PIPEDA Mandatory Privacy Breach Notification

Posted on January 19, 2020 by Jean Eaton in Blog No Comments

Organizations subject to PIPEDA are required to report to the OPC any breaches of security safeguards involving personal information that pose a risk of significant harm to the individuals.

PIPEDA

PIPEDA is a Canadian federal law that sets out the rules for the collection, use and disclosure of personal information in the course of those commercial activities. PIPEDA outlines the 10 Fair Information Privacy Principles that businesses must follow regardless of their size. Organizations need to know privacy rules and make sure that you have the appropriate safeguards implemented in your business.

Does PIPEDA Apply To You?

image of map of Canada

PIPEDA applies to most businesses across Canada, excepting Quebec, British Columbia, and Alberta. These provinces have their own private sector laws that are substantially similar to PIPEDA.

But even in those provinces, PIPEDA covers federally regulated industries like transportation, telecommunications and banking. In addition, all businesses that operate in Canada and handles personal information that crosses provincial or national borders are subject to PIPEDA, regardless of which province or territory that they're based in. All businesses in the three territories also fall under PIPEDA.

In Alberta, we have privacy legislation called the Health Information Act (HIA) that takes precedence over PIPEDA and Alberta's Personal Information Protection Act, (PIPA). If a business, like a physician's office, has a privacy breach which includes health information, then the custodian of the physician office must report the privacy breach following the HIA regulations. If employee information or other non-health information is included in the breach then that triggers privacy breach notification under PIPA. Sometimes, a breach can include both types of information and the physician office must notify under each legislation.

In BC, the Personal Information Protection Act (PIPA) is BC's private sector privacy law that has also been deemed substantially similar to the federal private sector privacy law. BC does not have health information specific privacy legislation, so PIPA applies to private organizations in BC, including physician practices, and governs how the personal information about patients, employees and volunteers may be collected, used and disclosed.

If you are a business in Canada, for example, an electronic medical records (EMR) business and you have a data center in Canada where all of your clients across Canada provide their information and store it in your data center, the EMR vendor likely falls under the PIPEDA regulations.

The vendor may be responsive to other legislation as well. If you are an EMR vendor, you do not directly comply with the HIA in Alberta because that applies only to custodians. However, as an information manager of a custodian under the HIA, you have some obligations under the HIA in the event of a privacy breach. But that does not mean that you don't also have obligations under PIPEDA.

What Is Included In Personal Information?

image file folders

Personal information is more than just a name or an address. It's data about an identifiable individual that can, by itself or combined with other information, identify a person. It could be a person's age, ethnicity, medical information, credit card number or even an income level. It might also include their Internet Protocol (IP) address or their website or email information.

Regular surveys done by the Office of the Privacy Commissioner of Canada says that small businesses tend to be less aware of their privacy responsibilities than larger organizations. In 2017, 65% of large organizations with more than 100 employees indicated that they were privacy aware. But only 43% of small businesses indicated that they were privacy aware. Smaller companies may not have dedicated compliance officers or privacy officers, and they may not have a sense of privacy knowledge.

The compliance challenge for smaller organizations is made more difficult by the limited human and sometimes the financial resources available to them and the gap on the knowledge about the privacy obligations.

Lack of awareness can potentially lead to complaints about your business, which has an impact on your business's reputation.

Privacy Breach

A privacy breach occurs when there is an unauthorized access to or the collection, use, disclosure, our disposal of personal information. There are many things that could qualify as a privacy breach. If you have a financial transaction that includes clients’ information and now is publicly available on your website, that's a privacy breach. If you have somebody in your organization who has access to personally identifying information as part of their job, but they use it for some purpose other than their job, that's snooping, and that is a privacy breach.

There are many examples about what is a privacy breach, but any time that you view, use, or disclose without aauthorization is considered a privacy breach.

Privacy breaches also have a negative impact to our business because it takes time and resources to manage a privacy breach, and it has a huge impact to the reputation of an organization.

Privacy Breach Notification

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The November 2018 PIPEDA mandatory privacy breach notification regulations requires you to know where all of your personally identifiable information sources are and know the safeguards implemented to protect the data.

Then, you need to monitor the data to identify any breaches. If there is a breach of those security safeguards, you need to record all breaches. So even if there is a breach of a safeguard that nobody has exploited, you still need to record that you have identified that there is a potential risk and what you've done to be able to manage that risk and prevent that from happening again.

