A Reference Guide, Nov. 2006
Download Print-Friendly PDF:
This Section | Entire Document
|
|
A Reference Guide, Nov. 2006 Download Print-Friendly PDF: |
| Section 5, part 1 | Table of Contents < Previous Page | Next Page > |
The ChildrenÕs Treatment
Network of Simcoe York is committed to protecting the privacy and security of
its participants. Any personally
identifiable information CTN collects will be used solely by and for CTN and
will not be sold or otherwise distributed to third parties. We recognize a special obligation to
protect personal information obtained from children and families.
i.
General Guidelines
Children, youth and their families are best served by the Network when:
á
staff in the Network have access to the data they require to support
their work together as an efficient team with the child and family
á
families can be assured that only authorized staff in the Network have
access to their personal information , and the confidentiality of their
personal information is protected by appropriate operational practices
according to the appropriate legislation
á
there are clear guidelines and communication regarding processes and
procedures for sharing information, ensuring that it is shared only with
informed consent, and that no harm is caused
Scope
This framework for privacy and security may include in its scope all
children, youth and families served by any staff whose organization is a member
of the Network. By virtue of the CTN model, the privacy guidelines will of
necessity spill over into the day-to-day operational practice of the CTN
partners. These guidelines are intended to guide the Network as a health
information custodian, its agents and partners, and specifically, the NetworkÕs
use of an electronic client record and single plan of care.
This guideline includes requirements under the following legislation:
Personal Health Information Protection Act (PHIPA)
Freedom of Information and Protection of Privacy Act (FIPPA and MFIPPA)
Child & Family Services Act (CFSA)
Education Act
ii.
Basic Rights of Individuals with
respect to Privacy
á
Individuals have the right of access to their own health information
á
Individuals have the right to privacy and protection of confidential information,
including the right to consent, withhold or withdraw consent
á
Individuals have the right to require the correction or amendment of
personal health information about themselves.
Definitions
Confidentiality
Information
of some sensitivity not already in the public domain or not readily available
from another public source, and which has been shared
in a relationship where the person giving it understood that it would not be
shared with others without their express consent.
Express
Consent
The client
provides informed, explicit, verbal or written consent based on their
understanding of what will occur and why. Express consent is required if a
health information custodian discloses information to a person who is not a
health information custodian or to a health custodian but not for purposes of
providing or assisting in providing health care.
Implied
Consent
If personal
health information is received for the purpose of providing health care, or
assisting in the provision of health care, the client is assumed to have
implied consent to collect, use or disclose the information for the purposes of
providing health care or assisting in providing health care, unless the
custodian becomes aware that the individual has expressly withheld or withdrawn
consent.
Health Information Custodian
A health
information custodian (HIC) is a person or organization who has custody or
control of personal health information as a result of or in connection with
performing the personÕs or organizationÕs powers or duties. The Network and
some of its members are HICs.
Agent, in relation to a health
information custodian, is a person who with the authorization of the custodian,
acts for or on behalf of the custodian, and not the agentÕs own purposes.
Health
Care and Health Care Practitioners
PHIPA
defines health care as any observation, examination, assessment, care, service,
procedure that is conducted for a health-related purpose, and is carried out or
provided to:
á
diagnose,
treat or maintain an individualÕs physical or mental condition
á
prevent
disease or injury or to promote health
Circle
of Care
PHIPA does not define Òcircle of careÓ.
The term refers to those in the health care team who are involved in the care
or treatment of a particular person. The Network would identify the circle of
care as including the members of the child and youth/familyÕs team as
identified on the Single Plan of Care.
Lockbox
The term Òlock boxÓ applies to situations where the
individual has expressly restricted disclosure of specific personal health
information to others -- even to others involved in the circle of care. This
decision and related discussions should be well documented in the patientÕs
record. It is to be noted that
individuals may not prevent the custodian from disclosing personal health
information permitted or required by law.
Documentation Guidelines
-Under Development
iii.
Information Sharing
Electronic Record
Information about children
and youth being served by the Network will be recorded in an electronic
record. Only authorized staff with
the consent of the young person or childÕs parent or guardian will access the
electronic record. In some
situations, access to some information will be restricted to a particular
category of practitioner or user.
Details about the clinical software application, the electronic record
and the single plan of care are in a separate module.
