Statement of Information Practices for the Role of the Prescribed Entity or Prescribed Person

Ontario Health is a provincial agency whose mandate is set out in the Connecting Care Act, 2019. To fulfill this mandate, Ontario Health receives personal health information and personal information relating to health care provided in Ontario and to Ontario residents. In respect of this confidential information, Ontario Health is committed to complying with its obligations under applicable privacy law and protecting the privacy rights of individuals and the confidentiality of their personal health information and personal information. For information about Ontario Health’s information practices, visit Ontario Health Statement of Information Practices.

This Statement of Information Practices explains how Ontario Health handles and manages personal health information and personal information, including Ontario Health’s authority under the law to collect, use, disclose and otherwise handle this information.

Authority to Collect, Use and Disclose Personal Health Information

PHIPA Roles

Prescribed Entity (PE)

Ontario Health has the status 'prescribed entity' under s. 18(1) of Ontario Regulation 329/04 for the purposes of s. 45 of PHIPA. As a prescribed entity, Ontario Health may collect personal health information without individuals' consent from health information custodians and use that information for analysis and compiling with respect to the management of, evaluation or monitoring of, the allocation of resources to or planning for all or part of the health system, including the delivery of services.

For a list of the types of personal health information that Ontario Health collects as a prescribed entity see Ontario Health's Data Assets and Statement of Purpose List.

Prescribed Person (PP)

Ontario Health has the status 'prescribed person' under PHIPA with respect to Ontario Health's role in compiling and maintaining prescribed registries:

• Ontario Cancer Screening Registry (OCSR).
• registry of cardiac and vascular services.
• registry of chronic diseases.

This designation grants Ontario Health the authority to compile or maintain a registry of personal health information (‘prescribed registry’) for purposes of facilitating or improving the provision of healthcare under s. 39(1)(c) of PHIPA. Other permitted uses and disclosures are described in Part IV of PHIPA and its regulation.

For a list of the types of personal health information that Ontario Health collects as a prescribed person see Ontario Health's Data Assets and Statement of Purpose List.

Collection of Personal Information and Personal Health Information

Ontario Health also collects personal information and personal health information from other government organizations and data partners such as:

• Ministry of Health,
• Ministry of Government Services,
• Pharmaceutical Manufacturers,
• Workplace Safety and Insurance Board,
• Ontario Health at Home,
• Canadian Institute for Health Information and
• Institute for Clinical Evaluative Sciences (ICES),

Ontario Health also collects personal information directly from individuals, if required, including for example, our cancer screening, patient and family advisor programs, and Out-of-Country Hemodialysis Reimbursement Program.

Use of Personal Information and Personal Health Information

Ontario Health uses personal information and personal health information, for example, to:

• Study and report on the use, effects and patterns of healthcare diagnosis, services and treatment in the province
• Estimate current and future needs for healthcare services
• Study wait times for healthcare services
• Facilitate the delivery of healthcare through the Ontario Cancer Screening Programs
• Determine eligibility for funding of healthcare services
• To engage patient and family members to learn about their experiences with the healthcare system

Ontario’s cancer screening programs as part of the Ontario Cancer Screening Registry

Ontario Health collects the following types of personal information and personal health information to support the planning and management of cancer services in Ontario or for Ontario residents:

• Information related to expenditures for clinics or services
• Clinical information, including images, that support diagnosis, treatment or services provided
• Screening information related to the early detection of cancer or the risks of developing cancer
• Patient-reported outcomes, satisfaction and experience to facilitate conversations with healthcare providers and increase patient involvement in care

Ontario Health also collects personal health information for the purposes of the cancer screening programs, and use this information to send letters to eligible individuals to:

• invite them to participate in screening
• inform them of their screening test results
• inform them of what to do if they have an abnormal test result
• connect patients without family doctors to a doctor if more tests are required
• generate reports for primary care physicians to inform them of their cancer screening rates, their patients’ test results and follow-up needs

More information on the Ontario Health’s Ontario Cancer Screening Registry is available at Personal Health Information Frequently Asked Questions

Registry of Cardiac and Vascular Services

Ontario Health collects personal health information from health information custodians – hospitals and health care providers, for the purposes of maintaining the Cardiac and Vascular Registry. Ontario Health also collects personal health information from the Provincial Client Registry (PCR) to ensure all personal health information about an individual is grouped under the correct patient’s record within the Cardiac and Vascular Registry.