Next, you need to determine the risk of significant harm, or ROSH. (more about this later.)

The risk of harm test that identifies what information had been included in the breach and the type of harm that could happen to that individual as a result of the breach. When it reaches that ROSH threshold, then you need to notify the Office of the Privacy Commissioner of Canada office. Or, if you are in BC, Alberta or Quebec, you need to report that to the provincial privacy commissioner.

You also need to notify other people about that privacy breach.

You probably need to notify your clients. If you are an EMR vendor or another vendor that's providing a service to healthcare providers, you need to notify them about the breach.

As an example, if you are an EMR vendor that has been breached–perhaps a security compromise or hack into your data centre–you have a responsibility to notify the healthcare providers who collected the personal information. The EMR vendor must also report the privacy breach to the Office of the Privacy Commissioner.

You might also have an obligation to notify the individuals that have been affected by that breach. In your information manager agreement in Alberta, you should have clear written expectations about whether or not a vendor should notify the patients directly about a privacy breach or if the custodian or the health care provider is going to assume that responsibility. This is an important detail that you need to identify in your information manager agreement.

Also see the Practice Management Success Tip Top 3 Agreements Your Healthcare Practice Must Have (And Why) from Information Managers at https://InformationManagers.ca/top-3 for more on information management agreements (IMA.)

ROSH

image lady with paper

The risk of significant harm (ROSH) is a framework for assessing the risk to the individual as a result of the breach of individually identifying information. Adopt and use a framework for your organization to assist you to quickly and consistently assess a breach for ROSH.

If there is personally identifying information included in the breach, we can assume that the information is sensitive information to the individual. Generally, I recommend a default that if individually identifiable information is included in the breach, then assess that there is a significant risk of harm to the individual.

The circumstances of a breach may make the information more or less likely to be used maliciously. For example, additional questions that you may want to consider include how did the breach occur? How likely is it that someone would be harmed by the breach? Who actually accessed or could have accessed that personal information? How long has that personal information been exposed? Is there evidence of malicious intent, like hacking? Or was it a theft? Or did somebody intentionally tried to use that information and use it in a very covert way? Were a number of pieces of personal information breached therefore, increasing the risk of misuse? Is the breached information in the hands of an individual that represents a reputation to the risk of that individual or themselves? Or, was the information exposed to a limited, known number of entities who have committed to destroy and not disclosed the data.

Privacy Is Good For Business

image people in business

As always, good privacy is good for business. Poor privacy protection can damage your company's reputation and cut into your profit margin. When your practice proactive privacy, you enjoy the confidence and trust of your customers. Canadians tell us that the more they trust a company, the more likely they are to do business with it. Getting privacy right is your opportunity to demonstrate that you deserve their trust and their business.

Remember that one of the fair information principles is accountability. At the end of the day, you are responsible for protecting the personal information that you have collected.

Reference: Privacy and your business: An introduction to the Personal Information Protection and Electronic Documents Act. Office of the Privacy Commissioner of Canada. https://www.priv.gc.ca/en/privacy-topics/privacy-laws-in-canada/the-personal-information-protection-and-electronic-documents-act-pipeda/pipeda-compliance-help/pipeda-compliance-and-training-tools/pp_bus/

Privacy Management Program

Build privacy protections into everything you do is a business. Having clear policies and procedures for the collection, use and disclosure of personal information is of vital importance for your business.

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.

How to Manage a Privacy Breach with Confidence

The 4 Step Response Plan will help you with prevent privacy breach pain and give you the tips, templates, training, and tools that you can use right away to prepare your privacy breach response plan:

In the world of privacy breaches ‘If’ has become ‘When’. Will you be ready?

The best way to do this is by developing a privacy management program that covers all aspects of how you handle personal information. The 4 Step Response Plan will help your organization be prepared to prevent privacy breach pain.

Click here for more information on the on-line 4 Step Response Plan course available now!

Learn How To Manage A Privacy Breach With Confidence

#PracticeManagementNugget, Canada, healthcare, mandatory notification, mandatory privacy breach notification, personal information protection electronic documents act, PIPEDA, podcast, privacy breach

Confident Women Leaders – 10 Key Steps To Prevent A Privacy Breach

Posted on October 22, 2019 by Jean Eaton in Blog

It only takes a little time and effort now to dramatically reduce the likelihood of a privacy breach in the future.

