Information Managers
  • Home
  • Services
    • All Services
  • Templates
  • Blog
  • Contact Us
  • Practice Management Success
  • Podcasts

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

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

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;

Recent Privacy Breach Convictions Under Alberta’s Health Information Act

Posted on October 15, 2019 by Jean Eaton in Blog

In August 2018, Alberta proclaimed amendments to the Health Information Act (HIA) that requires healthcare providers (custodians) to report a privacy breach with a risk of significant harm to the Office of the Information and Privacy Commissioner (OIPC), the Ministry of Health of Alberta, and of course, to patients affected by the privacy breach.

This requirement that custodians must report a privacy breach to the to the OIPC has resulted in a huge increase in the number of reported privacy breaches in healthcare.

Custodians includes healthcare providers like physicians, pharmacists, chiropractors, dentists, optometrists, registered nurses, health authorities, and more

This is not unexpected. We in healthcare know that there are many privacy breaches that happen everyday. Many of these breaches are honest mistakes. However, an increasing number are intentional, malicious actions intended to harm others.

The benefit of having these breaches reported to a regulator is to improve compliance to reasonable safeguards to protect the health information of Alberta residents. And, as a result, more custodians and affiliates (people that work for a custodian) are being held accountable under the HIA legislation to ensure that they are meeting the reasonable safeguards.

In the first year of mandatory privacy breach notification, the OIPC has received over 1,000 reports. Previously, when privacy breach reporting was discretionary, the OIPC received an average of 130 voluntary reports of privacy breaches annually.

​

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 will continue to press charges under the HIA.

Under the recent amendments to the HIA a custodian or an affiliate or both could if found guilty of an offence is liable for a fine anywhere between $2,000 to $500,000 depending on the circumstances and the nature of the offense. Other sanctions may also be applied by the court.

It takes time to report a privacy breach, have it reviewed and investigated by the OIPC and the Crown, and have individuals charged and appear in court.

We are now starting to see the first cases charged after the August 2018 amendments coming to court and privacy breach convictions under the HIA.

Unauthorized Access By Employees

During a routine internal audit of health records in the Alberta Public Laboratories clinical lab at the Red Deer Regional Hospital identified unauthorized access by lab employees. These breaches were first identified by the hospital during a routine audit of their electronic record systems. The internal investigation between December 2018 and May 2019 identified 2,158 patient records were accessed. Alberta Health Services reported that 30 staff were involved in these breaches and three staff are no longer employed by the lab.

Do you do routine audits? Here’s how.

There have been three recent decisions in from the Alberta provincial courts as a result of mandatory privacy breach reporting legislation.

Suspicious Activity Leads to Investigation And Charges

In June 2018, Alberta Health Services (AHS) received reports of suspicious activity by a billing clerk in Red Deer. An internal audit and investigation indicated that the clerk accessed the health records of 52 Albertans without authorization. AHS reported the breaches to the OIPC in June 2018.

The OIPC opened an offence investigation and referred its findings to the Specialized Prosecutions Branch of Alberta Justice. Charges were laid in July 2019. The former AHS billing clerk received a $5,000 fine on August 2019 and was ordered not to access health information for one year.

Snooping By A Clinic Employee

In another case, an Edmonton medical clinic employee was fined after pleading guilty to health data breach. The employee knowingly accessed health information of two people and made suspicious statements to the two individuals about their personal medical details. The individuals then requested access to the audit logs and the provincial electronic health record system, Alberta Netcare.

The individuals reported a complaint to the OIPC at which point the OIPC conducted an investigation.

The employee was charged in March 2019 and plead guilty in provincial court on September 26, 2019. She was fined $3,500 and ordered to pay a victim surcharge of $525.

Are Your Employees Privacy Aware? Start now!

Unauthorized Access By A Billing Clerk

On September 30, 2019 in Red Deer Provincial Court a billing clerk with Alberta Health Services was fined $8,000 for illegally accessing health records. The clerk opened health records of 81 people over 4,7471 occasions without authorization from his employer and custodian. The court also added the following conditions

  • 1-year probation
  • order to attend treatment and counselling and
  • not be employed in a position that allows him access to health information for 1 year

We will continue to see investigations under the HIA at appearing in our courts. The OIPC is currently investigating over 20 incidents and has flagged 70 more as potential offences.

Each of these incidents involved employees making poor choices about accessing patient health information. Reasonable prevention steps include privacy awareness training for every employee, healthcare provider, and contractor. In addition, every healthcare practice should be, monitoring access to records with routine audits and applying sanctions.

