Safe Haven Procedure for the Secure Transmission of Personally Identifiable Information

Safe Haven Procedure for the Secure Transmission of Personally Identifiable Information Im&t directorate\policies\approved ig policiesprocedures.1

Index 1. Purpose... 3 2. Introduction... 3 3. Scope... 3 4. Authorisation to transfer data... 3 5. Information Flow Mapping... 4 6. Electronic transfers of data on removable media (Disks/CDs/memory stick)... 4 7. E-mail... 4 7.1 Using NHSMail... 5 7.2 Approved encryption... 5 7.2.4. Additional guidance... 6 8. Sending Large Files... 6 9. Office 2007 encryption... 7 10. Fax Machines... 7 11. Communications by staff/post/courier... 8 11.1 Internal mail... 8 11.2 External Mail... 9 12. Verbal Communication... 11 13. Telephone Answering Machines... 12 14. SMS Text Messages... 12 15. Electronic Messaging Software... 12 Change Control Date Version Author Change 1.0 GL First version 7/12 1.1 GL Correct 7.2.1 re digital certificates Page 2 of 15

1. Purpose This procedure provides information on how to securely send personal identifiable information (PII) via: E-mail o NHS Mail o Voltage Encryption o SecureSend NHS Secure File Transfer (for large files) Office 2007 encryption Fax Staff/Post/Courier Verbal communication Telephone answering machines SMS text Instant Messaging 2. Introduction Transfers of information between an organisation s departments and sites, other NHS organisations, Councils with Social Service Responsibilities (CSSR) or other third parties are commonplace and may be achieved using a variety of transfer means and formats (ie digital and hardcopy). It is a legal responsibility of an organisation to ensure that transfers of personal information for which they are responsible are secure at all stages. The loss of personal information will result in adverse incident reports which will not only affect the reputation of the organisation but can also result in the organisation being fined by the Information Commissioner. Adherence to this procedure will ensure compliance with statutory obligations and NHS Guidance on keeping information secure. For more information on the obligations and requirements placed on the organization, please see the Policy for the Protection of Personal Information 3. Scope This procedure applies to all organisation employees, trainees, contractors, temporary staff, students, researchers, trainers, and consultants who may be involved in the transmission of PID in the course of their time with the organisation. 4. Authorisation to transfer data Authorisation is required to transfer new flows of PII between organisations. Authorisation will be gained either through a service level agreement, contract, information exchange agreement or an adhoc authorisation for which a template can be found in Appendix A. Page 3 of 15

5. Information Flow Mapping All transfers of PID will be identified as part of the quarterly data flow mapping exercise which will include authorisation for safe processes and alerts to relevant directors of those processes and flows deemed at risk. (See Information Flow Mapping Procedure). 6. Electronic transfers of data on removable media (Disks/CDs/memory stick) In 2008, the DoH prohibited the movement of unencrypted PII on removal media in the NHS 1. Removable media includes tapes, floppy discs, removable or external hard disc drives, optical discs DVD and CD-rom, solid state memory devices including memory cards and pen drives etc Since the organisation does not have routinely provided software to encrypt data on removable media to DoH standards, if there is a requirement to transfer data it must be done on an encrypted memory stick sourced from IM&T. 7. E-mail E-mail systems are inherently insecure and patient identifiable information or sensitive business information must not be sent via e-mail unless The e-mail address is in the NHS Northamptonshire network. (This network is defined as the PCT, Provider Services and Northamptonshire Healthcare Trust. It does not include GP s.) Communications between NHSN and MHSMK are yet to be secured. The e-mail is sent via NHSMail, i.e. if from an NHS.net e-mail account to o NHS (*.nhs.net) o GSi (*.gsi.gov.uk) o CJX (*.police.uk or.pnn.police.uk) o GSE (*.gse.gov.uk) o GSX (*.gsx.gov.uk) o GCSX (*.gcsx.gov.uk) o SCN (*scn.gov.uk) o CJSM (*cjsm.net) o MoD (*.mod.uk). Or vice versa. Note NHS Northants to NHS.Net e-mail is not secure A form of approved encryption is used. 1 http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/igap/msletter30jan08.pdf Page 4 of 15

