IPC/Ontario issues basic cyber hygiene decision

On July 5th, the IPC/Ontario held that an Ontario medical clinic breached its PHIPA safeguarding duties by:

Allowing staff to use personal e-mail accounts to send patient information provided staff referred to patients only by by initials, medical reference numbers or accession numbers
Allowing the posting of login credentials (on sticky notes or the equivalent) to enable shared access to two computers
Failing to abide by the IPCs model for agent information and instruction, which requires annual privacy training and the re-signing of confidentiality agreements on an annual basis

The clinic self-corrected upon receiving the complaint, but not without defending its posting of login credentials by explaining that the two computers were physically secure and did not contain patient information. It shouldn’t have bothered. Its information and instruction failure aside, the clinic committed plain and basic network security wrongs. The IPC’s decision is notable for calling them out.

A Medical Clinic (Re), 2022 CanLII 61410 (ON IPC).

Cyber security for the regulator and regulated

On Monday I addressed an audience a the Ontario Regulatory Authorities continuing professional development conference on the topic of cybersecurity. It was a good chance to record an updated and concise view of the Canadian threat environment along with the cyber defence and incident response issues facing Canadian organizations. Here are the slides for your reading pleasure.

Manitoba Ombudsman blesses response to e-mail incident

Manitoba Ombudsman Jill Perron has issued her report into Manitoba Families’ 2020 e-mail incident. The incident involved the inadvertent e-mailing of personal health information belonging to 8,900 children in receipt of disability services to approximately 100 external agencies and community advocates. It is such a common incident that it is worth outlining the Ombudsman’s incident response findings.

Manitoba Families meant to transfer the information to the Manitoba Advocate for Children and Youth to support a program review. It included information about services received. Some records included diagnoses.

Manitoba Families mistakenly blind copied the external agencies and advocates on an e-mail that included the information in an encrypted file and a follow-up e-mail that included the password to the file. It had made the same mistake about a week earlier. Several agencies alerted Manitoba Families to its error, and it began containment within a half hour.

The Ombudsman held that Manitoba Families’ containment effort was reasonable. She described it as follows.

Attempts at recalling the email began minutes later at 8:29 a.m. and continued at various intervals. Also, at 8:35 a.m., CDS sent an email to all unintended recipients noting in bold that they were incorrectly included on a confidential email from Children’s disAbility Services and requested immediate deletion of the email and any attachments. Follow up calls to the unintended recipients by CDS program staff began to occur that morning to request deletion of the emails and a list was created to track these calls and the outcomes. A communication outline was created for these calls which included a request to delete emails, a further request that emails be deleted from the deleted folder and that any emails that went to a junk email folder also be deleted…

In January 2021, we received additional written communication from the program stating that all agency service providers and advocates were contacted and verified deletion of the personal health information received in error. The log form created to track and monitor the name of the organization, the date and details of the contact was provided to our office.

The Ombudsman reached a similar finding regarding Manitoba Families’ notification effort, though she needed to recommend that Manitoba Families identify the agencies and advocates to affected individuals, which Manitoba Families agreed to do upon request.

What’s most significant – especially given class action proceedings have been commenced – is a point the Ombudsman made about evidence that Manitoba Families appears not to have gathered.

In addition to assuring families about the deletion of the email, additional information such as who viewed the email, if the attachment was opened and read, whether it was forwarded to anyone else or printed, whether it was stored in any other network drive or paper file or, conversely, that no records exist – can be helpful information to provide those affected by a privacy breach. It is best practice, therefore, to provide families with as much assurance as possible about the security of their child’s health information.

The question is, what is one to make of an arguable shortcoming in an incident response investigation? I say “arguable” because the probability of any of these actions occurring is very low in the unique circumstances of this incident, which involved trusted individuals receiving a password-protected and encrypted file. Manitoba Families ought to have collected this evidence because they called the e-mail recipients anyway, it is helpful and was probably available for collection. If it did not do so, however, I believe it is perfectly acceptable to for Manitoba Families to stand by the scope of a narrower investigation and and put the plaintiff to proof.

