HIC reporting obligations

Health Information Custodians (HICs) are required to report certain breaches to the Information and Privacy Commissioner of Ontario.

While the obligation to notify is quite broad, most provisions involve a reasonable belief that unauthorized access to personal health information may have occurred and/or information disclosed. Minor breaches involving unauthorized access that were promptly contained by the HIC would not have to be reported.

It is always a good rule that if you are in doubt of whether a breach needs to be reported, call the College or the Office of the Privacy Commissioner.

A HIC is required to notify the commissioner if:

1. The health information custodian has reasonable grounds to believe that personal health information in the custodian’s custody or control was used or disclosed without authority by a person who knew or ought to have known that they were using or disclosing the information without authority.
2. The health information custodian has reasonable grounds to believe that personal health information in the custodian’s custody or control was stolen.
3. The health information custodian has reasonable grounds to believe that, after an initial loss or unauthorized use or disclosure of personal health information in the custodian’s custody or control, the personal health information was or will be further used or disclosed without authority.
4. The loss or unauthorized use or disclosure of personal health information is part of a pattern of similar losses or unauthorized uses or disclosures of personal health information in the custody or control of the health information custodian.
5. The health information custodian is required to give notice to a College of an event described in section 17.1 of the Act that relates to a loss or unauthorized use or disclosure of personal health information.
6. The health information custodian would be required to give notice to a College, if an agent of the health information custodian were a member of the College, of an event described in section 17.1 of the Act that relates to a loss or unauthorized use or disclosure of personal health information.
7. The health information custodian determines that the loss or unauthorized use or disclosure of personal health information is significant after considering all relevant circumstances, including the following:
   i. Whether the personal health information that was lost or used or disclosed without authority is sensitive.
   ii. Whether the loss or unauthorized use or disclosure involved a large volume of personal health information.
   iii. Whether the loss or unauthorized use or disclosure involved many individuals’ personal health information.
   iv. Whether more than one health information custodian or agent was responsible for the loss or unauthorized use or disclosure of the personal health information.