Authorized users will access
the electronic record and single plan of care either through a secure web
interface, through their agencyÕs secure network, or through another designated
user. They will be trained to access and use the software application
appropriately, and to ensure that the information is accurate and secure. A system administrator will oversee the
access control process.
Guidance for Sharing
Information
To enable the development
and delivery of an integrated plan of care, Network members need to understand
when, why and how to share information with each other, so they can do so
confidently and appropriately in daily practice.
This will require ongoing
learning and collaboration among Network members to develop and practice new
processes for integrated assessments, planning and intervention. Privacy policy, procedures and training
will be updated as practices to support integrated working evolve.
Staff will continue to be
sensitive to the need to protect confidential information, and adhere to their
professional codes of conduct. The relationship between providers and client is
based on the assumption that the appropriate sharing of information within the
relationship is beneficial to the child and family.
Principles for
Information Sharing
1) Day to day operations are conducted so that personal
identifiable information is used in a fair and lawful manner that places the
client at the centre of the process
2) There must be a defined and justifiable purpose for
sharing information, and it is explained openly and transparently as early in
the engagement as possible
3) Every request for disclosure and reason for decision
must be recorded
4) Sharing personal identifiable information should be
the minimum information required for the stated purpose
5) Personal identifiable information should not be kept
for longer than necessary in accordance with the purpose, and be kept accurate
and up to date
6) Access to personal identifiable information should be
restricted to a Ôneed to knowÕ basis; when in doubt, seek advice
7) Those with access to personal identifiable
information should be trained in their responsibilities to protect it
8) Responsibility regarding personal information may
extend beyond the death of the person
9) All personal identifiable information must be held in
a safe and secure environment, including the means by which it is transmitted
or received
Governance for
Information Sharing
á Information sharing agreement will be developed with each of the Network partners
that will detail the governance and practice for the privacy and security of
personal information through common network approach to privacy and information sharing. It will cover issues
related to:
o Designated contact, Staff confidentiality agreements
o Operational policies and procedures
o Security Audit procedures and accountabilities for
security
o Training
o Data retention, destruction of records
o Communication to families
o Problem-solving and conflict resolution
o Terms of Reference for a Network Privacy Working
Group to oversee issues related to
privacy and information sharing, including the initial, and ongoing review of
the Privacy Impact Assessment (PIA)
á Each member will identify one contact person to ensure compliance with the legislation, be the
point person in the organization for the Goldcare system administrator to
ensure the right people have access to the electronic record, and to deal with
enquiries about information and privacy issues
á Communications/Short Notices:
Notices and Materials will be available – eventually in multiple languages, to inform
children, youth and families about their rights with respect to privacy, and
what to expect regarding Network practices. These will take the form of
pamphlets, posters, disclaimers on email, website, etc.
á The information sharing agreement will provide a
foundation for other CTN data-sharing partnerships, such as membership in the
Electronic Child Health Network (eCHN), Ontario Telemedecine Network
(OTN) or Smart Systems for
Health (SSHA) that support
integrated service delivery to children and families
iv.
Collection, Use and Disclosure
á
Generally, personal information can be collected, used and disclosed if
the individual consents, or the collection, use or disclosure is permitted or
required by legislation
o
Information should not be collected, used or disclosed if other
information will serve the purpose
o
Only the information necessary to meet the purpose can be collected,
used or disclosed
á
Express consent is required to collect, use or disclose personal
information for marketing purposes, including vendors
á
Express consent is required for participation in a research project.
Individuals have the right to expect that the research project has been
evaluated for ethics approval, and that the researcher has signed a
confidentiality agreement with CTN.
á
Personal information should generally be collected directly from
individuals, but can be collected indirectly if:
o
The individual consents
o
The information is necessary for the provision of health care and direct
collection is not reasonably possible
o
The custodian collects the information from a person who is not a custodian
for research purposes
á
Custodians can use information without consent or provide to an agent..:
o
For the purpose for which it was collected
o
For purpose for which it is permitted or required by law to disclose
o
For planning or delivering programs or services that the custodian
provides or funds
o
For risk management, error management or quality improvement of care
o
For educating agents who provide health care
o
For disposing of information or modifying information to conceal
identity
o
To seek consent of the individual
o
For purpose of a proceeding
á
Disclosure without consent:
As a general rule, personal information should only be disclosed with
the consent of the individual, except where
o
Required by law to disclose – e.g. CFSA Duty to Report, court
order
o
Emergency/Urgent circumstances - there are reasonable grounds to believe
that the disclosure is necessary to eliminate or reduce a significant risk
(good judgement) of serious bodily harm to a person or group of persons
á
The recipient of personal information from a custodian must not use or
disclose information for any purpose other than the purpose for which it was
disclosed.
