CAPÍTULO 1: FUNDAMENTACIÓN TEÓRICA
1.6.2. Lenguajes de Programación para la WEB
Alberta Health and Wellness (AHW) as custodian must identify its affiliates who are responsible for ensuring that the Health Information Act (HIA), the regulations and the policies and procedures established or adopted under s.63 are complied with.
This policy provides direction to AHW affiliates regarding established roles and the delegation of responsibility for the department under the HIA.
The senior manager of the Information Compliance and Access Unit (ICAU) Unit is the affiliate responsible for ensuring that the Parts 1, 3, 4, 5, 8 and 9 of the HIA, the regulations and the policies and procedures established or adopted under section63 are complied with.
The senior manager of the ICAU Unit is the responsible affiliate for Part 6 of the HIA except for section 67, “power to charge fees”. The FOIP/HIA coordinator and the HR/FOIP executive director are the responsible affiliates for this section as it relates to an individual’s right to access information (Part 2 of the HIA).
IM POLICY 002 June 2, 2010
Oversight 5
FOIP
The FOIP/HIA Coordinator has been assigned certain responsibilities under the FOIP Act. Contact the FOIP/HIA Office (780‐422‐5111) with questions related to the FOIP Act or refer to the FOIP
“Delegation and Assignment of Responsibility Table” in the linked documents (see below).
Contact the FOIP/HIA Office at 780‐422‐5111 if you have any questions pertaining to designated authority under FOIP.
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA or FOIP. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA and FOIP,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with sections 62 and 63 of the HIA. This policy also aligns with section 85(1) of the FOIP Act.
Linked documents Owner Location
HIA Guidelines and Practices Manual ICAU Unit 21st floor, TPNT and AHW Public Website
HIA AHW Alberta Queen’s Printer and
AHW Public Website
FOIP Government of Alberta Alberta Queen’s Printer and
AHW Public Website Administration of FOIP and appendices FOIP/HIA Office 19th floor, TPNT
Administration of HIA FOIP/HIA Office 19th floor, TPNT
HIA Assignment of Responsibility Table FOIP/HIA Office 19th floor, TPNT
Version Date Author Reviewers Approval
1.0 June 2, 2010 ICAU Unit ICAU Unit
Mark Brisson, A/ADM, Health System Performance and Information Management
IM POLICY 003 June 2, 2010
Highest Degree of Anonymity and Limited Manner Policy 6
Duty to Collect, Use and Disclose Health Information with the Highest Degree of Anonymity Possible affiliates have a duty to consider the principles of “highest degree of anonymity,” “least amount of information” and “need to know” when collecting, using or disclosing health information.
Purpose
The duties of custodians (and affiliates) are set out in Part 6 of the HIA and encompass a set of fair practices for health information. Under the HIA, the collection, use and disclosure of health information must, in all cases, be carried out in the most limited manner and with the highest degree of
Collect, use or disclose only the least amount of health information necessary to achieve the intended purpose.
Collect, use or disclose health information only in a manner that is in accordance with that affiliate’s duties to the custodian.
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Highest Degree of Anonymity and Limited Manner Policy 7
Contact the HIA help desk (427‐8087 or [email protected]) if you have questions about collecting, using or disclosing the least amount of information, using the highest degree of anonymity and based on a need to know.
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with sections 24, 28, 43, 57 and 58 of the HIA.
Linked documents Owner Location
Chapters 5‐8 of the HIA Guidelines and Practices Manual
Information Compliance and Access Unit (ICAU)
21st Floor, TPNT and AHW Public Website
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU Unit ICAU Unit
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Unit Linda Miller, Director,
IM Branch
Todd Heron, ADM, Health Accountability Division
IM POLICY 004 June 2, 2010
Duty to Assist Individual’s Right to Access 8
Duty to Assist Individual’s Right of Access to Information
Policy Statement
On request, Alberta Health and Wellness (AHW) as custodian and as a public body (including all AHW affiliates and employees) must make every reasonable effort to assist an applicant who makes a request to access a record that is in the custody or under the control of AHW. AHW must respond to including a record containing personal information about the applicant under section 6(1) of the Freedom of Information and Protection of Privacy Act (FOIP).
