Our Privacy Commitment To You
Privacy of personal health information is an important principle to the health care providers at Change Creates Change Eating Disorder Counselling. We are committed to collecting, using and disclosing personal health information responsibly and only to the extent necessary for the goods and services we provide. We try to be open and transparent about how we handle personal health information. This document describes our privacy policies.
What is Personal Health Information?
Personal health information is information about an identifiable individual. Personal health information includes information that relates to:
the physical, nutritional or mental health of the individual (including family health history);
the provision of health care to the individual (including identifying the individual’s health care provider(s));
a plan of service under the Home Care and Community Services Act, 1994;
payments or eligibility for health care or coverage for health care;
the donation or testing of an individual’s body part or bodily substance;
the individual’s health number; or
the identification of the individual’s substitute decision-maker.
Who We Are
Our organization, change.creates.change Eating Disorder Counselling, includes at the time of writing, Jillian Walsh, RD. We use a number of consultants and agencies that may, in the course of their duties, have limited access to personal health information we hold. These include computer consultants, office security and maintenance, bookkeepers and accountants, lawyers, temporary workers to cover holidays, credit card companies, website managers and cleaners. We restrict their access to any personal information we hold as much as is reasonably possible. We also have their assurance that they follow appropriate privacy principles.
Why We Collect Personal Health Information
We collect, use and disclose personal information in order to serve our clients. For our clients, the primary purpose for collecting personal health information is to provide nutrition counselling. For example, we collect information about a client’s health history, including their family history, physical condition and function and social situation in order to help us assess what their nutrition care needs are, to advise them of their options and then to provide the nutrition care they choose to have. A second primary purpose is to obtain a baseline of health and social information so that in providing ongoing health services we can identify changes that are occurring over time.
We also collect, use and disclose personal health information for purposes related to or secondary to our primary purposes. The most common examples of our related and secondary purposes are as follows:
Related Purpose #1: To obtain payment for services or goods provided. Payment may be obtained from the individual, OHIP, WSIB, private insurers or others.
Related Purpose #2: To conduct quality improvement and risk management activities. We review client files to ensure that we provide high quality services, including assessing the performance of our staff. External consultants (e.g., auditors, lawyers, practice consultants, voluntary accreditation programs) may conduct audits and quality improvement reviews on our behalf.
Related Purpose #3: To promote our clinic, new services, special events and opportunities (e.g., a seminar or conference) that we have available. We will always obtain express consent from the client prior to collecting or handling personal health information for this purpose.
Related Purpose #4: To comply with external regulators. Our professionals are regulated by [e.g., the College of Dietitians of Ontario] who may inspect our records and interview our staff as a part of its regulatory activities in the public interest. The College of Dietitians of Ontario has its own strict confidentiality and privacy obligations. In addition, as professionals, we will report serious misconduct, incompetence or incapacity of other practitioners, whether they belong to other organizations or our own. Also, our organization believes that it should report information suggesting illegal behaviour to the authorities. In addition, we may be required by law to disclose personal health information to various government agencies (e.g., the Ministry of Health, and Long- Term Care, children’s aid societies, Canada Customs and Revenue Agency, Information and Privacy Commissioner, Ontario, etc.).
Related Purpose #5: To educate our staff and students. We value the education and development of future and current professionals. We will review client records in order to educate our staff and students about the provision of health care.
Related Purpose #6: To fundraise for the operations of our organization, with the express or implied consent of our clients. If we rely on implied consent, we will only use the client’s name and address, we will provide clients with an easy opt-out option, and we will not reveal anything about our client’s health in the request.
Related Purpose #7: To facilitate the sale of our organization. If the organization or its assets were to be sold, the potential purchaser would want to conduct a “due diligence” review of the organization’s records to ensure that it is a viable business that has been honestly portrayed. The potential purchaser must first enter into an agreement with the organization to keep the information confidential and secure and not to retain any of the information longer than necessary to conduct the due diligence. Once a sale has been finalized, the organization may transfer records to the purchaser, but it will make reasonable efforts to provide notice to the individual before doing so.
Protecting Personal Information
We understand the importance of protecting personal information. For that reason, we have taken the following steps:
Paper information is either under supervision or secured in a locked or restricted area.
Electronic hardware is either under supervision or secured in a locked or restricted area at all times. In addition, strong passwords are used on all computers and mobile devices.