á
The health information custodian must have a process in place to revise
inaccurate records
General guidelines for Consent
á
The child, youth and family are at the centre of what happens to their
information – they are the owners of the information
á
The approach to requesting consent to share information must be open,
transparent and respectful, with the outcome of making the individual knowledgeable
about why data is being collected and how it may be used.
á
Providing individuals with all the information they need to make a
decision is the basis of informed consent
á
Informed Consent (See
definitions) can be:
o
Explicit/ express
o
Implicit/ implied (HICs to HICs; Circle of Care, except when withheld or
withdrawn)
o
verbal or written
o
Withheld or Withdrawn
o
Conditional
á
CTN will proactively inform users when they first engage with service as
to circumstances by which their information may be gathered, recorded and
shared
á
The governance framework of network partners must be respected
Who can Consent
v.
Security
of Personal Information
Security/Privacy Policy
CTNÕs
capacity to audit privacy and security compliance resides in the Goldcare
applicationÕs data trail functions.
An audit will be conducted on a regular basis to monitor adherence to
the privacy guideline, and address issues identified in the process.
System Security and
Access
At all times, information
will be held in a safe, secure environment, including the means by which it is
transmitted or received between partner organizations, and, in so far as it is
reasonably practicable, to be free from unauthorized or unlawful access or
interception, accidental loss or damage. The level of security will be
commensurate with the sensitivity and classification of the information to be
stored, shared, transmitted or received.
Physical Security
á All computers and other electronic devices should be
password protected
á Workstations and meeting places must provide
sufficient privacy for the protection of confidential information during normal
working. Access to locked filing
cabinets to be provided where necessary
á Fax machines used for personal health information
must be in a secure location, with a routine that ensures that they are
directed to the right person immediately
á When absent from the computer, personal identifying
information must not be on the screen, and the program should be locked from
inadvertent access
á Access to a shredder for secure destruction of paper records
Goldcare – Clinical
Software Application for the Electronic Record
á Access Security: the Designated Contact for each Network
member will provide to the CTN System Administrator
(michelle.biehler@ctn-simcoeyork.ca), the names of their employees who require
access to the electronic record and for what purpose
á
The CTN system
administrator confirms eligibility and assigns each individual to a user group,
identifies any restrictions to access, then notifies the data user of their
login ID and password for authenticated access to the system. The system
administrator maintains a current database of all system users.
á
Each data user will be oriented and trained to the use of Goldcare
á
Restricted Acess: The System
Administrator can restrict access for a specific user at the record level. However, the default is set to allow
all users to view all information in the client records in the local
teams in which they are involved, with write access restricted to the
userÕs own user groupÕs permissions in Goldcare
á LockBox: Any user
can restrict access to confidential information that an individual client does
not consent to be disclosed. There is provision to ÔlockÕ information from view
by inserting it into a Ôlocked fileÕ or folder in the Document Manager section
of the clinical application. The
information is encrypted and password protected and can only be accessed by the
person who has entered it.
á Password: A password policy is outlined for the use
of Goldcare to reinforce the care that must be taken to protect the personal
information stored within it.
Acceptable Use Policy – CTN Networks, Software, Hardware
Appropriate use:
a.
Users will employ only those accounts for which they are authorized, and
shall take necessary precautions to prevent others from obtaining access to
their computer accounts or passwords
b.
Users will be guided by their professional practice standards
c.
Minimal personal use is acceptable
d.
Data is to be treated as confidential, shared with informed consent
e.
While away from the office, keep all electronic devices with you, secure
from theft, loss and unauthorized access. Avoid removing personal information
from the office unless necessary and safeguard privacy in all conversations
Inappropriate use
a.
Activity for personal gain, or that is in contravention of the Criminal
Code or Ontario Human Rights Code is prohibited
b.
Accumulation of unnecessary, outdated or non-work related files is
discouraged
c.
activity that jeopardizes the integrity of the network, application or
computer, such as installing unauthorized software is prohibited
d.