We obviously don’t speak often enough about what is acceptable, appropriate, and authorized access to patient’s health information.

Preventing a privacy breach is always less expensive than managing a privacy breach.

A privacy breach management plan will help you to prevent a breach and, when a breach happens, identify a privacy breach early to limit the risk of harm, size, and the cost of 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?

 

References

CBC News. Investigation finds improper access to patient records at Red Deer hospital. Posted: Oct 04, 2019 12:48 PM MT | Last Updated: October 4 https://www.cbc.ca/news/canada/edmonton/red-deer-patient-records-breach-1.5309419

CBC News. Edmonton medical clinic employee fined after admitting to health data breaches. Posted: Oct 03, 2019 10:56 AM MT | Last Updated: October 3 https://www.cbc.ca/news/canada/edmonton/health-information-alberta-access-1.5307453

CBC News. AHS billing clerk fined $8,000 for illegally accessing health records Posted: Oct 09, 2019 10:47 AM MT | Last Updated: October 9. https://www.cbc.ca/news/canada/edmonton/ahs-billing-clerk-fined-8-000-for-illegally-accessing-health-records-1.5314783

CBC News. Jennifer Lee. Reports of health-care privacy breaches spike in Alberta. Posted: Oct 11, 2019 5:00 AM. https://www.cbc.ca/news/canada/calgary/health-care-privacy-breaches-spike-alberta-1.5316230

clinic, custodian, health, Health Information Act, healthcare, HIA, mandatory privacy breach notification, medical, physicians, privcy breach, reasonable safeguards

The Top 3 Agreements Your Healthcare Practice MUST Have (and Why)

Posted on November 29, 2018 by Jean Eaton in Blog

In order to provide services, healthcare practices must collect pertinent information from patients. This data gathering often includes many sources of information, across different types of technology, among multiple vendors. Good business practices and health records management is supported by three agreements your healthcare must have: information manager agreement (IMA), information sharing agreement (ISA), and successor custodian agreement.

For instance, when a patient attends a clinic, their details are nearly always entered into a computer software program to maintain demographic information, manage patient appointments, and to process payments. Often, health service providers (including physicians, pharmacists, chiropractors, dentists, psychiatrists and more) record their patients’ notes into an electronic medical record (EMR).

Patient information is shared between providers where required. For example, when the patient visits a diagnostic lab for testing, results are often transmitted electronically to the ordering physician’s fax machine or to the EMR.

Custodians including physicians, pharmacists, chiropractors, dentists, and psychiatrists, as defined by the Alberta’s Health Information Act (HIA), must follow HIA legislation when they collect, use, and disclose health information.

Often, custodians are also the owners of independent healthcare practices. However, an owner of a healthcare practice is not the custodian if they are not also an active member of a regulated health profession named as custodians in the HIA.  

1. Information Manager Agreement

The HIA allows custodians to contract with other health service providers and vendors for the purposes of providing information management or information technology services, so patients can receive health services, and make payments. This often requires the custodian to share patient information with a vendor (or give them access to) so the vendor can process, store, or provide information as needed.

The custodian selects one or more business to provide the services, equipment, or software to assist in the management of health information. For example: EMR provider, contracted transcriptionist, billing agent, remote backup service, etc. These businesses are known in the HIA as information managers.

Before sharing health information with someone else, the custodian must ensure that the partners and vendors have reasonable safeguards in place to protect sensitive health information. The custodians must ensure that there is a written agreement between the custodian and the information manager. These agreements are known as “Information Manager Agreements.” This requirement is stated in the HIA section 66(2).

The Information Manager Agreement (IMA) is one of three crucial agreements a healthcare practice must have in place.

If You Don’t Have an IMA

If you are a custodian who uses vendors as part of your business and you do not have an IMA with that vendor…

  • You are in breach of the HIA.
  • You may incur fines under the HIA.
  • You may face sanctions and disciplinary actions from your professional regulatory college.
  • Almost certainly, you will encounter conflicts, poor communication, between yourself and the vendor(s) and the other participating custodians in your practice.
  • You may lose control of the health information as reported in the Investigation Report H2013-IR-01from the Alberta Office of the Information and Privacy Commissioner (OIPC).

In a press release from the Alberta OIPC in 2013, Information and Privacy Commissioner Jill Clayton noted that:

“The HIA allows custodians to disclose health information to IT service providers, such as EMR vendors, under an appropriate Information Manager Agreement. When custodians do not sign these agreements, they may find themselves in the unfortunate position of losing control over the health information they need to provide health services.”