7.1 Using NHSMail It is recommended to use of generic (or shared) mailboxes for the transfer of confidential information particularly patient related which supports a regular business process. This is to limit the possibility that the communication of information will be delayed by the failure of individuals to check their personal NHS mail inboxes, i.e. when absent from work. A generic mailbox is a mailbox which is set up to receive personally identifiable information or other confidential information for a particular team and can be accessed by several members of staff, rather than information being sent to a personal mailbox, to which only one person has access. 1. A roster for checking the generic account inboxes MUST be put in place by the local manager which guarantees that the generic mailbox is checked regularly, for example at handover time. 2. Generic accounts need to be set up by the IM&T Service Desk. 3. When e-mail is sent via NHS mail the originator must request a read receipt. The receiving party must in turn agree to the read receipt being sent to the originator on opening the e-mail. 4. The read receipts on NHS mail make it easy for the originator to see which e- mails have or have not been read, and to chase up in the event of any delay. 7.2 Approved encryption 7.2.1 NHSMail and digital certificates It is not currently possible to securely send an e-mail from an NHSMail account to a non secure e-mail address, although this facility is being tested by CfH. There are detailed instructions in NHSMail user guidance for using digital certificates for securely sending data between non NHSMail accounts. Seek advice from the Service Desk before attempting this. 7.2.2 Voltage encryption This is a software solution purchased by NHS Northamptonshire which offers the highest levels of encryption protection. The software needs to be installed on the sender s machine Contact the IM&T Service Desk for this installation. The receiver does not need any special software or version of software but the first time they receive an encrypted email they will need to go on-line and download a licence key. Page 5 of 15

Encrypted emails using Voltage can be sent anywhere at any time and are not restricted to the NHS alone. Guidance on using Voltage is available on the intranet. http://nww.northants.nhs.uk/top_menu/northamptonshire_teaching_pct/left_menu /DepartmentsFunctions/Info_Governance/Voltage_instructions.pdf 7.2.3 Securesend SecureSend provides a facility to securely send documents that are encrypted to nationally approved NHS security standards (using 256 bit AES encryption). It has been developed by Somerset Primary Care Trust and offered free of charge to other NHS and partner organisations. https://securesend.somersetpct.nhs.uk/index.asp?version=somersetpct 7.2.4. Additional guidance Whichever method of encryption you use the following procedure should always be followed when sending confidential e-mail:- You should make sure that any exchange of confidential information is part of an agreed process. This means that both those sending and receiving the information know what is to be sent; what it is for and have agreed how that information will be treated. Under no circumstances should the encryption password be sent alongside the encrypted e-mail. It is best practice to send the password either by separate e-mail or over the telephone. In the subject line of the e-mail, begin by typing CONFIDENTIAL (this informs the receiving team that personal or sensitive information is enclosed) and then enter the subject of the e-mail. Minimise the use of personally identifiable information use only the NHS Number as personal identifier is this is possible. Do not use any names or identifiers in the e-mail subject line. 8. Sending Large Files If user who is connected to the N3 needs to send a large file (between 20Mb and 1Gb) to another use on the N3 network, the NHS Secure File Transfer Program should be required. Page 6 of 15

Both the sender and recipient will need to have NHS Mail e-mail accounts A detailed user guide is available here. 2 Access to the secure file transfer web site is available here. 3 9. Office 2007 encryption Office 2007 normally encrypts files to a standard (AES 128 bit) below the DoH recommendations (AES 256 bit). Password protecting files (eg using Microsoft Office 2007) will assist in preventing casual compromise if the file is sent to the wrong recipient but is of limited use to prevent a person with a little knowledge or determination accessing the file. The more complex the password used to encrypt the file the more secure the data will be. Users are recommended to use a password of a minimum of 8 characters, containing upper and lower case characters, numbers and special characters (for example, @,!, #) Use of Office password protection should be subject to risk assessment considering the content and volume of data to be transmitted. Advice on the suitability of using Office encryption can be obtained from Information Governance. 10. Fax Machines All safe haven fax machines should be located in a secure environment and the faxes removed from the machine on receipt. The sender should be contacted to confirm receipt and the fax appropriately dealt with and safely stored. Improper use of fax machines have resulted in many confidentiality breaches throughout the Public Sector. Therefore, fax machines must only be used to transfer personal information where it is absolutely necessary to do so. The following rules must apply: The fax is sent to a Safe Haven location where only staff that have a legitimate right to view the information can access it. The sender must be certain that the correct person will receive it and that the fax number is correct i.e. phone the recipient to say that you are sending a confidential fax and to confirm the fax number and ask the recipient to confirm that the fax has arrived. 2 Secure File Transfer User Guide http://nww.connectingforhealth.nhs.uk/infrasec/sft/sft-user-guide.pdf 3 Secure File Transfer web site https://nww.sft.nhs.uk/sft/upload1 Page 7 of 15