Recently, I was a guest on Confident Women Leaders Community Facebook Live hosted by Kathy Archer, Leadership Development Coach with Silver River Coaching.

It was a lot of fun to talk with Kathy about how small business, not-for-profit organizations, and clubs can quickly and easily build in privacy with their employees and volunteers as part of good business practices.

Practical Privacy Tips

We talked about the 3 simple practical tips every organization can use to prevent a privacy breach. This works for every type of organization.

Tip #1: Create an inventory of the personal information that your organization collects and is now responsible to keep confidential and secure.

Know what you collect, and review the reason why you collect the information. Make sure that you collect the least amount of information on a need to know basis at the highest level of anonymity. Use the inventory like a library account – keep track of who has access to the information, and when it is returned.

Tip #2: Create a checklist for the orientation of each new employee and volunteer that clearly tells them of your organizations expectations about how they will keep volunteer, employee, client, and donor personal information private, confidential, and secure.

Name a privacy officer in your organization and make sure everyone knows who this is. Make sure to train and support your privacy officer so that they can do a good job for you.

You can use the 10 Key Steps To Prevent A Privacy Breach Checklist as part of your orientation package.

Tip #3: Make it easy for volunteers and employees to keep information confidential and secure.

It’s not always about technology.

You can manage personal information on paper. Or, you could use private shared computer networks for your authorized users, like board directors and managers, to access all of their organization business records.

Here’s an example of a breach in a social service agency who did not properly secure board minutes containing confidential information on a computer server and faced a $25 million lawsuit.

Join Kathy's Private Community of Women Leaders to watch the Facebook Live replay (available for a limited time!) You can take these easy to implement steps to protect your clubs, healthcare practices, and small businesses from errors, omissions or attacks that could result in complaints, fines and even jail time!

I've put together a checklist for you about the 10 Key Steps To Prevent A Privacy Breach.

Download the checklist and make sure that you implement these best practices in your business.

Confident Women Leaders Community

Confident Women Leaders Community with Kathy Archer is ongoing training for women leaders in Canada’s non-profit organizations.

Leaders often hit a point where they find themselves in over their heads and wondering if they have what it takes to lead. Maybe that is where you are at now! Know you are not alone!

As a Leadership Development Coach and Leader of the Confident Women Leader’s Community Kathy Archer is here to provide you with guidance, support, information and a big hug when you need it!

But it’s not just me. We are all in this together!

CONNECT WITH Kathy Archer
https://www.silverrivercoaching.com/

confident, Kathy Archer, leaders, privacy breach, Silver River Coaching, women

Do You Know Where Your Policies And Procedures Are?

Posted on September 2, 2019 by Jean Eaton in Blog

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. #PoliciesClick 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.

Policy and Procedure Manual

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.

Find your policies and procedures and review them with all staff and custodians. Make sure you document that this has been done.
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.
Oath of confidentiality documents should be signed by all of all clinic staff and custodians and maintained in a secure location.
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:

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

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

Meeting Leadership Podcast – Why Leaders Should Understand Privacy

Posted on September 2, 2019 by Jean Eaton in Blog

I'm tickled pink to be a guest on the 5 minute podcast with Gord Sheppard!

Meeting Leadership Podcast – Learn How To Become An Outstanding Leader Who Runs Highly Effective Meetings

On the podcast, we talked about What Leaders Need To Know To Start a Privacy Program.

Here’s a summary of our discussion.

Train Your Team About Privacy And Security

You must train your team about privacy and security in your practices.

Let me use an example. A business in Alberta had a privacy program in place in 2013. In 2018 they experienced a privacy breach where an employee was snooping and got caught. When the Commissioner's office did the investigation, nobody in that practice, nobody in that business could find the policies and procedures that they had in place in 2013. The staff told the investigator that they hadn't received any training since that time. (See the article, “Do You Know Where Your Policies Are?”)

We need to make sure that we're providing privacy and security training on a regular basis, not just on orientation. You need to keep privacy and security top of mind.