Ontario Health helps to plan, coordinate, implement, and evaluate cardiovascular care and is responsible for the Cardiac and Vascular Registry. Ontario Health facilitates the improvement of quality, efficiency, accessibility, and equity of cardiovascular services across the continuum of care for Ontario. The personal health information collected in the Cardiac and Vascular Registry includes wait time information, as well as specific clinical details. The Cardiac and Vascular Registry uses cloud-based technology, and all activities are guided by Ontario Health's Privacy and Security Policies.

Registry of Chronic Diseases

Ontario Health collects personal health information from health information custodians such as hospitals, Ministry of Health, physicians and laboratories to operate the registry of chronic diseases. Chronic diseases are long-lasting and may be caused by many factors, such as behaviour and lifestyle, genetics, physiology, social determinants of health and the environment. The chronic diseases that are the leading cause of death and disability in Ontario include cardiovascular disease (e.g., myocardial infarction or stroke), cancer, chronic respiratory disease (e.g., chronic obstructive pulmonary disease and asthma) and diabetes.

Ontario health uses personal health information maintained in the registry of chronic diseases to facilitate contact with eligible individuals for the Abdominal Aortic Aneurysm Screening Program (OAAASP) in the same manner Ontario Health does for the existing cancer screening programs.

OAAASP is a population-based screening program that detects Abdominal Aortic Aneurysm and reduces avoidable Abdominal Aortic Aneurysm ruptures and deaths. Like the cancer screening programs, the OAAASP sends screening invitation letters to eligible participants based on their age and encourages participants to be screened by way of an ultrasound.

Ontario Health also uses personal health information in the registry of chronic diseases to carry out quality improvement activities. This includes analyzing information collected from hospitals and clinicians to evaluate how health services are being delivered, to identify gaps in care and to support initiatives that improves care outcomes.

As part of these quality improvement efforts, Ontario Health produces reports on areas such as surgical oncology and colonoscopy/colposcopy that identify outlier performance on key quality indicators. Ontario Health may disclose linked, patient level PHI to qualifying hospitals and clinicians identified as outliers in these reports, enabling them to conduct comprehensive analysis and implement targeted quality improvement interventions to enhance patient care and safety.

Access to Care Information

Ontario Health collects personal health information relating to initiatives to reduce wait times and improve patients’ access to healthcare services for the following areas:

• Surgery Wait Times and Efficiencies – measures, manages and publicly reports on surgical wait times for almost 3,300 surgeons across 121 healthcare sites: helps capture and report on data about surgical efficiency in 850 operating rooms across Ontario
• Diagnostic Imaging Wait Times and Efficiencies – measures, manages and publicly reports on magnetic resonance imaging (MRI) and computerized tomography (CT) wait times and efficiencies for 107 healthcare sites
• Emergency Room Information – uses the National Ambulatory Care Reporting System (NACRS) to measure, manage and publicly report on emergency room performance at 126 sites
• Alternate Level of Care Information – measures, manages and reports on patients occupying a hospital bed who do not need the intensity of resources or services provided in that care setting, across 186 healthcare sites
• Electronic Canadian Triage and Acuity Scale (eCTAS) – improves patient safety and quality of care by creating an electronic decision-support tool to standardize the way the scale is used

Ontario Renal Network Information

The Ontario Renal Network is a division of Ontario Health that advises the Ontario government on chronic kidney disease. For the purposes of the Ontario Renal Network, Ontario Health collects personal health information for the management and coordination of the Provincial Chronic Kidney Disease program. Ontario Health uses renal personal health information to effectively organize and manage the delivery of renal services in Ontario. The aim is to reduce the burden of this disease on Ontarians and the healthcare system. The Ontario Renal Network provides evidence-based decisions and advice to government to help them effectively plan, program and fund services to support a continuously improving kidney care system in Ontario.

Ontario Health provides reports based on the analysis of renal personal health information collected from chronic kidney disease. to the kidney disease community, which includes the Ministry of Health, nephrologists, and dialysis centres.

