandatory notification, a custodian must report the breach regardless of how many people's information have been included in the breach.

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

Each breach is important and needs to be recognized. Contain the breach so that it doesn't get any bigger.

Step 2 – Evaluate the Risks

Your privacy officer will investigate the incident and learn about the size, scope, and details about the breach. Consider if there is a reasonable basis to believe that there is a risk of harm to an individual

Step 3 – Notify

Notify the custodian, the affected individuals and (now, with the 2018 amendments), the Alberta OIPC, Minister of Health, Alberta Health (if the breach includes Netcare) and others.

The individual who's information has been breached needs to be made aware of the problem and the risk that might be experienced so that they can be prepare to limit the risks. The custodian needs to know how to manage the privacy breach and report it – internally and perhaps to other stakeholders.

Step 4 – Prevent the Breach From Happening Again

Correct and monitor the incident(s). Actively take steps so that the breach does not happen again.

Not Sure What To Do?

You never know when a privacy breach will happen! Prepare now with a privacy breach management program and coaching from the Practical Privacy Coach!

Learn what to do if you have a privacy breach.

4 Step Response Plan, Alberta, breach, Health Information Act, HIA, OIPC, privacy, privacy breach, training
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"I had the pleasure of working alongside Jean to develop a PIA for my Dental Office. I could not have completed this document without her. She was there to help me every step of the way. Her online course made it easy to communicate with her as well as having so many resources to use that were so helpful. Each Module had videos to watch that explained step by step what needed to be done. The PIA document is a lot of information to put together and if it's not enough information on its own, you also need to develop a policy and procedures manual. Jean has developed an amazing resource for this manual that was very user friendly and made a 300 page manual a lot more attainable than creating it on your own. I highly recommend taking Jean's PIA course and having her help throughout the process!"

- Lindsey Cave, Office Manager, Orion Dental Group

Register for Free On-line Privacy Breach Awareness Training!

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