Care should be taken when dialling the number. Best practice involves always checking the safe-haven fax number before dialling; never dial from memory. Valid sources would include a locally compiled safe haven directory; alternatively a telephone call to the safe haven to check up to date details. It is good practice to identify frequently used numbers and program these into a fax machine "memory dial" facility; equally computer dialling facilities may be used where available. However, numbers must be tested in conjunction with a telephone call before using them for confidential information. Faxes containing personal information should not be left lying around for unauthorised staff to see. Only the minimum amount of personal information should be sent. Where possible the data should be anonymised or a unique identifier used. Faxes should include a front sheet, which contains a suitable confidentiality clause. For example, IMPORTANT NOTICE The information in this fax is confidential and privileged If you are not the intended recipient please accept our apologies. Please do not disclose copy or distribute information in this fax or take any action in reliance on its contents to do so is strictly prohibited and may be unlawful. Please inform us that this message has been received in error, by contacting the sender. The sender will advise you of suitable action to take regarding the material received, as we may require information to be reclaimed. Thank you for your co-operation Fax machines should have a code password and be turned off out of office hours where the fax is not in a secured office. 11. Communications by staff/post/courier All personal information/data should be addressed to a person, post holder, a consultant or a legitimate Safe Haven location - but not to a department, a unit or an organisation. 11.1 Internal mail Page 8 of 15

Mail containing PID should be sent in a securely sealed envelope and marked accordingly e.g. Confidential or Addressee only as appropriate. 11.2 External Mail Mail containing PID should be sent in a securely sealed envelope and marked accordingly e.g. Confidential or Addressee only as appropriate Additional special care should be taken with bulk and/or sensitive personal information such as health records, financial records, or collections of paper records. These should be either: Hand delivered by NHSN staff in a new sealed envelope; taped to seal it shut, and signed over the seal. Packages should be kept out of sight and locked away if left unattended for short periods. Sent by Royal Mail special delivery allowing tracking of delivery and signature by receiver or By an approved courier service providing proof of receipt and an audit trail. Procedures around using an approved courier service are given below. Health records, case notes and other bulky material should only be transported in approved boxes and never in dustbin sacks, carrier bags or other containers. These containers should not be left unattended unless stored, waiting for collection, in a secure area e.g. locked. The containers should only be taken and transported by the approved courier or authorised internal transport systems. Individual sets of health records and case notes should still be handled with extreme care and attention. When a record is transferred by courier it should be Placed in an new sealed envelope (not a transit envelope) Taped to seal it shut Signed over the seal When a record is transferred by a clinician it should be: Placed in a new sealed envelope (not a transit envelope) and Not left open Not left unattended Kept out of sight (locked in the boot of your car not left on the back seat) Staff should make a log of what health records/case notes have left the department (e.g. home visits etc), with who, when taken, when returned. This is formally referred to as systems for tracking records. Electronic media e.g. CD s DVD s tapes etc transported between departments, sites or organisations should be properly packaged in tamper proof envelopes and clearly and labelled confidential (See 5). Page 9 of 15

Packaging should be checked to ensure it is sufficient to protect the contents from any physical damage likely to arise during transit such as exposure to heat, moisture or electromagnetic fields. These should be hand delivered, sent by Royal Mail special delivery allowing tracking of delivery and signature by receiver (not recorded or registered delivery), or by approved courier service as above. Staff should request that external organisations use secure post when forwarding PII to the organisation, with tamper-evident packaging that will clearly show if the information has been accessed without authorisation. 11.3 Use of couriers If a courier is used, the courier used should have a contract that includes agreed minimum standards relating to security and confidentiality. The organisation will draw up an authorised list of trusted and reliable courier services for routine and secure courier transfers. Note that the internal delivery van service should be regarded as a courier service and, where relevant, the same processes followed as for an external courier. When using a courier service for the transfer of personally identifiable information the following process must be followed: 11.3.1 Routine Courier Services For transfer of non-personal or non-sensitive information only) Authority to use courier service is obtained from appropriate level of management. Courier is selected from contracted or authorised list. A telephone call is made from the despatching organisation to the intended recipient at the receiving organisation to notify despatch Information for despatch is placed in a sealed envelopes or wallet. A signature sheet is signed by despatching and receiving organisations. 11.3.2 Secure Courier Process For transfer of person identifiable or sensitive information A Secure Courier will provide a secure and tracked mode of collection and delivery rather than a by hand / personal delivery service. Some Secure Courier services allocate a container to an organisation s items while others may store them in the same container as other organisations courier items at lesser cost. A Secure Page 10 of 15

