Digital health care in a pandemic – risks and rewards
As the COVID-19 pandemic has pushed digital functionalities to the fore, it is impacting significantly the delivery of health care, in particular virtual care and access to medical records. However, as in other areas, privacy and security risks abound.
Digital health modalities are playing a key role in facilitating continuity of care in the pandemic. Providers of virtual medical services such as Maple and Cover Health have seen exponential growth; provincial public health insurance plans have expanded their eligibilities for services provided remotely.
Virtual care covers the spectrum from routine private practitioner consultations to specialized virtual services providers. Functionalities include telephone and video call consultations, remote testing and imaging capabilities, and e-mail and other digital messaging assessments and diagnoses. Several models exist, ranging from telemedicine (Ontario Telemedicine Network), to a no-fee “virtual clinic” platform, funded entirely through public health insurance (Cover Health), to pay-per-visit fee-paying models (Maple).
Electronic medical records are a key facilitator of remote care, permitting health professionals to view a patient’s record from any location and to upload their own care prescriptions and records, accessible by collaborating providers and care institutions as well as, potentially, the patients themselves.
Simplified patient access to their digital medical records speaks to patient-centric control, one of the key dictates of recent public policy manifestos. Such functionalities make more accessible to a patient their personal health information records – a legal requirement under privacy laws such as Ontario’s Personal Health information Protection Act, 2004 (PHIPA). Importantly, they also serve a health system purpose by lessening the need for one-on-one interactions with medical professionals for activities such as receiving test results and reviewing diagnoses.
Risks with digital health
However making medical records accessible online presents privacy and security issues. Compared with a paper-based system, digital records enable wider potential points of contact, typically into a consolidated central database of all records of a patient’s interactions with a health system. Not surprisingly, incidents of unauthorized access, surreptitious viewing and theft of records, as well as exposure to ransomware and other external threats, are becoming commonplace. The increased reliance on electronic medical records systems in the pandemic context is further exposing weaknesses in cybersecurity protections that in many cases have not been updated to align with the new and expanded virtual communications channels, or increasingly interconnected databases.
Virtual care platforms entail privacy and security risks. Their databases are as vulnerable as any digital system to external attacks and the communications media are vulnerable to interception. Furthermore, the expanded use of digital media increases opportunities for unauthorized recording, access to patients’ records and uses of patient data for marketing and other secondary purposes.
Surge of health data breaches
Even before the pandemic, data breach incidents involving medical records were proliferating. The health sector and in particular hospitals, have been the subject of both targeted “snooping” scandals as well as system-wide attacks. The pandemic has elevated these risks as more individuals communicate digitally, often from home computers, using inadequate security protections.
In a case that resulted in a multi-million dollar class action, up to 14,450 expectant mothers were notified that their medical records might have been accessed by clerical staff for commercial exploitation purposes over a period of five years between 2009 and 2014. Ultimately, the action failed to be certified on the basis that the circumstances did not meet the requirements of the common law privacy tort of “intrusion upon seclusion” – the information disclosed (patient contact information) did not constitute private, sensitive medical information, the release of which would cause embarrassment, humiliation or anguish.
More recently, last October, LifeLabs, a laboratory testing provider which enabled online reporting and patient access to lab results, notified some 15 million patients that their records had been subject to a cyberattack. At least two class actions have been commenced on behalf of affected patients and in June the B.C. and Ontario Privacy Commissioners completed an investigation which found LifeLabs deficient in its security safeguards.
In January of this year, a class action was certified in a case involving a hospital nurse at the William Osler Health System accessing 11,000 patients’ records surreptitiously over a nine-year period. And this past September, Medisys Health Group – an executive, personal and virtual health care provider owned by Telus – notified 60,000 patients that their records may have been accessed in a ransomware attack for which the company’s security firm paid an undisclosed sum to retrieve stolen records.
Regulatory responses and private law remedies
This surge of “snooping” and cyberattack incidents has led to increased regulator scrutiny as well as legislative responses. Outside of the legal system, there are calls for more resources to be applied to cybersecurity, to protect the interconnected digital networks as well as the internal electronic records systems of health care institutions. However experience suggests that the legal system, in particular the privacy laws, has limited ability to prevent such breaches, or to provide the impacted persons with adequate compensation for the harms they incur.
While the privacy laws provide for offences, punishable by fines or imprisonment, and in some instances, administrative monetary penalties, such remedies do not address the injury incurred by affected parties. Furthermore, they have little impact in preventing system-wide cyberattacks where no identifiable perpetrator can be found. Even where prosecutions have been taken against perpetrators who can be identified, the ability to obtain private compensation from such persons is limited. The Ontario health privacy law, PHIPA, contains a provision for seeking damages from persons against whom an order, or successful prosecution, has been made. However the scope for recompense is limited to “actual harm” – meaning, personal injury, physical loss or financial loss and if the breach was intentional or committed recklessly, damages “for mental anguish “up to $10,000. Establishing proof of such harm may be difficult, if not impossible.
The most likely scope for financial compensation can be found in the evolving common law tort of invasion of privacy, or as the leading case of Jones v. Tsige characterized it, “intrusion upon seclusion”. For liability to be found, the defendant’s conduct must be intentional and they must have invaded, without lawful justification, the plaintiff’s private affairs or concerns in circumstances where a reasonable person would regard the invasion as highly offensive, causing distress, humiliation or anguish. The courts have awarded damages against defendants in the range of $10,000 – $20,000.
Class action lawsuits, undertaken outside of the privacy laws against the organizations responsible for protecting the data, may provide some level of compensation to individual patients, and, while not a deterrent to unreachable perpetrators, should be an incentive the health care sector to invest in required enhancements to cybersecurity systems.
With the increasing focus on digital health modalities, sharpened in the context of the current pandemic, cybersecurity enhancements and regulatory prevention tools should be an urgent priority. The challenge for all stakeholders is how to best action prevention and to which persons or entities should prevention strategies be directed? Do severe financial penalties and multi-million dollar class actions provide sufficient incentives? The experience may indicate otherwise.
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Note: The foregoing does not constitute legal advice. Readers are cautioned that for application to specific situations, legal advice should be obtained.
© David Young Law 2020