Intentional breach of privacy or confidentiality
vi.
Procedures
Consent: Roles and
Responsibilities
|
|
Service
Navigators |
Service
Coordinators |
Clinicians/Practitioners |
|
Consent
to collect, use, disclose personal information to HICs & non-HICs |
Express verbal consent to
do the CFI, and refer to service coordinator and initial team |
|
|
|
Consent
for assessment and planning; and to proceed with the single plan of care when
consensus is reached |
|
á Add information to initial consent to gather, share
information with additional members,
to develop plan á a single plan of care is consented to as treatment
plan and circle of care |
á May need written consent for a specific procedure
or assessment |
|
Consent
to treat |
|
|
Regularly, ongoing |
Consent Form
The way consent is collected
may vary depending on the purpose or stage of care. The form for consent allows
for all the individual information and wishes to be inserted electronically in
either a verbal conversation, or in written form prior to printing and
signing. If there is a necessity
to disclose your personal information beyond the parameters of the original
consent, especially where express consent is required, individuals will be
notified with a request to update the consent.
Recording Consent
All requests for consent and
consents received – including any conditions or changes, are logged in
the individualÕs electronic record, in the consent tracking log. Written
consents are scanned into the Document manager consent folder.
If there are restrictions to
access, the System Administrator and Privacy Officer must be notified
immediately, to enable the appropriate restrictions to user ID. In such cases, an alternate process
will grant access to only those members who have consent.
Consent is refused or
withheld
Children/young people and
their parents/guardians can refuse to give consent, and refuse to receive
treatment and intervention services. In these circumstances, their views must
be respected, once they have a clear idea of the consequences of withholding
consent.
If this occurs, service
navigators or coordinators or the Privacy Officer will explore opportunities
for supporting the child/or and family in universal settings (e.g. child care,
school), perhaps as a stepping stone to encouraging them to take up the more
targeted support available. There may be opportunities for parents to
participate through drop-in programs (Ontario Early Years Centres, Best Start
hubs), parenting support (Hanen Programs, Triple P programs), etc.
Process for Managing a Privacy
Breach
a.
Identify the scope of the breach and contain it.
b.
Report to the agency designated contact person, and the privacy officer,
who will investigate as the type of breach warrants; breaches may be
categorized as:
i. not serious, e.g.
inadvertent access that is unintentional and has no negative consequences, and
may require additional training
ii. serious but
unintentional, e.g. confidential information was inappropriately disclosed, but
without negative intent, and may require a review of practices
iii. serious and
malicious intent that requires significant investigation, and potentially
involvement of the police
c.
Notify the individual whose information was breached that a breach has
taken place along with the steps taken to resolve the breach. A HIC must notify
the individual at the first reasonable opportunity if the
information is stolen, lost or accessed by unauthorized persons.
d. Review and
revision of organizational policies or procedures as necessary, and/or Network
policies
Request to Access/Review
Record
a) Confirm the type of information sought, and the scope
of the request, e.g. any particular part of the record, involving a specific
incident as well as the individualÕs identity
b) Direct the requester to the request form, and submit
to the Privacy Officer, who will evaluate and respond to the request within 30
days, with a possible 30 day extension
How to Correct Records
a) Strike out the incorrect information in a manner that
does not obliterate it or
b) Label the information as incorrect and sever from the
record, while maintaining a link to the record
c) If the correction cannot be recorded in the record,
every effort must be made to inform persons accessing the record that the
information is incorrect and where to obtain the correct information.
Complaints Process
a) Encourage the individual to discuss the nature of
their complaint, including other members of the team as needed, clarifying the
specifics of the complaint
b) If further process required, ask the individual to
submit complaint in writing to the Privacy Officer who will gather information
and make findings
c) If the complaint is substantiated, immediate action
will be undertaken to rectify the situation, responding to the individual with
the explanation
d) If the complaint cannot be substantiated, review the
findings with the individual, and indicate the opportunity to make complaint to
the IPC
vii.
Forms
The following draft forms are
attached below, and will be posted to the website when finalized:
á Consent
á Request to access individual record (attached as
separate PDF file)
á Complaint (in development)
á Fact Sheet for families
| Section 5, part 1 | Table of Contents < Previous Page | Next Page > |