Personal health information is only stored on mobile devices if necessary. All personal health information stored on mobile devices is protected by strong encryption.
We try to avoid taking personal health information home to work on there. However, when we do so, we transport, use and store the personal health information securely.
Paper information is transferred through sealed, addressed envelopes or boxes by reputable companies with strong privacy policies.
Electronic information is either anonymized or encrypted before being transmitted.
We do not post any personal information about our clients on social media sites and our staff members are trained on the appropriate use of social media.
External consultants and agencies with access to personal information must enter into privacy agreements with us.
Openness about the Personal Information Process
Right to Access Personal Information
Individuals have the right (with some exceptions) to access personal information about themselves held by the organization and to know what the organization has done with it. This ensures that the personal information is adequate, correct and up to date.
Staff know where to refer a request or inquiry for access if they are not able to answer it themselves;
The organization can require the request to be in writing (verbal request can be answered);
The organization will help a person make an access request if asked (e.g., to explain the filing system at the organization);
The organization provides access upon request within 30 days unless grounds of refusal exist;
The organization normally provides access not only to personal information on record, but also to how the organization has used and disclosed it. Thus, reasonable records should be kept;
The organization keeps reasonable records of any unusual uses or disclosure of personal information (e.g., systematically filing a cover letter, fax sheet or email in the relevant file);
The organization confirms the identity of the individual requesting the information before disclosing it;
The organization takes reasonable and necessary steps to ensure that the individual requesting information can understand it (e.g., explain short forms or codes, provide it in an alternative format where the requester has a sensory disability);
Access must be provided, despite a ground for refusal (except law enforcement) where the
– individual’s life, health or security is threatened. Grounds for refusal to access personal information would include:
– It is quality of care information or information generated for the College’s quality assurance program;
– Raw data from standardized psychological tests or assessments;
– There is a risk of serious harm to the treatment or recovery of the individual or of serious bodily harm to another person; or
– Access would reveal the identity of a confidential source of information (s. 51-52).
Even if the organization refuses the request, it cannot destroy the information until the individual has had a chance to challenge the refusal.
Additional procedures for handling access requests:
The Health Information Custodian (HIC) must notify the individual of his or her right to complain to the Information and Privacy Commissioner of Ontario if the request for access is refused (along with the reasons for the refusal) and the burden of justifying the refusal is on the HIC;
The HIC can refuse frivolous, vexatious and bad faith requests for access; ando The HIC can only charge a reasonable cost recovery fee for access and must provide an estimate of the fee in advance (s. 53-54). The Information & Privacy Commissioner’s Office of Ontario suggests a charge of $30.00 for the first twenty pages of records and 25 cents for each additional page.
Clients have the right to request a correction of erroneous information held by the organization. The purpose is to maintain appropriate and accurate information on clients.
The organization’s process for handling correction requests is fair to the individual.
Correction requests are restricted to factual information. Professional observations and opinions are not generally subject to correction requests.
Corrections are made without obliterating the original entry.
A notice of the disagreement is filed with the record where the organization does not agree that the information is incorrect. Any notice of refusal must advise the individual of his or her right to complain to the Information and Privacy Commissioner about the refusal (s. 55).
Corrections or notice of the disagreement are sent to third parties who have received the erroneous information unless doing so is not appropriate. However, there are limits that may include the following:
– the individual must request it;
– the notification need only be made where reasonably possible; and
– the HIC can refuse to give the notification if the correction cannot reasonably be expected to have an effect on the ongoing provision of health care or some other benefit to the individual.
- The individual is given a timely response (usually within 30 days) to a request to correct, along with reasons for any refusal to do so and notice of any recourse.
Grounds to refuse correction may include requests where:
– the request is frivolous, vexatious or made in bad faith; or
– the HIC did not create the record and the HIC does not have sufficient knowledge, expertise or authority to make the correction.
Retention and Destruction of Personal Information
We need to retain personal information for some time to ensure that we can answer any questions you might have about the services provided and for our own accountability to external regulatory bodies.
We keep our client files for at least ten years from the date of the last client interaction or from the date the client turns 18.
We destroy paper files containing personal health information by crosscut shredding. We destroy electronic information by deleting it in a manner that it cannot be restored. When hardware is discarded, we ensure that the hardware is physically destroyed or the data is erased or overwritten in a manner that the information cannot be recovered.