Privacy Is An Investment That Will Save You Money

Privacy awareness training and proper policies and procedures is an investment and it is part of your operating costs. It will also save you time and money by avoiding re-work and re-training. When you have good policies and procedures in place and you're making the right decisions, you're avoiding all sorts of other costs about fines, a bad reputation, poor customer service. When you build that into your practice, you're going to reap the rewards about having an efficient practice and making sure that you're meeting all those requirements.

The Benefits Of Naming a Privacy Officer

Every business needs to have a privacy officer in your organization. This is somebody that you have assigned with the responsibility to make sure that there's a privacy management program in place. Now, not all privacy officers need to know everything. They do need to know those important questions and they need to know how to make it practical for your business.

Stay tuned for an announcement about the new course, The Practical Privacy Officer starting in September.

When You Understand Privacy, You Make Better Business Decisions!

When you have good privacy practices in your business, you will make sure to also select the best vendors who can work with you that also demonstrate their knowledge and support about privacy practices. You can build privacy practices into your business contracts and your agreements. This will also help you to grow your business reputation and attract better business partners and business suppliers and better clients and customers for your organization.

I've put together a checklist for you about the 10 Key Steps To Prevent A Privacy Breach.

Download the checklist and make sure that you implement these best practices in your business.

Meeting Leadership Podcast

Learn How To Become An Outstanding Leader Who Runs Highly Effective Meetings – Daily Episodes – in just 5 minutes!

Poor communication is bad for business. At Meeting Leadership Inc. we take a unique approach to helping you learn how to communicate more effectively. First we help you turn your meetings into highly productive events that drive your organization strategy. Then we empower you with the ability to use online education to tell your story to the most important people in your world.

Check out the Meeting Leadership Podcast here!

leaders, Meeting Leadership Podcast, privacy breach, privacy management, privacy officer, privacy officer training, privacy program

Privacy Principles Applies After Death

Posted on August 5, 2019 by Jean Eaton in Blog

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

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

You can’t.

We see over and over again in ‘snooping’ cases where seasoned and new healthcare providers and support team members don’t realize that looking at patient’s health information without a need to know that information to provide a health service right away is wrong.

Kate Dewhirst summarized this as

Privacy = don’t look
Confidentiality = don’t tell

We still need privacy awareness training – even those experienced healthcare providers who push back and say that they have been in the business for years still often have more to learn.

Yes, we still need privacy awareness trainingClick to Tweet

In this post I am sharing an example of the Ontario’s Information Privacy Commissioner (IPC) complaint investigation from the family of a deceased individual. 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

In 2014, a physician acting in his role as a coroner, accessed the deceased’s health record. Shortly thereafter, the family alleged that the physician, who was also a family member of the deceased, continued to access the deceased’s personal health information (PHI) contrary to Ontario’s Personal Health Information Protection Act (PHIPA).

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

The IPC started a complaint investigation.

Privacy Breach Investigation

Privacy Complaint Investigation

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

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

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

The physician acknowledged he did not fully appreciate the related but distinct concepts of patient privacy, the circle of care, and the ‘need to know’ principle.

Confidentiality rights arise out the special relationship between the client and the health professional or provider.

In contrast, privacy rights are the general rights of all persons to limit the access to their PHI. Individuals have the right to privacy, even after death.

Individuals have the right to #privacy, even after death. Click to Tweet

4 Step Response Plan

The hospital received a complaint from the family, which triggers the first step to spot and stop the breach.

Secondly, the hospital did an initial investigation to evaluate the risks of the incident. Later, after the IPC initiated their complaint investigation, the hospital re-visited the internal investigation and completed a comprehensive review and used audit log reporting tools to assist them.

Eventually, the hospital took the third step and notified the individuals’ family of the privacy breach. However, the notification was not timely. A more comprehensive response to the families’ complaint, followed by a notice to the family may have provided a better response.

Preventing a similar breach is the fourth step.

Since this incident, the hospital has:

installed a new auditing program that considerably enhances its ability to detect unauthorized access.
updated its Privacy and Confidentiality Policy, which applies to all agents of the hospital.
developed a yearly electronic privacy training program for all staff, volunteers and learners and will require all credentialed physicians to complete this training as part of the annual reappointment process.
strengthened the privacy warning on its electronic system, which warns users that unauthorized use of personal health information may result in disciplinary action.