Investigation Report H2013-IR-01 (https://www.oipc.ab.ca/news-and-events/news-releases/2013/investigation-report-h2013-ir-01.aspx)

Who Must Create the Information Manager Agreement?

The custodian is responsible to ensure that there is an appropriate IMA created and signed.

The information manager can assist the custodian by preparing templates of the IMA including specific details of the services that they will provide and the safeguards that the vendor will implement to protect personal health information.

Key Points About IMAs

A few important notes about IMAs.

  • IMA must be signed by the custodian.
  • Agreements signed by individuals who are not custodians are not valid under the HIA.
  • Custodians are required under the HIA to have an IMA with the vendor before disclosing health information. If there is no agreement in place, the custodian is in breach of the HIA.
  • Custodians are responsible for the health information that they collect, use, and disclose. Therefore, the custodian is responsible for the IMA and to ensure that the health information will be handled confidently and securely.

Key Points IMA

The custodian can select the best vendor and information manager for the job. The vendor who understands the requirements of the HIA and who can demonstrate that they have implemented the appropriate reasonable safeguards and can assist the custodian to develop an appropriate IMA is, in my opinion, demonstrating a significant competitive advantage.

All healthcare providers in a community practice should spend time when creating their business to establish good business practices, including developing written contracts and agreements to improve the efficiency of the business and to make things happen in the way that they are planned.

Here is a common example

Dr. Alice and Dr. Mark created a welcoming family medical practice in a new sub-division of their city. They each worked hard to attract new patients, hire and train staff, and develop a profitable business.

In the last few years, Alice and Mark had differences of opinion on how to grow their business. In the end, Alice decided that this type of practice wasn’t for her. She decided to leave and join a larger practice in a neighbouring subdivision. Alice wanted to take her patient’s records with her to her new practice and continue to see her patients at the new location.

Mark, who had signed the IMA with the EMR vendor, did not agree to Alice’s request to transfer her patient records to her new group practice.

Alice and Mark argued and eventually involved a professional mediator to help them resolve their business conflict. Hurt feelings between the providers and staff, costly delays in their business and expenses could have been avoided if Alice and Mark had established clear expectations in the event of the termination of their business partnership when they started their group practice. An IMA between custodians in a group practice is a recommended best practice.

When You Have Multiple Custodians in Your Healthcare Practice

When the practice has multiple providers, the owner and custodian frequently assumes responsibility for maintaining the contracts and IMAs with the vendors. Each of the participating healthcare providers may delegate the responsibility of maintaining the vendor arrangements to the custodian owner. This can be achieved with an IMA between the owner / custodian and each participating custodian.

Custodian Owner IMA

Each healthcare provider custodian is considered the custodian of the health information that they collect. The custodians can jointly agree to all use the same EMR. This provides continuity of care for the patients and economy of scale for the participants of the practice.

When the owner/custodian signs the agreement with the EMR, they become the signatory custodian. The EMR vendor takes their instructions from the signatory custodian.

The owner / custodian is now an information manager for all the participating custodians.  but does not become a custodian of the health information provided to them in their roles as an information manager.

For example,

Dr. Bill opened his medical practice, ABC Clinic. Later, additional physicians were recruited to work at ABC Clinic. The physicians are each custodians as defined by the HIA.

Dr. Bill assumes the responsibility for the operations of the clinic including the computer network and the contract with the EMR vendor. Dr. Bill is the information manager for the patient records at the clinic.

Each physician signs an IMA with Dr. Bill and agree that he will continue to manage the patient records on their behalf. Dr. Bill is operating as an information manager.

In his role of the information manager, Dr. Bill must follow the instructions from each physician, the custodian, as it relates to the management of their patients’ records.

2. Information Sharing Agreement (ISA)

When you have more than one physician in your practice, you need an agreement about how you will decide to manage the personal health information in your practice.

An Information Sharing Agreement (ISA) focuses on the internal decision making about all things related to personal health information whereas, an IMA is an agreement with a single vendor about the services that the vendor provides.

ISA IMA

An ISA may include things related to the services that a vendor provides but is not limited to just vendor services.

It also includes decisions about the process to ensure appropriate role based access to personal health information in the EMR, computer network, and paper formats; the regular review of health information privacy and security policies and procedures, ensuring privacy and security awareness training, the regular review of administrative, technical, and physical safeguards in the practice, and so on.

In larger organizations or when several smaller organizations participate in an information sharing initiative, a Data Management Committee may provide oversight and facilitate this process.