Ontario Palliative Care Network Repository

Ontario Health routinely links health administrative data to better understand the care people receive near the end of life. This information helps the Ontario Palliative Care Network review patterns such as use of health services, disease identification, significant health events, and treatments. Personal health information is used in accordance with Ontario’s Personal Health Information Protection Act (PHIPA). Ontario Health applies strict privacy and security measures to protect this information, and analyses are conducted to support improvements in palliative care planning and quality across Ontario.

Orthopedic Information

Ontario Health collects patient-reported outcome data on orthopedic services from hospitals that provide those services. The information helps local quality improvement and research initiatives evaluate the appropriateness and effectiveness of orthopedic surgery.

Patient and Family Advisor Information

Ontario Health collects personal information directly from patient and family advisors who provide valuable perspectives by sharing their experiences within the Ontario Healthcare System. The information gathered through these engagements offers important insights into the current healthcare landscape, including the challenges patients and caregivers face from a “user perspective. Ontario Health utilizes this enhanced understanding of the Ontario Healthcare System to inform recommendations for improvements. As part of the Patient Family Advisor requirement process, OH collects personal information from individuals interested in participating in OH engagements for the following purposes:

• Determining if they have relevant experience to participate in a particular engagement.
• Ensuring that engagements have participants that are representative of the diversity of Ontario’s population.
• Scheduling engagement meetings.

Reimbursement Program Operation

Ontario Health collects personal information and personal health information related to eligibility for reimbursement for healthcare or related goods, services or benefits in Ontario. Ontario Health’s Reimbursement Programs include:

• New Drug Funding Program
• Evidence Building Program
• Case-by-Case Review Program
• Brachytherapy Program
• Out-of-Country Program
• Chimeric Antigen Receptor (CAR) T-Cell Therapy
• Home Hemodialysis Utility Grant
• Out-of-Country Hemodialysis Reimbursement Program
• Special Access Program
• High-Cost Therapy Funding Program

Ontario Health uses the information gathered under these programs to determine or verify eligibility for reimbursement for healthcare services provided to patients and to provide recommendations on eligibility to the Ministry of Health.

Health Research Support

Ontario Health collects high-quality data from healthcare facilities, patients and health system partners for research, and health system management and planning. Along with partners across the healthcare system, Ontario Health’s team of experts use the data to help healthcare providers, health system administrators, policy makers and researchers to improve Ontario’s health systems by delivering high-quality clinical care Outputs include, for example:

• evidence-based guidance, tools and advice on health services
• reports on cancer, renal and other health system topics
• information for health system planning to ensure Ontario can meet the growing demand for greater accountability, better outcomes and improved patient experiences.

Who at Ontario Health can Access Personal Information and Personal Health Information

Only a limited number of staff have access to personal information and personal health information within Ontario Health. A data steward assigned to each holding is responsible for authorizing access to the data holding. Access is limited to those staff who need it to carry out their jobs at Ontario Health, such as analysts and information technology support staff. Access permissions are reviewed regularly to ensure they remain appropriate.

Disclosure of Personal Information and Personal Health Information

Ontario Health does not disclose personal information or personal health information with identifiers unless the individual consents and it is necessary for a lawful purpose or where it is permitted or required by law, for example: Ontario Health may disclose personal health information that was collected for the purposes of a prescribed entity or prescribed person to:

• researchers who comply with the research requirements set out in PHIPA, and if the research meets our scientific standards and is consistent with our mission and objectives
• other prescribed entities, prescribed persons or certain organizations or government agencies as permitted under PHIPA
• operate Ontario’s screening programs to determine if an individual needs to be screened
  • send letters inviting or reminding an individual to be screened or informing the individual of the results
  • ensure an individual’s doctor knows whether or not the individual has been screened or needs more tests
  • connect an individual with a doctor if the individual does not have one and need to get more tests done
• For the Reimbursement Programs, Ontario Health may disclose an individual’s personal health information to organizations such as the Ministry of Health, the Kidney Foundation of Canada and requesting physicians to determine eligibility for reimbursement.
• Ontario Health may disclose information about an individual to a care provider or organization that currently or has previously provided the individual with care, to facilitate quality improvement of health care services.

Safeguards for the Protection of Personal Health Information

Visit Ontario Health Safeguards for the Protection of Personal Information and Personal Health Information for more information on Ontario Health’s general safeguards.

Contact Us

View our Privacy Contact page form more information on how to reach the Ontario Health Privacy team and the Information and Privacy Commissioner of Ontario.