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Duty to Assist Individual’s Right to Access 9
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA or FOIP. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA and FOIP,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with sections 7 – 17 and 87 of the HIA.
This policy statement aligns with sections 6, 7(1) and 36(1) of FOIP.
Linked documents Owner Location
Chapters 2‐4 of the HIA Guidelines and Practices Manual
Information Access and Compliance Unit (ICAU)
21st Floor, TPNT and AHW Public Website
HIA Request to Access Information Form ICA Unit 21st Floor, TPNT and AHW Intranet
FOIP Request to Access Information
Form Government of Alberta GoA Public Website
HIA Internal Policy and Procedures FOIP/HIA Office 19th Floor, TPNT and AHW Public Website
HIA Delegation Of Authority Matrix (Part
2) FOIP/HIA Office 19th Floor, TPNT
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU Unit ICA Unit
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Unit Linda Miller Director IM
Branch
Todd Heron ADM Health Accountability Division
IM POLICY 005 June 2, 2010
Collection of Health Information 10
Collection of Health Information
Policy Statement
As a custodian, Alberta Health and Wellness (AHW) and its affiliates must only collect health information in accordance with the Health Information Act (HIA).
IM POLICY 005 June 2, 2010
Collection of Health Information 11
Alignment
This policy statement aligns with section 18 of the HIA.
Linked documents Owner Location
Chapter 6 of the HIA Guidelines and
Practices Manual ICAU 21st floor, TPNT
AHW Public Website
Version Date Author Reviewers Approval
1.0 June 2, 2010 ICAU Unit ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management
IM POLICY 006 June 2, 2010
Collection of Personal Health Number Policy 12
Collection of Personal Health Number (PHN)
The PHN provides a single point of access to an individual’s identifying health information and is therefore a critical point of risk. As such, the Health Information Act (HIA) intentionally limits the collection of PHNs. Only custodians or persons designated by the Health Information Regulation can
When requesting a PHN from an individual, AHW must advise the individual of its authority to collect that PHN.
If you are unsure whether you should be collecting PHNs or have questions about AHW’s authority to collect PHNs, then contact the HIA help desk in the Information Compliance and Access Unit (ICAU), AHW, at 780‐427‐8089 or [email protected].
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Collection of Personal Health Number Policy 13
Linked documents Owner Location
Chapter 6 of the HIA Guidelines and
Practices Manual ICAU 21st floor, TPNT
AHW Public Website
Version Date Author Reviewers Approval
1.0 June 2, 2010 ICAU ICAU Mark Brisson, A/ADM, Health System Performance and Information Management
IM POLICY 007 June 2, 2010
Collection Notice 14
Collection Notice
Section 22(3) of the Health Information Act (HIA) states that when collecting individually identifying health information about an individual directly from the individual, the custodian must take reasonable steps to inform the individual (a) of the purpose for which the information is collected, (b) of the specific legal authority for the collection, and (c) of the title, business address and business telephone
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Collection Notice 15
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with section 22(3) of the HIA.
Linked documents Owner Location
Chapter 6 of the HIA Guidelines and Practices Manual
Information Compliance and Access Unit (ICAU)
21st floor, TPNT and AHW Public Website Collection Notice Guidelines ICAU 21st floor, TPNT and AHW
Intranet
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Unit Linda Miller, Director IM
Branch
Todd Heron, ADM Health Accountability Division
IM POLICY 008 June 2, 2010
Use of Health Information 16
Use of Health Information
To ensure that AHW as custodian and its affiliates understand how to appropriately use health information as set out in the HIA. This includes understanding the appropriate and controlled access to and sharing of health information within the department listed in section 27(1) of the HIA as well as the additional uses of health information that involve sharing that information beyond the department (section 27(2)).
AHW as custodian and its affiliates may use non‐identifying health information for any purpose under section 26 of the HIA.
AHW as custodian and its affiliates may use individually identifying health information in its custody or under its control for any of the purposes listed in section 27
To assist with using health information, refer to the “Use of Health Information Decision Tree” and the “Considerations for Use” guideline document located under the linked documents.