Courier will be an organisation providing courier services which provide adequate security assurances set out in a written contract. For public sector bodies these courier organisations may have already signed up to the OGC buying solutions framework agreement and therefore already been assessed on the basis of their technical ability and financial standing, eg (as at June 2009): CitySprint DX Group E-Courier UK Ltd Government Car and Despatch Agency TNT UK Royal Mail Group Procedure Authority to use courier service is obtained from appropriate level of management. Only authorised courier services used A signature sheet is used to capture details of handover/takeover of the data disks The data file creation is authorised (name/role/date/time). Packaging is checked to ensure it is sufficient to protect the contents from any physical damage likely to arise during transit such as exposure to heat, moisture or electromagnetic fields; The identification of courier is checked before handover of media The courier collects the information and the signature sheet is signed by both parties. A telephone call to notify despatch is made from the despatching organisation to a named individual in the receiving organisation. Nominated staff at the destination receive the information and sign the signature sheet. 12. Verbal Communication The security and confidentiality of telephone and personal conversations should be considered within the organisation s policy and procedures and included in staff training. Staff should be mindful of the need to maintain security and confidentiality when discussing personal or other sensitive information. Page 11 of 15

13. Telephone Answering Machines Recorded telephone messages may contain personal or sensitive information such as names and addresses of service users, details of health or social care professionals phoning with queries about service users or applicants for jobs advertised. Consideration should be given to which staff members have access to answering machines. Password protected voicemail boxes can be used to control access where this functionality is available on the phone. Otherwise, physical protection should be considered, eg locating the phone in a lockable office, lowering the speaker volume, etc. 14. SMS Text Messages There are various potential applications for text messages in the provision of services, eg service user appointments. The benefits of using text messages to convey personal information must be weighed against the risks. Key considerations when using text messages are: is the mobile phone number correct? is the mobile phone receiving the text message being used by the intended recipient of the message? has the message been received, and what provision is there to audit message receipt? text messages are normally stored on SIM cards and are typically only cleared when overwritten (not necessarily when erased) - as mobile phones are easy to misplace or may get stolen, there is a danger of a breach of confidentiality occurring that the patient / service user may find distressing or damaging. Text messages should not normally be used to convey sensitive information, eg test results and the use of text messages for the transfer of personal data should be kept to a minimum, eg an appointment reminder does not need to include the name of the specific clinic. When consent is sought for appointment reminder services, service users should be informed of what information will be included in standard SMS messages sent to them via the service and the option to opt out must be available on request. 15. Electronic Messaging Software Electronic instant messaging (IM) software, such as MSN Messenger and Yahoo! Messenger is not suitable for use for the transmission of personal data as it presents a number of risks: IM software is particularly vulnerable to malware, such as virus, Trojans and worms; in many IM services, data is unencrypted. Such services therefore do not provide sufficient security for transmission of service user data, as they are at risk of unauthorised access and electronic surveillance; Page 12 of 15

in many IM services, there are no audit trails of access and transmission. The Care Record Guarantee (NHS and Social Care) has a requirement for systems to maintain audit trails for the access and transmission of service user data; IM services can be used to bypass restrictions on what can be sent as e- mail attachments. Whilst it is possible that solutions will be developed in future which offer the necessary security and audit controls, there are no IM solutions currently recognised by the NHS nationally as suitable for transmission of personal information. Page 13 of 15

Appendix A PID Transfer Authorisation Form (process) Process Authorisation Form Outbound Transmission of Personally Identifiable Data/Information (PID) - Before creating a new process to send bulk or sensitive PID, please complete this form, and submit it to the Caldicott Guardian for approval. Please note that this form should be used for all bulk and sensitive transmissions of PID across or out of NHSN. What is the data? What is the purpose of the transfer? Approximately how many records at a time? Is it sensitive data? Which location is it going to? Which organisation/person is it going to? Destination description (optional) By e-mail? By fax? By post? By text message? Is data e-mailed to and from NHSmail with @nhs.net account? Do you confirm the email address before sending? Do you request receipt of e-mail? Do you encrypt e-mailed data by recommended method? Do you phone/fax recipient in advance? Is a cover sheet used? Do you receive confirmation of fax? Is data faxed to a safe haven? Page 14 of 15

Is data sent on removable media? Is data encrypted by recommended method? Is data sent by courier or registered post? Is receipt of post confirmed? Is data sent in tamperproof wallet? Is data sent to a safe haven? Authorised by Director or Associate Director, signature and date Authorised by Caldicott Guardian, signature and date Contact details for Caldicott Guardian: Medical Director/Caldicott Guardian Dr Sarah Whiteman Francis Crick House Tel: 01604 651158 E-mail sarah.whiteman@northants.nhs.uk Page 15 of 15