Privacy Breach Physician Sanctions

The hospital’s Medical Advisory Committee recommended to the Board of Directors that the physician’s privileges be suspended for three months, that the hospital conduct enhanced monitoring of the physician’s access to the electronic medical record for three years, and that, on his return to practice, the physician be required to present at Grand Rounds on the topic of privacy.

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

Privacy Breach Nuggets You Need to Know

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

Privacy awareness education is more than just having policies and procedures. Demonstrating good practices, regular discussion about examples, and even gamification helps to ensure that all members of your healthcare team understand their roles and responsibilities.

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

If you need to start or update your privacy breach management program, check out the 4 Step Response Plan; Prevent Privacy Breach Plan.

When we know better, we can do better…

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?"

References and Resources

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

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

#PrivacyBreachNugget, 4 Step Response Plan, clinic, complaint investigation, death, deceased, healthcare, IPC, medical, Ontario, PHIPA, privacy, privacy after death, privacy awareness training, privacy breach, privacy breach nugget, privacy principles

Meeting Leadership Podcast – Why Leaders Should Understand Privacy

Posted on July 26, 2019 by Jean Eaton in Blog

I'm tickled pink to be a guest on the 5 minute podcast with Gord Sheppard!

Meeting Leadership Podcast – Learn How To Become An Outstanding Leader Who Runs Highly Effective Meetings

On the podcast, we talked about Why Leaders Should Understand Privacy.

Here’s a summary of our discussion.

Privacy is Good For Business!

Privacy applies to every leader in every business. We each have personal information in our businesses. It might be information about our employees, our volunteers, or our directors. It might be information about clients and customers, our business partners, and our business suppliers. We each have sensitive information about our business.

When leaders understand privacy, you have privacy practices in place including good written policies and procedures about how you will collect, use, and disclose personal information you will be able to make sure that you are meeting regulatory compliance. Written policies and procedures makes it easy to consistently onboard employees and volunteers in a consistent way to confidently and properly manage personal information in your business.

Avoid Fines, Penalties, Charges, Time-Sucking Notification Process and Even Jail!

When you have written policies and procedures in place and you provide privacy awareness training to your staff, you can avoid fines, penalties, charges, and time sucking notification process and even jail time!

We've seen recently in the Desjardins data breach in July 2019 where an employee–somebody that was trusted within that organization—who had access to client banking and financial information improperly used that information for their financial gain. This included access to client’s name, address, date of birth, and the social insurance number and other really sensitive financial information. Apparently, because this employee wasn't happy with where they worked, they shared sensitive personal information inappropriately. This breach has affected tens of thousands of clients and individuals in Canada and it's being talked about in emergency session of parliament.

This is an absolute financial disaster for any large business because you know immediately just the marketing goodwill impact alone it takes what a million years to build up your business in an hour to tear it down in this kind of thing.

But maybe it's even more important for the smaller business. That one privacy breach is going to have a huge impact the amount of time and reputation of your business. If you also receive a fine of, say, $200,000, well I don't know many small businesses that can absorb that in a business financial cycle.

When You Understand Privacy, You Make Better Business Decisions!

I've put together a checklist for you about the 10 key steps to prevent a privacy breach.

Download the checklist and make sure that you implement these best practices in your business.

Meeting Leadership Podcast

Learn How To Become An Outstanding Leader Who Runs Highly Effective Meetings – Daily Episodes – in just 5 minutes!

Check out the Meeting Leadership Podcast here!

Desjardins, leaders, Meeting Leadership Podcast, privacy breach, privacy management

Safeguards: The What, Why, and How

Posted on July 14, 2019 by Meghan Davenport in Blog

Guest Blog Post by Tamara Beitel

Health Information Management Student, Centre for Distance Education, May 2015

Picture this, the reception room of the clinic was clean and organized, the patients were happy as they were quickly seen by an efficient, positive and qualified healthcare team. This is what happens when the clinic has taken the time to design their safeguards.

What are safeguards? Why are they important to you? How do you implement these safeguards into your clinic/office?

These are important questions to consider when thinking about safeguards. Implementing safeguards will make your clients/patients feel more confident that their personal information is safe. They will be more willing to share their information.

Why should you safeguard health information?

It is important to safeguard health information to protect your business, your reputation, and helps employees understand privacy, security and confidentiality. When your clients/patients see that you are actively making sure that their personal information is safe, they feel more confident in sharing that information knowing it will be protected.