Because the department has additional health system mandates, the department has additional authorized uses of health information under section 27(2) of the HIA:
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Use of Health Information 17
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with sections 25‐30, 57 and 58 of the HIA.
Linked documents Owner Location
Use of Health Information Decision Tree Information Compliance and Access Unit (ICAU)
21st Floor, TPNT and AHW Intranet
Chapter 7 of the HIA Guidelines and
Practices Manual ICAU 21st Floor, TPNT
and AHW Public Website
Considerations for Use ICAU 21st floor, TPNT and AHW
Intranet
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Unit Linda Miller Director IM
Branch
Todd Heron ADM Health Accountability Division
IM POLICY 009 June 2, 2010
Consent-based Disclosure 18
Consent‐based Disclosure
Policy Statement
Subject to the exceptions noted in the Health Information Act (HIA), Alberta Health and Wellness (AHW) as custodian and its affiliates may disclose individually identifying health information to a person other than the individual who is the subject of the information if the individual or the individual’s authorized representative has consented to the disclosure.
Purpose
Individually identifying health information may be disclosed to a person other than the individual who is the subject of the information if the individual or the individual’s representative has consented to that disclosure.
Consent under section 34 must be provided in writing or electronically and must include the following:
o an authorization for the custodian to disclose the health information specified in the consent o the purpose for which the health information may be disclosed
o the identity of the person to whom the health information may be disclosed
o an acknowledgement that the individual providing the consent has been made aware of the reasons why the health information is needed and the risks and benefits to the individual of consenting or refusing to consent
o the date the consent is effective and the date, if any, on which the consent expires (AHW should try and avoid promoting a blanket consent)
o a statement that the consent may be revoked at any time by the individual providing it
The section 34 consent form located under the linked documents section follows the requirements above and may be used as a template for requesting consent. If your program area would like to amend this consent form to meet the specific needs of your program area, please consult with the
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Consent-based Disclosure 19
Information Compliance and Access (ICAU) Unit before amending the forms. ICAU may be contacted at 780‐427‐8089 or via email at [email protected].
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with section 34 and 104(1)(c) to (i) of the HIA and section 6 of the Health Information Regulation.
Linked documents Owner Location
Section 34 Consent Form ICAU AHW Public Website
Chapter 8 of the HIA Guidelines and
Practices Manual ICAU 21st Floor, TPNT and
AHW Public Website
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS
Unit
Linda Miller, Director IM Branch
Todd Heron ADM Health Accountability Division
IM POLICY 010 June 2, 2010
Exceptions to Consent Based Disclosure 20
Exceptions to Consent Based Disclosure
Policy Statement
Alberta Health and Wellness (AHW) as custodian and its affiliates may disclose individually identifying diagnostic, treatment and care information without the consent of the individual who is the subject of the information for any of the specific circumstances identified in section 35(1) and (4) of Health Information Act (HIA).
Purpose
Section 35 of the HIA provides for limited and specific exceptions to the disclosure of health information without consent. Disclosures pursuant to sections 35(1) and (4) require the maintenance of certain disclosure information (section 41) and recipients of individually identifying diagnostic, treatment and care information must be notified of the purpose and authority for the disclosure (section 42).
Applicable Groups and Assets
AHW as custodian
All AHW affiliates (may include but not necessarily be limited to):
o AHW employees o Contractors/vendors o Agents
o Appointees o Volunteers o Students
o Information managers
Subject to exceptions set out in the HIA, all individually identifying diagnostic, treatment and care information in the custody or under the control of AHW
Compliance with Policy Statement
Consult with the “Exceptions to Consent Based Disclosure” list in the linked documents and/or section 35 of HIA to ensure that the disclosure fits with exceptions to consent based disclosure.
See the Disclosure Notice policy for rules regarding notification when disclosing diagnostic, treatment and care information.
If you have any questions regarding disclosure of health information, please contact the HIA helpdesk (780‐427‐8089 or [email protected]).
