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

You might be wondering why you would face fines and penalties for not having written policies and procedures in the first place.

The HIA requires the custodian – which includes the physician, pharmacist, dentist or dental hygienist – to take reasonable safeguards to protect the privacy and confidentiality of patients’ health information.

Having written policies and procedures is a common, expected, and reasonable safeguard.

Let’s say you have a privacy breach in your practice or an error (like sending a fax to the wrong number or you are a victim of a phishing or ransomware attack).

You can learn more about what makes a privacy breach a privacy breach here.

If you can’t demonstrate that you had the appropriate reasonable safeguards, like written policies and procedures in place, you are guilty of an offence under the law.

It’s illegal not to have policies and procedures when you collect health information.

If you are guilty of this offence, you are liable for a fine of a minimum of $2,000 and not more than $500,000. (HIA section 107(7)).

3 Policies and Procedures Myths

One reason some healthcare practices fail to have written policies and procedures is because they believe they don’t need them.

Often, this is because they’ve fallen prey to the common myths about policies and procedures.

There are 3 of the common myths that stop healthcare providers and their clinic managers from creating written policies and procedures:

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.

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.

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

How Long Does It Take to Do a PIA?

Posted on December 3, 2021 by Jean Eaton in Blog

Click the >> arrow above to play the video.

I’m opening my practice next month.

I just learned that I need to complete a Privacy Impact Assessment.

What do I do now?

Unfortunately, I hear this question far too often!

Here’s What You Need to Know About the Timelines Required to Complete a Privacy Impact Assessment

In the perfect world, you will start your PIA process about 6 months before you plan to open your practice.

You will start with developing the privacy and security policies and procedures.

Next, you will discuss with the EMR vendors, computer IT support vendors, and other stakeholders about your operational needs and ensure that the vendors can meet PIA requirements.

At this point, about 4 months before Go Live, you will start writing your Privacy Impact Assessment documents.

You will review and accept the Privacy Impact Assessment internally to your organization and ensure that each of the custodians have reviewed, understood, and accepted the Privacy Impact Assessment.

Then, you will submit the Privacy Impact Assessment to the Office of the Information and Privacy Commissioner (OIPC) about 3 months before your go-live date.

Start With Privacy and Security Policies and Procedures

If you are planning to open your healthcare practice soon or planning to implement a new project in your existing clinic, your first step is to review (or create) your privacy and security policies and procedures..

Templates make it easier to complete your policies and procedures. Make this fast and easy with our templates!

Guidance for Electronic Health Record Systems

To help you with your discussion of PIA requirements with your vendors, the OIPC has produced a document, “Guidance for Electronic Health Record Systems“.

This guide was developed to assess the safeguards in electronic health record (EHR) systems. Custodians and their EHR service providers may use this document to support a Privacy Impact Assessment on an EHR system, or to examine whether changes to a system comply with Health Information Act requirements. Published in June 2016.

This is intended to assist you to have a discussion with your vendors. The guidelines are not part of the PIA submission. The Guideline will help you to ask good questions with your vendors so that you can get good answers. You will include the answers to the questions in your PIA submission.

If you are currently looking for a vendor for your EMR, practice management system, computer network system or, perhaps, your billing system, these are the questions that you need to discuss with your vendor. Their answers will help to inform you and assist you in selecting good vendors for your practice.

If You Are a Vendor That Supports Healthcare Practices

If you are a vendor that supports healthcare practices, I encourage you to download the document, Guidance for Electronic Health Record Systems, and complete it from the perspective of your product or service even if your product isn't an EHR. Then, you can share the completed document with your prospective clients and custodians as a demonstration of your privacy and security practices and support your clients with their PIA submission.

Don't Wait!

If you haven’t done your PIA yet, you definitely need to get this completed. You need to have your policies and procedures completed and your PIA submitted to the OIPC for their review and acceptance before you open your new practice.

Want more content like this?

For more information about Privacy Impact Assessments, see

Click Here to Get More About PIA's

health care, healthcare, medical, plan a PIA, Privacy Impact Assessment, timeline

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.

Privacy-Breach-Nugget-023-Policies-Procedure-Manual

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.

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:

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

Why Would a Dentist Want Access to the Alberta Netcare Portal?

Posted on April 27, 2021 by Meghan in Blog

Why Would A Dentist Want Access To The Alberta Netcare Portal?

As a dentist or dental hygienist, if you have concerns about a patient’s health history, you may want to have access to the Alberta Netcare Portal to view the patient's history of health concerns and current medications.

Alberta Netcare provides personal health information that is available through a province-wide electronic record system under the authority of the Health Information Act (HIA).

Whether a dentist uses paper records, electronic dental records (EDR), or electronic medical records (EMR), using the Alberta Netcare Portal will help dentists monitor their patient’s interactions with other parts of the health care system.

What is the Alberta Netcare Portal?

