Privacy of personal information is an important principle to me, Lisa Rutledge, RD. I am committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services I provide. I try to be open and transparent about how I handle personal information. This document describes my 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 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).
• community and home care services.
• 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?
My organization, Lisa Rutledge, RD, includes at the time of writing Lisa Rutledge. 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
I collect, use, and disclose personal information in order to serve my clients. For my 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 health needs are, to advise them of their options and then to provide the health 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. I review client files to ensure that I 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 my clinic, new services, special events and opportunities (e.g. a seminar or conference) that I have available. I 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. As a professional, I am regulated by the College of Dietitians of Ontario and the Order of Dietitian Nutritionists of Quebec who may inspect my records and interview my staff as a part of its regulatory activities in the public interest. The Colleges have their own strict confidentiality and privacy obligations. In addition, as a professionals, I will report serious misconduct,
incompetence, or incapacity of other practitioners, whether they belong to other organizations or my own. Also, my organization believes that it should report information suggesting illegal behaviour to the authorities. In addition, I 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 my staff and students. I value the education and development of future and current professionals. I 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 my organization, with the express or implied consent of our clients. If I rely on implied consent, we will only use the client’s name and address, I 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 my 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
I understand the importance of protecting personal information. For that reason, I 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.
• I 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.
• I do not post any personal information about my clients on social media sites and my staff members are trained on the appropriate use of social media sites.
• External consultants and agencies with access to personal information must enter into privacy agreements with me.
Retention and Destruction of Personal Information
I need to retain personal information for some time to ensure that I can answer any questions you might have about the services provided and for our own accountability to external regulatory bodies. However, in order to protect your privacy, I do not want to keep personal information for too long. We keep our client files for at least ten years from the date of the last client interaction if the client was younger than 18 at the date of the last visit, at least 10 years after the date that the client turns, or would have turned, 18 years of age. I destroy paper files containing personal health information by cross-cut shredding. I destroy electronic information by deleting it in a manner that it cannot be restored. When hardware is discarded, I ensure that the hardware is physically destroyed, or the data is erased or overwritten in a manner that the information cannot be recovered.
You Can Look at Your Records
With only a few exceptions, you have the right to see what personal information we hold about you, by contacting Lisa Rutledge. I can help you identify what records we might have about you. I will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). I will need to confirm your identity, if we do not know you, before providing you with this access. I reserve the right to charge $30.00 for the first twenty pages of records and 25 cents for each additional page. I may ask you to put your request in writing. I will respond to your request as soon as possible and generally within 30 days, if at all possible. If I cannot give you access, I will tell you the
reason, as best we can, as to why. If you believe there is a mistake in the information, you have the right to ask for it to be corrected. This
applies to factual information and not to any professional opinions we may have formed. I may ask you to provide documentation that our files are wrong. Where we agree that we made a mistake I will make the correction. At your request and where it is reasonably possible, we will notify anyone to whom we sent this information (but we may deny your request if it would not reasonably have an effect on the ongoing provision of health care). If I do not agree that I have made a mistake, I will still agree to include in our file a brief statement from you on the point.
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:
We will contain the breach to the best of our ability, including by taking the following steps if applicable:
Retrieving hard copies of personal health information that have been disclosed
Ensuring no copies have been made
Taking steps to prevent unauthorized access to electronic information (e.g., change passwords, restrict access, temporarily shut down system)
We will notify affected individuals
We will provide our contact information in case the individual has further questions
We will provide the Commissioner’s contact information and advise the affected individual of their right to complain to the Commissioner
We will investigate and remediate the problem, by:
Conducting an internal investigation
Determining what steps should be taken to prevent future breaches (e.g. changes to policies, additional safeguards)
Ensuring staff is 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.
Do You Have Questions or Concerns?
Our Information Officer, Lisa Rutledge, can be reached at email@example.com. I will attempt to answer any questions or concerns you might have.
If you wish to make a formal complaint about our privacy practices, you may make it in writing to our Information Officer. They will acknowledge receipt of your complaint and ensure that it is investigated promptly and that you are provided with a formal decision and reasons in writing.
You also have the right to complain to the Information and Privacy Commissioner of your province if you have concerns about our privacy practices or how your personal health information has been handled, by contacting:
Information and Privacy Commissioner/Ontario
2 Bloor Street East, Suite 1400
Toronto, Ontario M4W 1A8
Telephone: Toronto Area (416/local 905): (416) 326-3333
Long Distance: 1 (800) 387-0073 (within Ontario)
TDD/TTY: (416) 325-7539
FAX: (416) 325-9195
Commission d’access a l’information du Quebec
2045, rue Stanley
Montréal (Québec) H3A 2V4
Téléphone : 514 873-4196
Sans frais : 1 888 528-7741
Télécopieur : 514 844-6170
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.