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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!

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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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How Do You Declare as an Affiliate?

Podcast – Close, Move, Merge Your Practice | Episode #090

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

OIPC Annual Report

Posted on December 27, 2020 by Meghan in Blog

Alberta Office of the Information Privacy Commissioner Annual Report

Recently, the Alberta Office of the Information Privacy Commissioner (OIPC) released their Annual Report 2019/2020.

The report is from April 2019 to March 2020. This is the first full year of mandatory privacy breach reporting requirements in Alberta.

Because of the volume of the privacy breaches, the OIPC have now chosen to triage privacy breach reports. They are fast tracking any of those breaches where individuals have not yet been notified about that privacy breach or where there is a potential offense is suspected.

If you've submitted a privacy breach report to the commissioner's office and haven't heard from them yet, it may be because it's gone through this triage process and, if you have completed an internal investigation and notified affected individuals, your breach report has not been flagged as a high priority.

OIPC Report

OIPC Investigations

The OIPC conducted investigations regarding offences under the Health Information Act (HIA), usually privacy beaches. In that time period, they forwarded 18 cases to the Special Prosecutions Branch of Alberta Justice for further investigation. 

Privacy Breach Trends

There were some interesting privacy breach trends that were reported by the commissioner's office that were reported to them under the PIPA legislation, the Personal Information Protection Act. Of the cases that were reported to them, a hundred of them were all electronic systems compromises. So they have lost some security in the computer network system of some kind, either that was in their direct control or by a third party vendor.

Human error is still a large source of privacy breaches. This can include both misdirected communications, such as miss-sent snail mail, email, or faxes; and unauthorized disclosure, such as when health providers discuss health information with other providers not involved in the patient care.

There were also 20 incidences of theft that they noted in this report and it included rogue employees.

Snooping continues to be an issue, although the report did not provide numbers to go with that.

Ransomware is also a serious issue, one that the commissioner office predicts to continue, particularly in clinics who have a lack of technical security controls on their computer systems.

Social engineering, which is tricking someone into divulging information based on false pretenses and assumptions, is a significant danger in the healthcare industry.

 

Social Engineering Example

Somebody posed as a pharmacist and wrote emails to pharmacies in order to get information about a particular patient. The email reads like the patient traveled from one location to another location and the fraudulent pharmacist is asking their buddy pharmacists at the other location to provide some information. 

This social engineering campaign was considered a significant threat and the college of pharmacists actually released an advisory to pharmacies to warn them of this social engineering attack.

This is a good word of caution for all of us is to not make assumptions just because somebody's email signature line says a pharmacist or other healthcare provider. We still need to make sure that we have verified the identity of that individual and not rely on that email signature alone.

You can download the report from the OIPC website. It provides a variety of other statistics and examples about investigations reports and privacy breach trends that may be of interest to you.

Download the OIPC Annual Report Here

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Health Information Act, medical clinic, OIPC, privacy and security, privacy breach

Do You Know Where Your Policies And Procedures Are?

Posted on December 14, 2020 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?"

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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

Safeguards: The What, Why, and How

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

#PrivacyBreachNugget, 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

Why You Need Policies and Procedures

Posted on December 7, 2020 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 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

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When Do You Need a PIA Amendment?

What is a PIA?

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

Healthcare Policies And Procedures

Posted on November 30, 2020 by Jean Eaton in Blog

Healthcare Policies and Procedures: What Are They and Why Do Practices Need Them?

 

Healthcare policies and procedures are essential tools in EVERY healthcare practice.

We use written policies and procedures to ensure consistent office procedures and good communication between team members, but it doesn’t stop there.

Before we get to the many benefits of healthcare policies and procedures, let’s cover exactly what these terms mean.

Not sure which policies and procedures you need? Click here to find out!

Policies and Procedures Defined

For our purposes today, this is what we mean by these terms:

Policy: A set of ideas or plans that is used as a basis for making decisions.

Procedure: A fixed, step-by-step sequence of activities or course of action.

Both policies and procedures serve several important purposes in a healthcare practice.

Policies and procedures can help you:

  • Protect your practice with consistency in decision making and implementing routine tasks.
  • Provide team members direction and guidelines; help avoid micromanaging. Here’s more information on how policy and procedure checklists help with employee privacy and security.
  • Ensure quality and cost-effective processes.
  • Well thought out policies and procedures reduce re-work and make for more efficient practices.
  • Encourage team members to work to their full scope of responsibilities.
  • Contribute to compliance, including professional standards, HIA, insurance.
  • Protect your healthcare practice by demonstrating your administrative safeguards.

As powerful and effective as policies and procedures can be, they can also pose certain problems or risks if they’re not implemented properly — or if they don’t exist in the first place.

On that note, if you have policies and procedures in place, it’s also imperative to know where they are. Don’t miss this cautionary tale where I tell you why.