What are safeguards?

There are three types of safeguards to use in maintaining the privacy and confidentiality of health information in your clinic.

Administrative safeguards are the policies and procedures and other written documents. Policies and procedures direct staff to properly access patient information, privacy training for staff, monitoring the policies and procedures, dealing with receiving and responding to privacy complaints and inquiries, and dealing with transferring, retaining and destroying personal information contained on electronic devices.

There is privacy breach management to help prevent or in case of a breach what the procedure is in dealing with the breach. In the blog, When is a privacy breach a privacy breach?, it discusses the repercussions of not implementing breach policies and also discusses the legislation that is in place to safeguard personal information from breaches. It is important to acknowledge when a breach has occurred, that you have taken the proper steps to address the breach, and have learned from the breach so as not to repeat the same mistakes.

Examples of Policies and Procedures:

Signed oaths of confidentiality for all affiliates
Screens should be private and not viewable from public areas
Prohibit disclosure of patient diagnostic, treatment and care information over the phone, even to an individual who claims to be the patient

Technical Safeguards are controls that protect and control access to personally identifiable and health information. Technical safeguards include electronic devices, surveillance cameras, security systems, and telephone systems. Let’s focus on electronic health information and computer networks for example.

Audits of the security and computer systems are vital to maintain privacy and security of personal information. Through audits you can enforce compliance of the policies and procedures and see where changes, if any, are needed. It helps the staff to be aware of the importance in protecting the client/patient personal information. They see that there are consequences for not following policies and procedures.

You should also be aware of the risks from external threats. These include:

identity theft
loss of information
information shared with unauthorized individuals
Some examples of external threats are: malware (malicious software, designed to infiltrate or damage a computer system), spyware (a type of malware that collects information, such as key loggers), and irresponsible use of the Internet

Mitigation strategies include:

regular training and refreshers on privacy and security
IT professionals reassess any software/hardware additions/changes

Examples of technical safeguards in electronic medical records (EMRs) are:

Strong passwords
Encryption of data
Using role-based access to limit access to health information to a need to know basis (user-based access rights ((secure)), role-based rights ((more secure)) and context-based rights ((most secure))

Physical Safeguards are the physical measures used to protect electronic health information from unauthorized access. This includes precautions to prevent break-ins, theft of computers and files, unauthorized access to personal information, applying physical barriers and control procedures against threats to personal information, and policies and procedures on locking up at night, computer etiquette, and office set up (how and where computers, fax machines etc. are set up).

Examples of physical safeguards are:

Limiting access to the building, clinic and storage areas
Alarms and security cameras, doors and locks, lighting
Placing fax machines and printers out of sight and reach of public areas

Safeguards Next Steps

All three of the safeguards should be used in conjunction with each other. The use of these safeguards will help protect your client/patient information from breach, identity theft, loss and unauthorized access. You have the power to make the clinic/office safe from threats to security, privacy and confidentiality. Your clients/patients will know that you have taken all reasonable steps to ensure that their personal information has been protected and appreciate it. It is beneficial to your clinic to review all of your safeguard measures with staff and have regular audits, reviews, updates to the policies and procedures, systems, and security of the clinic. There are many self-assessment tools available from the Privacy Commissioners in the provinces and from the federal government. See the resources below.

About the author: Tamara Beitel has successfully completed the Health Information Management Diploma at Centre for Distance Education, she is currently preparing to challenge the National Certification Exam in July 2015. Tamara is looking forward to work as a Certified Health Information Management (CHIM) professional in the area of policy and privacy protection in the Calgary area.

Resources

Privacy Awareness Training– Corridor Interactive – Privacy Awareness in Healthcare: Essentials

Jean Eaton, When is privacy breach a privacy breach? https://informationmanagers.ca/privacy-breach-privacy-breach/

Office of the Information and Privacy Commissioner of Alberta

Office of the Privacy Commissioner of Canada

best practice, clinic management, good security practices, privacy, privacy breach, Safeguards, security

When is a Privacy Breach a Privacy Breach?

Posted on July 13, 2019 by Jean Eaton in Blog

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

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

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

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

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

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

What Is Considered a Privacy Breach?