IM POLICY 010 June 2, 2010
Exceptions to Consent Based Disclosure 21
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this policy may result in:
o public investigations and Orders by the Office of the Information and Privacy Commissioner, o fines under the HIA,
o disciplinary action for AHW affiliates.
Alignment
This policy statement aligns with sections 35, 41 and 42 of the HIA.
Linked documents Owner Location
Exceptions to Consent Based Disclosure List
Information Compliance and Access Unit (ICAU)
21st Floor, TPNT and AHW Intranet Site Chapter 8 of the HIA Guidelines and
Practices Manual ICAU 21st Floor, TPNT and
AHW Public Website
Version Date Author Reviewers Approval
2.0 June 2, 1010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Unit Linda Miller, Director IM
Branch
Todd Heron ADM Health Accountability Division
IM POLICY 011 June 2, 2010
Disclosure of Information Process 22
Disclosure of Information Process
AHW affiliates must consult with ICAU (780‐427‐8089) about disclosures of individual and/or potentially identifiable health information subject to the following exceptions; all disclosures to individuals that the information is about (i.e., HIA access requests, statement of benefits paid, AHCIP/Premiums issues); consented disclosures to third parties; all routine and/or publicly available data products or other summarized aggregate data products; and direct/live access to electronic data sources held by the department. (Use of health information by AHW affiliates is governed by the access to data holding policy).
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Disclosure of Information Process 23
Linked documents Owner Location
Chapter 8 of the HIA Guidelines and
Practices Manual ICAU 21st Floor, TPNT and
AHW Public Website Data Disclosure Guidelines Information and Analysis
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS
Unit
Linda Miller Director IM Branch
Todd Heron ADM Health Accountability Division
IM POLICY 012 June 2, 2010
Third Party Disclosures 24
Third Party Disclosure
Policy Statement
When Alberta Health and Wellness (AHW) as custodian and its affiliates are dealing with requests from third parties to disclose individually identifying health information about a specific individual, there must be a legislative authority for the disclosure.
Consider as a factor, together with any other relevant factors, any expressed wishes of the individual who is the subject of the information before deciding how much, if any, information should be disclosed (section 58(2)).
Contact the HIA helpdesk (780‐427‐8089 or [email protected]) to determine whether legislative authority exists. LLS will be consulted by the helpdesk [part of the Information Compliance and Access Unit (ICAU)] as required.
IM POLICY 012 June 2, 2010
Third Party Disclosures 25
Alignment
This policy statement aligns with sections 31 – 58 of the HIA.
Linked documents Owner Location
Chapters 3 and 8 of the HIA Guidelines
and Practices Manual ICAU 21st Floor, TPNT
and AHW Public Website Section 34(2) Consent Form ICAU 21st Floor, TPNT
and AHW Public Website
Version Date Author Reviewers Approval
2.0 June 2, 2010 ICAU ICAU
Mark Brisson, A/ADM, Health System Performance and Information Management 1.0 June 13, 2003 RAPS Linda Miller Director
IM Branch
Todd Heron ADM Health Accountability Division
IM POLICY 013 June 2, 2010
Disclosure Notice 26
Disclosure Notification
Policy Statement
When disclosing individually identifying diagnostic, treatment and care information, Alberta Health and Wellness (AHW) as custodian and its affiliates must provide the recipient with a disclosure notice subject to some exceptions.
Purpose
Section 42(1) of the Health Information Act (HIA) states that a custodian disclosing individually identifying diagnostic, treatment and care information must inform the recipient in writing of the purpose for the disclosure and the authority under which the disclosure is made.
Confirm with your business unit whether disclosure notification(s) have been or still need to be sent. Make sure that the notification(s) meets with the following requirements:
o The notice must be in writing
o The notice must inform the recipient of the purpose of the disclosure
o The notice must inform the recipient of the authority under which the disclosure was made
Each business area should retain a copy of disclosure notices that have been issued by that business area.
To help ensure compliance with this policy, use the appropriate disclosure notice template form.
All disclosure notice template forms are available under the linked documents section.
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Disclosure Notice 27
Penalties and Consequences
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this
This policy ensures that AHW complies with and is not in breach of the HIA. Failure to comply with this