Teresa Scassa - Blog

Ontario plans to introduce digital identity services (Digital ID) to provide Ontarians with better access to their personal health information (PHI) in the provincial Electronic Health Record (EHR). This is being done through proposed amendments to the Personal Health Information Protection Act (PHIPA) introduced in Schedule 6 of Bill 231, currently before the legislature. Schedule 6 replaces proposed amendments to PHIPA regulations that were introduced in the summer of 2024 and that were substantively criticized by Ontario’s Privacy Commissioner. In introducing Bill 231, Health Minister Sylvia Jones stated that the goal is “to provide more people with the right publicly funded care in the right place by making it easier to access your health care records”.

Digital ID is an electronic means of verifying a person’s identity. Typically, such systems include some form of biometric data (for example, a face-print) to create a secure and verifiable ID system. We are becoming increasingly used to consuming products and services from both public and private sector sources in mobile and online contexts. Digital ID has the potential to improve secure access to these services.

Digital ID is already in place in many countries, but adoption has been slow in Canada. This may be in part because Digital ID raises concerns among some about the empowerment of a surveillance state. There are rumours that Ontario retreated from plans to introduce a more ambitious public sector Digital ID system over concerns about potential backlash, although it is quietly moving ahead in Bill 231 with the Digital Health ID. Unfortunately, Digital ID is most advantageous where a single Digital ID can be used to access multiple sites and services, eliminating the need to manage numerous usernames and passwords (with the security risks such management can entail). It is important to note that under Bill 231, the Digital Health ID will be single purpose, significantly reducing its advantages.

There is no doubt that Digital ID systems raise important privacy and security issues. They must be carefully implemented to ensure that the sensitive personal information they incorporate and the identities they represent are not misappropriated. They also raise equity issues. If Digital ID provides better and faster access to information and services, those who are not able to make use of Digital ID – because of age, disability, or the digital divide – will be at a disadvantage. Attention must be paid to ensuring that services and information are still available to those who must use other forms of identification – and that those other forms of identification remain accessible so long as they are needed.

Ontario’s Privacy Commissioner, in her comments on Bill 231 indicates that she fully supports the Ontario government’s goal in introducing Digital ID for the Electronic Health Record. She notes the importance of “enabling meaningful access to one’s health records” and agrees that “EHR access can help Ontarians better manage their health, and in turn, help create efficiencies in the health care system”. However, while she endorses the objectives, the Commissioner is highly critical of Bill 231. Her detailed comments note that the proposed amendments to PHIPA have the potential to reduce rights of access to personal health information in the EHR; that the bill contains no parameters on how, why and by whom the Digital ID scheme will be used; and that it includes broad regulation and directive making powers that could unravel rights and requirements already in place under PHIPA. She also observes that it conflates and converges the role of Ontario Health with respect to health data and Digital ID, and that it creates inconsistent and incomplete powers that will hinder enforcement and oversight. These are important concerns, articulately expressed by the head of perhaps the only independent body in the province capable of making sense of Bill 231’s Schedule 6.

Schedule 6 is brutally difficult to read and comprehend. This is largely because the introduction of Digital Health ID is being done as a series of amendments to an already (overly) complex piece of health privacy legislation. New legislation often has a narrative structure that – although not gripping reading – is at least relatively easy to understand and to follow. Bills that amend existing legislation can also generally be understood by those who work with them. You can cross-reference and see where new powers are added, and where the wording of clauses has been changed. But Schedule 6 of Bill 231 is an ugly hybrid. It introduces a complex new Digital Health ID scheme as an amendment to existing health privacy legislation, even though Digital Health ID is more than just a privacy issue. There is no doubt that such a system would have to be compliant with PHIPA and that some amendments might be required. However, Digital Health ID creates a new system for accessing health data in the EHR. It could have been introduced as a separate bill. Such an approach would have been clearer, more transparent and more accessible than the convoluted and incomplete scheme that has been shoe-horned into PHIPA by Bill 231.

It is not just the lack of transparency caused by such a contorted set of amendments that is a problem. In a 2019 presentation by Assistant Deputy Minister of Health Hein, the government’s approach to their “Digital First for Health” program promised to “[m]odernize PHIPA to make it easier for Ontarians to access their information, streamline information sharing processes, and support the use of data for analytics and planning.” One of the goals of PHIPA modernization was “[r]educing barriers to patient access by enabling patients to more easily access, use, and share their personal health information, empowering them to better manage their health.” This sets up Digital ID as part of the PHIPA modernization process. But Digital ID is not a “solution” to barriers caused by privacy laws. For Digital ID, the real barriers to better access to health data are structural and infrastructural issues in health data management.

Let me be clear that I am not suggesting that the Ontario government’s health system reform goals are not important. They are. But Digital Health ID should not be framed as “PHIPA modernization”. The objectives of such a system are not about modernizing health privacy legislation; they are about modernizing the health care system. They will have privacy implications which will need to be attended to but framing them as “PHIPA modernization” means that you end up where we are now: with changes to the health care system being implemented through complicated and problematic amendments to legislation that is first and foremost meant to protect the privacy of personal health information.

Australia and New Zealand have both introduced government-backed digital ID systems through specific digital identity legislation. Admittedly both statutes address digital identity more broadly than just in the health sector. Nevertheless, these laws are examples of how legislation can clearly and systematically set out a framework for digital identity that includes all the necessary elements – including how the law will protect privacy and how it dovetails with existing privacy laws and oversight. This kind of framework facilitates public debate and discussion. It makes it easier to understand, critique and propose improvements to the Bill. In her comments on Bill 231, for example, the Privacy Commissioner notes that “[c]larity and coherence of the many roles of Ontario Health would also assist my office’s oversight and enforcement role.” She observes that Schedule 6 “is inconsistent and incomplete in its approach to my office’s oversight and enforcement authority”. These are only two examples of places in her comments where it is evident that the lack of clarity regarding the proposed Digital Health ID scheme hampers its assessment.

Schedule 6 also leaves much of its substance to future regulations and directives. This is part of a disturbing trend in law-making in which key details of legislation are left to behind-the-scenes rulemaking. As the Privacy Commissioner notes in her comments, some of the matters left to these subordinate forms of regulation are matters of policy for which public consultation and engagement are required. As she so aptly puts it: “Directives are appropriate for guiding the implementation of legal requirements, not for establishing the very legal requirements to be implemented.”

Clearly, technology moves fast, and it is hard to keep laws relevant and applicable. There may be a need in some cases to resort to different tools or strategies to ensure that the laws remain flexible enough to adapt to evolving and emerging technologies. The challenge is, however, to determine which things belong in the law, and which things can be ‘flexed’. There is a difference between building flexibility into a law and enacting something that looks like a rough draft with sticky notes in places where further elaboration will be needed. Schedule 6 of Bill 231 is a rough draft of a set of amendments to an already overly-complex law. It should be its own statute, carefully coordinated with PHIPA and its independent oversight.

Digital Health ID may be important to improve access to health information for Ontarians. It will certainly carry with it risks that should be properly managed. As a starting point, Ontarians deserve a clear and transparent law that can be understood and debated. Further, privacy law should not be set up as a problem that stands in the way of reforming the health care system. Such an approach does not make good law, nor does it bode well for the privacy rights of Ontarians.