Alberta Netcare Portal is the secure vehicle through which patient health information from a variety of health care providers is shared and accessed electronically, by independent and hospital-based health service providers like dentists, physicians, nurses and pharmacists. The Alberta Netcare Portal is a data collection centre for registries and systems such as laboratories, diagnostic imaging facilities, hospitals and some specialized clinics. Alberta Health and Wellness is the Netcare information manager.

Dentists and Dental Hygienists Are Custodians

Dentists were designated in 2010 as authorized custodians under the Health information Act (HIA). Dentists can now request access to Alberta Netcare by showing that they meet the Netcare requirements.

Dentists who manage patients with complex medical conditions or for the provision of treatment requiring sedation or general anaesthesia may require additional information about the patients’ health history. Dentists can use Alberta Netcare Portal to view medication profiles, laboratory data and tests results.

Ensuring reasonable safeguards to protect the privacy and security of personal health information of your patients and residents of Alberta is critical! We want everyone who has access to these health data repositories to follow the same best privacy and security practices. The HIA has regulated requirements for all custodians to follow.

Everyone needs to follow the rules to play in the sandbox!

How To Get Started

Before you are granted access to Alberta Netcare Portal, you must complete the following steps.

Step 1: Create or update your Health Information Management Privacy and Security Policies and Procedures including the rules governing the access, collection, use, of health information from Alberta Netcare.

Step 2: Complete a Privacy Impact Assessment (PIA) and submit this to the Office of the Information and Privacy Commissioner for review. For more information on how to complete a PIA, click here.

Step 3: Train your team on privacy awareness. I recommend the Privacy Awareness in Health Care Training — Dental Practices.

Step 4: Contact the eHealth Netcare Support Services Team.

Step 5: Complete a Provincial Organizational Readiness Assessment (pORA). See What is a pORA.

Step 6: Sign an Informational Manager Agreement (IMA) and Review Informational Exchange Protocol (IEP) with Alberta Netcare

For more tips on implementing reasonable privacy and security safeguards for your dental practice, see https://informationmanagers.ca/privacy-impact-assessment-pia/.

You can also watch the FAQ video on this topic by clicking the button below!

Watch the FAQ Video HERE!

You May Also Be Interested In:

What is a pORA?

New Health Information Policy and Procedure Manuals

Do You Need An Expedited Netcare Privacy Impact Assessment?

Who Is Doing the Recalls In Your Dental Practice?

Privacy Awareness in Healthcare Training: Dental Practices

Privacy Impact Assessment – Consultation Options Available!

When we know better, we can do better…

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

Jean L. Eaton
Your Practical Privacy Coach
INFORMATION MANAGERS

Alberta Netcare, ANP, dental hygienist, dentist, healthcare, PIA, PIA Consultant, privacy, Privacy Impact Assessment

Privacy Compliance and Technology in Healthcare

Posted on March 7, 2021 by Meghan in Blog

Privacy Compliance and Technology in Healthcare

Event by Rafiki Technologies with Information Managers

A Privacy Impact Assessment (PIA) is a practical business tool in your healthcare practice.

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

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

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

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

Join Rafiki Technologies’ Naheed Shivji and Information Managers’ Jean L. Eaton for a guide to successfully keep your patients’ information safe, follow cyber security best practices, and comply with the requirements of the Health Information Act (HIA).

This on-line workshop will provide you with practical tips to plan your Privacy Impact Assessment (PIA) amendment as well as a strategic cybersecurity checklist.

Who Should Attend?

Medical, dental, chiropractic, optometric, pharmacy practices in Alberta.
Clinic manager, privacy officer or administrative lead responsible for updating your Privacy Impact Assessment.
Healthcare provider

Join Naheed Shivji and Jean L. Eaton for a guide to your PIA completion and technology requirements

Thursday, March 18th, 2021

6:00 PM – 7:00 PM MT

Free Registration

Click the button below to register for the workshop!

Register for the Complimentary Workshop HERE!

Meet Naheed Shivji, Founder & President of Rafiki Technologies Inc.

Naheed has more than 20 years of experience in IT with expertise in the dental industry. He is a passionate entrepreneur helping companies understand and embrace technology and is always searching for business best-practices while giving back to the community.

Naheed works hands-on with his clients to develop winning IT strategies and smooth implementations. He is constantly learning and adapting to industry trends to maintain Rafiki Technologies’ position as a leading managed IT services company in Canada.

Meet Jean L. Eaton, BA Admin (Healthcare), CHIM, CC

Your Practical Privacy Coach and Practice Management Mentor with Information Managers Ltd.

Jean has helped hundreds of physicians, chiropractors, pharmacists, and other healthcare providers complete their Privacy Impact Assessment. She has visited hundreds of practices across Canada.

Jean helps independent healthcare practices with practice administration, privacy awareness, privacy breach management, and legislated regulation compliance in Canada.

Jean's career started as a receptionist and transcriptionist in a busy family medical walk-in practice. She moved into health records and health information management and hospital administration in hospitals, regional health authorities, cancer agencies across Canada and Alberta Health.