If your policies and procedures are unclear or non-existent, these are some of the risks you expose a healthcare practice to:

  • Fines and even jail time for the healthcare provider
  • Increased conflict and potential for misunderstanding within a practice
  • Increased conflict between employees, misunderstanding, and poor customer service
  • Poor business decisions and wasted time and money

Simply talking about your policies and procedures is not a good business strategy! You need to have clear healthcare policies and procedures in place if you want to reap all of their benefits.

So, let’s go over what makes a good healthcare policy with a clear and effective design.

Policies ask WHY and WHAT

Policies are the steps to put your goals into action — policies are proactive.

The WHY: Why is this policy needed? It is the general guide for decision-making.

The WHAT: What do you want to show for programs, activities, and services?

Each year, policies need to be reviewed and authorized by the clinic manager, privacy officer, healthcare provider and/or owners. Your team members need the opportunity to review and understand the policies regularly, too.

Review policies to assure that they reflect what the clinic is doing and that the clinic is following the written policy. Changes may need to be completed and approved.

Now, let’s cover what makes for good procedures before we get to how to create your manual.

Procedures ask HOW

The HOW: How you plan to carry out the objectives and details listed in your policies?

Your procedures should include sufficient detail so a new employee can complete a task based on the information provided.

We’ve discussed the objectives of your policies and procedures for your healthcare practice, now here are some useful tips for actually creating your policies and procedures manual:

  1. Include screen prints if computer-based.
  2. Include video explanations.
  3. Format the policy and procedures so that each policy or procedure is a separate, stand-alone document.
  4. Assign a NUMBER to each policy and procure to make it easy to reference in your PIA, or direct your staff to review. You can use any numbering system that you want — I usually use a sequential numbering system.
  5. Headings make it easier to group your information which makes it easier for the reader to review and then focus on the details that they need. Repeat the same headings throughout the policies and procedures to provide consistency across the manual. Use the headings as needed; not all policies or procedures need all the headings.
  6. Cite legislative and standards requirements, like the HIA.

When you’re implementing changes to these policies and procedures or creating them in the first place, be sure to involve key parties. This includes:

  • Custodian/trustee/business owner
  • Clinic manager/team lead
  • Privacy officer

Remember, implementing a new procedure or policy successfully must always include training and discussion with your team.

Which Privacy and Security Policies and Procedures Do YOU Need?

Without well-documented, written policies and procedures, you open your healthcare practice up to a whole host of problems, including major legal issues.

Does your clinic have appropriate policies and procedures?

Not sure which policies and procedures you need? Click here to find out!

Get the Reliability And Power of Policy and Procedure Templates Without Spending Hours (or Days) Creating Them!

Your healthcare practice needs written policies and procedures to assist you to correctly, efficiently, and confidently collect, use, access, and disclosure of health information so that you can meet your accreditation, privacy impact assessment, and regulatory compliance requirements.

Now For Medical, Dental, Chiropractic and Nursing, Too!

  • Starting with a template saves you time and money
  • Be privacy and security compliant
  • No special software to buy or learn
  • Use your existing MS Word and MS Excel office productivity software
  • One-time fee
  • On-line support
  • Available now!

Click the >> arrow to watch a short demo of the robust manual you can create quicker than you thought possible!

Show Me Policy And Procedure Templates!

Different Policy and Procedure versions available for your specific type of healthcare practice

Medical Doctor Health Information Policy and Procedure

Medical Practice

Dental Practice Health Information Policy and Procedure

Dental Practice

Chiropractor Health Information Policies and Procedures

NEW!
Chiropractic Practice

Nurse Practitioner Health Information Policy and Procedure

NEW!
Nurse Practitioner Practice

Registered Nurse Health Information Policy and Procedure

NEW!
Registered Nurse Practice

Health Information Policy and Procedure Manuals ready for you now!

Step 1: Complete the questionnaire and download the templates

Step 2: Easily generate draft 24+ policies and 28+ procedures and forms using MS Word

Step 3: Edit the documents

Step 4: Video coaching and best practices for the policies and procedures and implementation tips

Step 5: Customize for your healthcare practice

Step 6: Video orientation for your employees

Show Me Policy And Procedure Templates!

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?

New! Health Information Policy and Procedure Manuals

Safeguards: The What, Why, and How

When Do You Need a PIA Amendment?

When is a Privacy Breach a Privacy Breach?

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

New Health Information Policy and Procedure Manuals!

Posted on November 23, 2020 by Meghan in Blog

Written Health Information Policies and Procedures

Most healthcare practices have good systems in place to properly collect, use, and disclose health information – but most practices don’t have these in writing!

Patients have the right to access their personal health information but yet frequently complain about long wait times and uncooperative front office staff when trying to request their personal information.

New staff members are hired and don’t receive clear written instructions on how to perform routine health information management tasks.

Why do these same problems repeatedly appear in practice audits and privacy complaints?

The most common reason that I see is incomplete, outdated or missing written policies and procedures! It doesn’t have to be this way.