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

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

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

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

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

4 Step Response Plan

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

Step 1 – Spot and Stop the Breach

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

Step 2 – Evaluate the Risks

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

Step 3 – Notify

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

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

Step 4 – Prevent the Breach From Happening Again

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

Not Sure What To Do?

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

Learn what to do if you have a privacy breach.

4 Step Response Plan, Alberta, breach, Health Information Act, HIA, OIPC, privacy, privacy breach, training

Tax Season and Fraud Prevention Patient Access to Information

Posted on April 2, 2019 by Jean Eaton in Blog

Ever thought that someone might want to submit your tax returns for you?

No problem.

They will even collect your refund – their payday when they scam your personal identity.

Michael Kaiser Blog, Executive Director of Stay Safe Online, notes on his blog that tax cyber crimes are on the rise. The Tax ID thieves usually file returns early using the taxpayers' stolen personal information so that they can cash the refunds before the taxpayer can file their legitimate tax return.

Help Your Patients to Understand How to Safely Access Their Information

When patients or clients ask you for their account statement information, take the time to ask them for photo ID and a proper authorization to disclose their personal information.

Help them to understand that you can release their own information to the patient or to another person (a spouse, for example) only with the patient's written authorization. Even ‘just' health care billing information is important.

Show your patients that you care about the safety of their information by taking steps to make sure we are protecting their patient and client information.

This Practice Management Success Tip includes

Tips to help you implement this procedure
Template authorization form
Poster to quickly explain to your patients how your procedure helps to protect their privacy

Yes I Want the Poster and Procedure Template!

authorization, disclosure, patient access to information, Phishing email, privacy breach, tax cyber fraud, tax fraud

Fax Received in Error – Is this a Notifiable Privacy Breach?|

Posted on March 28, 2019 by Jean Eaton in Blog

Has this ever happened to you?

You are a clinic manager in a healthcare practice. One day, you receive a phone from a healthcare provider in another clinic.

They have received a fax with patients’ health information from someone in your clinic. But the fax is not addressed to them – they received it in error.

Is this a mandatory notifiable privacy breach under Alberta’s new Health Information Act (HIA) regulations?

Part A: Circumstances Where Notification Is Required

There are 5 triggers under the Alberta Health Information Act (HIA) that require mandatory privacy breach notification to the Office of the Information and Privacy Commissioner (OIPC) and the Alberta Minister of Health and the individual(s) affected in the breach.

In this scenario, the receiving custodian accessed health information for an individual who was not his patient. Clearly, there is a reasonable basis to believe that the information has been accessed (read) by a person (section 8.1(1)(a) of the Health Information Regulation.)

However, the sending custodian had no reason to believe that the information would be misused.

Fax Sending Receiving Error

Part B: Circumstances Where Notification Is Not Required

The sending custodian assessed the circumstances of the breach and concluded (as per section 8.1(1)(i) of the Health Information Regulation) that the receiving custodian:

Accessed the health information in a manner consistent with his role as a health services provider and did not do it for an improper purpose.
Is subject to confidentiality policies and procedures that meet the requirements of section 60 of the Act.
Did not use or disclose the information beyond determining that he received it in error.

The sending custodian assessed that the risk is appropriately mitigated and this privacy breach incident did not trigger mandatory notification requirements.

Next Steps

The sending custodian must record the privacy breach in their business records. (I suggest that you use an internal privacy breach reporting form and spreadsheet. You can access these templates in the 4 Step Response Plan.) Remember to include your determination that you do not need to report this breach and the reasons that support your decision.

We know that faxes are a frequent source of privacy breach incidents. What can you do in your practice to reduce the risk of faxes in error?

Practice Management Nuggets Podcast

This topic is included in our Practice Management Nuggets podcast! Be sure to tune in to the podcast episode Fax Received in Error – Is this a Notifiable Privacy Breach? | Episode #067 .

Listen to the Podcast

My Favorite Takeaways From the Podcast

Understand the mandatory privacy breach notification triggers and the circumstances where notification is not required.
Record your privacy breaches – even the ones that do not trigger mandatory privacy breach notification.
Review and improve your fax procedures. We know that this continues to be a frequent source of breaches. What can you do to better manage this known risk?

If you are a member of Practice Management Success, login here and view the webinar replay.

#PracticeManagementNuggets, clinic, fax, healthfare, mandatory privacy breach notification, medical, podcast, privacy breach

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