Now, Jean specializes her consulting practice to independent healthcare practices who want to start, grow, or improve their practice administration so that healthcare providers can focus on providing quality healthcare services. Jean provides training to businesses including healthcare on practical privacy and security best practices and privacy breach management.

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

You May Also Be Interested In:

“What is a Privacy Impact Assessment?”

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

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

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

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

cybersecurity, dentist, healthcare, privacy, privacy compliance, privacy consultant, Privacy Impact Assessment, security, technology

What Is a pORA?

Posted on January 6, 2021 by Meghan in Blog

What Is A pORA?

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

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

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

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

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

PIA

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

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

pORA

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

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

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

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

Watch the FAQ video here!

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

Add Custodians To Your PIA

Posted on December 28, 2020 by Meghan in Blog

Add Custodians To Your PIA

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

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

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

HIA Definitions:

Custodian

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

Affiliate

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

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

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

How To Add Custodians To Your PIA

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

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

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

Routine Onboarding Of New Employees

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

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

Do You Need Help With Your PIA?

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

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

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:

Include screen prints if computer-based.
Include video explanations.
Format the policy and procedures so that each policy or procedure is a separate, stand-alone document.
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.
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.
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

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!

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

New Health Information Policy and Procedure Manuals!

Posted on November 23, 2020 by Meghan in Blog

Written Health Information Policies and Procedures

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

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

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

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

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

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

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

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

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

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

Now For Chiropractic and Nursing, Too!

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

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

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

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

Medical Practice

Dental Practice

NEW!

Chiropractic Practice

NEW!

Nurse Practitioner Practice

NEW!

Registered Nurse Practice

Health Information Policy and Procedure Manuals ready for you now!

Step 1: Complete the questionnaire and download the templates

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

Step 3: Edit the documents

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

Step 5: Customize for your healthcare practice

Step 6: Video orientation for your employees

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

Show me the Policy and Procedure Templates!

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Do You Know Where Your Policies and Procedures Are?

Why Do You Need Health Information Policies and Procedures?

Healthcare Policies And Procedures: Essential in EVERY Practice

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

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

Do You Need An Expedited Netcare Privacy Impact Assessment?

Posted on November 6, 2020 by Meghan in Blog

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

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

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

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

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

Is It Time To Amend Your Privacy Impact Assessment?

Maybe you want to:

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

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

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

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

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

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

I'd Like To Help You!

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

Sign up for the complimentary workshop HERE!

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

About Jean L. Eaton

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

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

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

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

You May Also Be Interested In:

“What is a Privacy Impact Assessment?”

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

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

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

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

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

Why You Need Health Information Policies and Procedures

The Health Information Act (HIA) and the Personal Information Privacy Act (PIPA)

Benefits of Policies and Procedures

Fines And Penalties For Not Having Written Policies And Procedures

3 Policies and Procedures Myths

Not Sure Which Policies and Procedures That You Need?

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I’m opening my practice next month.

I just learned that I need to complete a Privacy Impact Assessment.

What do I do now?

Here’s What You Need to Know About the Timelines Required to Complete a Privacy Impact Assessment

Start With Privacy and Security Policies and Procedures

Guidance for Electronic Health Record Systems

If You Are a Vendor That Supports Healthcare Practices

Don't Wait!

Want more content like this?

Do You Know Where Your Policies and Procedures Are?

What Happened

Understanding the Health Information Act

Access To Patient Information

Privacy Breach Nuggets You Need to Know

Get Your Privacy Documents In Order

New Amendments To The HIA

When we know better, we can do better…

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References and Resources

Why Would A Dentist Want Access To The Alberta Netcare Portal?

What is the Alberta Netcare Portal?

Dentists and Dental Hygienists Are Custodians

Everyone needs to follow the rules to play in the sandbox!

How To Get Started

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Privacy Compliance and Technology in Healthcare

Event by Rafiki Technologies with Information Managers

Who Should Attend?

Meet Naheed Shivji, Founder & President of Rafiki Technologies Inc.

Meet Jean L. Eaton, BA Admin (Healthcare), CHIM, CC

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

Policies and Procedures Defined

Policies ask WHY and WHAT

Procedures ask HOW

Which Privacy and Security Policies and Procedures Do YOU Need?

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

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

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

Medical Practice

Dental Practice

NEW!Chiropractic Practice

NEW!Nurse Practitioner Practice

NEW!Registered Nurse Practice

Health Information Policy and Procedure Manuals ready for you now!

Written Health Information Policies and Procedures

Now For Chiropractic and Nursing, Too!

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

Medical Practice

Dental Practice

NEW!

Chiropractic Practice

NEW!

Nurse Practitioner Practice

NEW!

Registered Nurse Practice

Health Information Policy and Procedure Manuals ready for you now!

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

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Is It Time To Amend Your Privacy Impact Assessment?

I'd Like To Help You!

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