Risks of Over-Collecting Health Information for Clients and RMTs

Gathering health history information from a client is an important part of providing safe, quality treatment. However, some RMTs may feel that asking for all health history – even if it is not relevant – is useful in managing the client’s risk, or for professional liability purposes.

In September 2023, CMTO’s Board discussed the evolution of expectations around collecting sensitive information, such as HIV status, and the need for CMTO to update its guidance in this area. Health information is currently being discussed at CMTO’s fall open houses. Please see the important message below and stay tuned for further updates and conversation about collecting health history.

Introduction
Health history questions are important to setting the stage for safe, client-centred treatment. CMTO’s Guide to Record Keeping Requirements outlines the minimum amount of information that needs to be collected and documented in a client’s health record. Information sought (over and above required information) should link to safe, effective treatment.

Discrimination and Privacy Concerns
Sensitive health information routinely requested on some health history forms (including CMTO’s old sample form), creates the potential for discrimination, and does not comply with the Personal Health Information Protection Act, 2004 (PHIPA) including the risk for data breaches once it is collected. PHIPA requires health professionals to “not collect, use or disclose more personal health information than is reasonably necessary to meet the purpose of the collection, use or disclosure”, meaning only information needed to provide safe and effective Massage Therapy treatment can be collected.

Example: HIV Status
HIV status is an example of sensitive information that should not be routinely collected via health history forms. Routinely collecting HIV status does not comply with PHIPA and creates the potential for discrimination. This is an example of sensitive information that (given current Standards of Practice for Infection Prevention and Control; and Safety and Risk Management) is not required for safe Massage Therapy treatment.

RMTs are required to use routine practices with all clients and awareness of the HIV status of a client would not change the measures taken; routine practices would be used regardless. As the Ontario Human Rights Commission (OHRC) explains, “With universal blood and body-fluid precautions widely in place, there is no need for using additional precautions for patients who are known or believed to have illnesses that can be transferred by blood.[1]” The OHRC also describes “universal precautions” as “a set of risk reduction measures employed at all times by medical and health-care professionals and workers whenever they encounter blood or other identified body fluids.”

In addition to HIV, other types of sensitive health information including mental health information and requesting a comprehensive list of all medications could also be classified as over-collecting.

Developing New Guidance:
CMTO will develop new guidance on collecting health history information with input from the profession and health system partners. This will be a topic of discussion with the Registered Massage Therapists’ Association of Ontario and with other health regulators in the province.

In the meantime, RMTs and employers should review routine collection forms and remove what is not required for safe and effective assessment and treatment. RMTs are required to collect health information, but there is no requirement to use a particular form or template. CMTO’s old sample form has been removed from the website, as it is outdated and included HIV status.

Please keep an eye on your inbox for future updates on this topic.

Questions?
Please contact CMTO’s Practice Specialist with questions at practicespecialist@cmto.com.

[1] Ontario Human Rights Commission, Policy on HIV-AIDS-related discrimination (2009) at p. 7.