PHIA Case 2020-1304

Acceptable use policies – answers to ten common employer questions

I’ve been doing substantial work on employer acceptable use policies lately and would like to publish a draft Q&A for feedback.

If you have feedback please comment or send me an e-mail.

Dan

1. What should employers do today to ensure their acceptable use policies effectively manage the implications of personal use?

In light of recent developments, employers should ensure that their acceptable use policies (1) articulate all the purposes for which management may access and use information stored on its system and (2) make clear that engaging in personal use is a choice employees make that involves the sacrifice of personal privacy.

2. What are the most common purposes for employer access?

Consider the following list: (a) to engage in technical maintenance, repair and management; (b) to meet a legal requirement to produce records, including by engaging in e-discovery; (c) to ensure continuity of work processes (e.g., employee departs, employee gets sick, work stoppage occurs); (d) to improve business processes and manage productivity; and (e) to prevent misconduct and ensure compliance with the law.

3. How should employers describe the scope of application of an acceptable use policy?

Acceptable use policies usually apply to “users” (employees and others) and a “system” or “network.” To effectively manage employee privacy expectations, policies should make clear that devices (laptops, handhelds…) that are company owned and issued for work purposes are part of the system or network even though they may periodically be used as stand alone devices.

4. Should employers have controls that limit access to information created by employees even though they don’t want to acknowledge that employees can expect privacy in their personal use?

Access controls are an important part of corporate information security. Rules that control who can access information created by employees (e.g., in an e-mail account or stored in a space reserved for an employee on a hard drive) are, first and foremost, for the company’s benefit. Access controls should be clearly framed as being created for the company’s benefit and not for the purpose of protecting employee privacy.

5. How should passwords be addressed in an acceptable use policy?

Password sharing should be prohibited by policy. Employees should have a positive duty to keep passwords reasonably secure. An acceptable use policy should also make clear that the primary purpose of a password is to ensure that people who use the company system can be reliably identified. Conversely, an acceptable use policy should make clear that the purpose of a password is not to preclude employer access.

6. Does access to forensic information raise special issues?

Yes. Acceptable use policies often advise employees that their use of a work system may generate information about system use that cannot readily be seen – e.g., information stored in log files and “deleted” information. It is a good practice to use an acceptable use policy to warn employees that this kind of information exists and may be accessed and used by an employer in the course of an investigation (or otherwise).

7. How should an employer address the use of personal devices on its network?

Ensuring work information stays on company owned devices has always been the safest policy, though cost and user pressures are causing a large number of organizations to open up to a “bring your own device” policy. Employers who accept “BYOD” should use technical and legal means to ensure adequate network security and adequate control of corporate information stored on employee-owned devices. For example, employers may require employees to agree to remotely manage their own devices as a condition of use and with an understanding that they will sacrifice a good degree of personal privacy.

8. Should an acceptable use policy govern the use of social media?

Only indirectly. An acceptable use policy governs the use of a corporate network. A social media policy governs the publication of information on the internet from any computer at any time. In managing social media risks, employers should stress that publications made from home are not necessarily “private” or beyond reproach, so putting internet publication rules in an acceptable use policy sends a counter-productive message.

9. Should employers utilize annual acknowledgements?

Annual acknowledgements are not a strict requirement for enforcing the terms of an acceptable use policy but are helpful. The basic requirement is to give notice of all applicable terms in a manner that allows knowledge to be readily inferred in the event of a dispute. “Login script” with appropriate warning language is also common and helpful. Nowadays, a good login script will say something like, “If you need a confidential means of sending and receiving personal communications and storing personal files you should use a personal device unconnected to our system.”

10. Are there special concerns for public sector employers?

Most public sector employers in Canada are bound by the Canadian Charter of Rights and Freedoms and by freedom of information legislation. Many have workforces that are predominantly unionized. The guidance to public sector employers on their acceptable use policies is no different than to employers in general, but the need to manage expectations that employees may derive from personal use is particularly strong for public sector employers given the legal context in which they operate.