An ISA is a requirement of the College of Physicians and Surgeons of Alberta.

Identifying a successor custodian is also a requirement of the College of Physicians and Surgeons (CPSA).

3. Successor Custodianship Agreement

As a business owner, you need to plan a successor to the business. This might be an interim or short-term decision to ensure continuity during an absence or future retirement planning or unexpected illness or death.

In healthcare, physicians and custodians have the added responsibility as the ‘gatekeeper’ for patient records. In the event of a sudden inability to meet these responsibilities, physicians need to identify a successor custodian to ensure appropriate and continued access by patients to their health information for their continuing care and treatment and to ensure that the continuing confidentiality, security, and access to patient records continue to be fulfilled.

Have you identified a successor custodian? Each of the physicians in your group practice should also identify their own successor custodian.

This is a CPSA requirement and should also be included in the Privacy Impact Assessment if you have this information available. See CPSA, Patient Record Retention, s.5:

A regulated member acting as a custodian must designate a successor custodian to ensure the retention and accessibility of patient records in the event the regulated member is unable to continue as custodian. (Reference: Health Information Act Section 35(1)(q)

If you are a chiropractor, the Alberta College and Association of Chiropractors (ACAC) further requires its members to name a chiropractor as the successor custodian to maintain the status of ‘chiropractic’ records. (See the ACAC’s Standards of Practice s5.3 Custodianship of Health Records.)

A chiropractor, as a custodian of health records, is responsible for the care and control of the health records in their practices as required by the Health Information Act of Alberta. A custodian of active chiropractic files must be under the custody or control of an active, registered member of the ACAC.

Note that under the Health Information Act, a chiropractor may disclose files to another custodian who is not a chiropractor, and only a chiropractor may have custody or control of chiropractic files. Chiropractic files disclosed to a non-chiropractor should no longer be considered chiropractic files.

A custodian must implement technical and physical safeguards to protect the confidentiality of the information and privacy of individuals as well as protections against reasonably anticipated threats to the security or integrity of the information. A custodian must also defend against unauthorized uses, disclosures or modifications of the information. Safeguards must be periodically assessed and documented in policies and procedures.

If you are working in an owner/custodian scenario discussed above, clearly identifying a successor custodian becomes imperative. An unplanned absence of the owner / custodian can seriously jeopardize the business and the continuing care and treatment of patients.

The custodian can, but is not required to, name another custodian in the same practice to be their successor. Whatever your decision, ensure that this is well documented and easily accessible to the other custodians and key decision makers in your organization in the event of an emergency.

The best time to create IMA, ISA, and Successor Custodianship Agreements is when you start your healthcare business.

The second best time in now.

What are you waiting for?

If you need assistance, contact Jean L. Eaton, Your Practical Privacy Coach and Practice Management Mentor with Information Managers. I’m here to help you with your Practice Management Success.

Download the FREE Report - Top 3 Agreements Your Healthcare Practice MUST Have

If you are a member of Practice Management Success, login here to access the Top 3 Agreements.

When we know better, we can do better…

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

Jean L. Eaton
Your Practical Privacy Coach
INFORMATION MANAGERS 

chiropractors, dentists, health care, Health Information Act, healthcare, HIA, IMA, information management agreement, information manager agreement, information sharing agreement, ISA, medical, physicians, Practice Management Success, successor custodian

Privacy Impact Assessments for Chiropractors – We can Help!

Posted on December 11, 2013 by Jean Eaton in Blog

Chiropractors are now named custodians under the Health Information Act (HIA). Your office will be expected to submit a Privacy Impact Assessment (PIA) to the Office of Information and Privacy Commissioner. Are you finding the PIA process overwhelming? Does your office have the time and resources to prepare your PIA submission? We can help! Check out our article What is a Privacy Impact Assessment?

chiropractors, chiropractors HIA, custodians, physicians, PIA, Privacy Impact Assessment, What is a PIA?

Search the site

What is the elephant in the room?

The Elephant in the Room Find out here...

Privacy Policy

"The 15 Day Privacy Challenge has given me some great resource information and helped me to identify the areas that I need to work on. I found value in almost all of the Privacy Challenges, but I would say Risk Assessment, Social Media, Email Phishing and Spam, and Confidentiality are the top four."

- Sharon

Register for Free On-line Privacy Breach Awareness Training!

Privacy Policy

Copyright 2022 Information Managers Ltd.

Manage Cookie Consent
To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
Manage options Manage services Manage vendors Read more about these purposes
View preferences
{title} {title} {title}