The organization develops and maintains an internal complaint system and makes external recourse publicly available in order to be able to receive, investigate and respond to complaints. Every effort is made to investigate and decide a simple complaint within 30 days. For more complex complaints, the person investigating or deciding the complaint will advise the person making the complaint within 30 days of how long it will likely take to investigate and decide it.
1. The individual who is designated to investigate complaints will:
a) receive and promptly acknowledge receipt of a complaint;
b) investigate the complaint;
c) decide on the complaint.
In addition, the individual who decides on the complaint has the authority to:
a) ensure compliance with the organization’s policies in respect of the complaint;
b) change the organization’s information handling policies (after consultation with other
leaders of the organization);
c) award a refund, credit or financial compensation to the individual (after consultation with other leaders of the organization).
The Complainant has recourse to external bodies as follows:
a) the regulatory body(ies) for the organization or members of the organization (e.g., College of Dietitian of Ontario);
b) the Office of the Privacy Commissioner of Canada;
c) the Information and Privacy Commissioner of Ontario to the extent that the Personal Health Information Protection Act, 2004 applies.
If there is a Privacy Breach
While we will take precautions to avoid any breach of your privacy, if there is a loss, theft or unauthorized access of your personal health information we will notify you.
Upon learning of a possible or known breach, we will take the following steps, as applicable:
Step 1: Respond immediately by implementing the organization’s privacy breach protocol.
- Inform the necessary staff within the organization.
Consider whether the Commissioner must or should be notified (PHIPA provides that regulations may be passed setting out certain kinds of breaches that must be reported to the Commissioner: s. 12(3). As of the date of this Guide, no such regulations have been passed.)
Step 2: Containment – Identify the scope of the potential breach and take steps to contain it.
- Assess what and how much information was breached and in what manner (e.g., paper format, electronic format).
- Determine whether copies were made.
- Implement any necessary action to contain further unauthorized access (e.g., change passwords, identification numbers and/or temporarily shut down a system).
- Notify all individuals whose personal health information has been compromised in the most appropriate way possible in light of the sensitivity of the information (e.g., by phone, in writing, at your next appointment, etc.).
- Inform all individuals of the steps that have or will be taken to address the privacy breach and that the Information and Privacy Commissioner’s Office, Ontario has been informed.
- Provide the individuals with the organization’s and the Information and Privacy Commissioner’s Office of Ontario contact information in case individuals have further questions.
- Advise the individual of their right to make a complaint to the Commissioner (s. 12). Step 4: Investigation and Remediation
- Conduct an internal investigation into the matter to identify how and why the privacy breach occurred.
- Take the necessary steps to implement a plan that strives to avoid a similar privacy breach from occurring in the future.
We will advise the Information and Privacy Commissioner’s Office of Ontario of the investigation findings and proposed future prevention plan and work together to make any necessary changes.
Report the results of investigation to the relevant regulatory College if appropriate or required (PHIPA requires HICss to report certain events to the relevant regulatory College, including when a member is suspended, terminated or otherwise disciplined or has had their privileges or business affiliation revoked or restricted as a result of a privacy breach: s. 17.1. The organization may also be required to report the circumstances to a regulatory College under the Regulated Health Professions Act, 1991 in cases of professional misconduct, incompetence or incapacity.)
Ensure all staff are appropriately trained and conduct further training if required.
Depending on the circumstances of the breach, we may notify and work with the Information and Privacy Commissioner of Ontario. If we take disciplinary action against one of our practitioners (or revoke or restrict the privileges or affiliation of one of our practitioners) for a privacy breach, we are required to report that to the practitioner’s regulatory College. We may also report the breach to the relevant regulatory College if we believe that it was the result of professional misconduct, incompetence or incapacity.
Access to Health Records
You have the right to seek access to your health records that we keep and to ask us to correct a record if you believe it is inaccurate or incomplete. Please contact us for more information.
Questions or Concerns?
If you have questions or want to make a complaint about our privacy practices, please contact:
Jillian Walsh, RD, MACP at firstname.lastname@example.org
You also have the right to complain to the Information and Privacy Commissioner of Ontario at the address below if you have concerns about our privacy practices or how your personal health information has been handled:
Information and Privacy Commissioner of Ontario
2 Bloor Street East, Suite 1400, Toronto, Ontario M4W 1A8
Telephone: 1 (800) 387-0073
Fax: (416) 325-9195
This policy is made under the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3. It is a complex statute and provides some additional exceptions to the privacy principles that are too detailed to set out here.