I have seen how privacy compliance and patient satisfaction improves when practices have access to written templates. But templates and checklists alone are not enough!

You know your practice better than anyone else. When you customize standard policies and procedures to best reflect your practice, you develop strategies for your daily tasks.

And, when your team receives short on-demand video tutorials about the purpose of the policies and procedures and how it impacts patient care, the staff better understand and more consistently follow the policies and procedures.

That’s why I’ve developed the Health Information Privacy and Security Policies and Procedures Manual with templates and training to help you with your health information practice management and practice management. These policies and procedures have been implemented in hundreds of practices across Alberta and Canada.

I have consulted with medical, pharmacy, chiropractic, nursing, and nurse practitioners to create practical policies and procedures for them. Now, I’ve used these best practices as templates that you can use right away!

Now For Chiropractic and Nursing, Too!

Your healthcare practice needs a Health Information Policy and Procedure Manual. Written policies and procedures assist you to correctly, efficiently, and confidently collect, use, access, and disclose health information so that you can meet your accreditation, privacy impact assessment, and regulatory compliance requirements.

  • Starting with a template saves you time and money
  • Be privacy and security compliant
  • No special software to buy or learn
  • Use your existing MS Word and MS Excel office productivity software
  • One-time fee
  • On-line support
  • Available now!
Health Information Policy and Procedure Manual

Click the >> arrow to watch a short demo of the robust manual you can create quicker than you thought possible!

Different Policy and Procedure versions available for your specific type of healthcare practice

Medical Doctor

Medical Practice

Dental Practice

Dental Practice

Chiropractor

NEW!

Chiropractic Practice

Nurse Practitioner

NEW!

Nurse Practitioner Practice

Registered Nurse

NEW!

Registered Nurse Practice

Health Information Policy and Procedure Manuals ready for you now!

Step 1: Complete the questionnaire and download the templates

Step 2: Easily generate draft 24+ policies and 28+ procedures and forms using MS Word

Step 3: Edit the documents

Step 4: Video coaching and best practices for the policies and procedures and implementation tips

Step 5: Customize for your healthcare practice

Step 6: Video orientation for your employees

Get the Reliability And Power of Policy and Procedure Templates Without Spending Hours (or Days) Creating Them.

Show me the Policy and Procedure Templates!

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

Do You Use Employee Privacy and Security Policy and Procedure Checklist Templates?

chiropractors, dentist, health information, Health Information Act, healthcare, medical clinic, Nurse Practitioners, Policies and procedures, policy, privacy and security, Privacy Impact Assessment, procedure, Registered Nurses, template

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 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 e-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.

Corridor_Privacy_Awareness_In_Healthcare_banner

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

Get Free Access Now Arrow

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

Snooping Conviction Earns 3 Years’ Probation

Posted on September 14, 2020 by Jean Eaton in Blog

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 Practices.

This Is What Happened

The clinic recognized that one of their employees viewed the health records of close acquaintances, friends, and others in the community. She did not have a need to know this information to do her job.

In one case, the employee disclosed an individual’s health information to a friend.

In June 2018, a medical clinic in Alberta reported a privacy breach to the Alberta Office of the Information and Privacy Commissioner.

The OIPC opened an investigation and subsequently referred its findings to the Specialized Prosecutions Branch of Alberta Justice. Charges of an offence under the Health Information Act (HIA) were laid.

Unauthorized Access By Employees

On September 2, 2020 the clinic former employee plead guilty in court to breaching the HIA. It is an offence under HIA to knowingly gain or attempt to gain access to health information in contravention of the Act (section 107(2)(b)).

The judge sentenced the employee to

  • $6,000 fine
  • three years probation, and
  • 180 hours of community service

 

This breach was entirely preventable.

Keep this story in mind when you are trying to determine the return on investment to deliver privacy awareness training and EMR user monitoring tools to prevent and identify early snooping privacy incidents.

You can invest a little now with privacy awareness training . . . or you can pay over and over again for an investigation and bad publicity that never ends!

 

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 using only access 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.

 

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 15 Minute 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:

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

 

Do you do routine audits? Here’s how.

Are Your Employees Privacy Aware? Start now!

References

Edmonton Journal. Former Camrose medical clinic worker hit with fine, probation for snooping health records. Nicole Bergot, Sep 10, 2020. https://edmontonjournal.com/news/local-news/former-camrose-medical-clinic-worker-hit-with-fine-probation-for-snooping-health-records

Alberta OIPC. Multiple Penalties Issued to Individual Convicted of Health Information Breaches. https://www.oipc.ab.ca/news-and-events/news-releases/2020/multiple-penalties-issued-to-individual-convicted-of-health-information-breaches.aspx 

clinic, custodian, health, Health Information Act, healthcare, HIA, mandatory privacy breach notification, medical, physicians, privcy breach, probation, snooping in healthcare;
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"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

Register for Free On-line Privacy Breach Awareness Training!

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