Unencrypted Email

Nostalgia: Recently, I was reading some of my grandfather’s faded postcards from World War I. I happened to read one in which he mentioned being released from quarantine: March 11, 1918, Fort Lewis, Washington – the Spanish Flu pandemic.

Postcards were how our grandparents sent brief messages over long distances. They are the antique analogs to modern email. The messages and attachments you send via email are every bit as private and secure as that dusty, old postcard.

Everyday PII Exposure: Recently, a close associate of mine, I’ll call him “John”, was required to take a defensive driving course. The business providing the service asked John to send a copy of his driver’s license. John promptly took a picture of his driver’s license in beautiful, high-definition color and attached it to an unsecure email. He didn’t even question it.

How It Works: Let’s look momentarily at a seemingly benign example to illustrate what happens when you hastily click the “send” button. Say you work for a medical practice and you send an email from your office to a patient. Here’s what happens:

  1. The email leaves your computer.
  2. It travels on your Internet Service Provider’s (ISP) network.
  3. It arrives at your mail server – a server you probably don’t control.
  4. Your hosted email provider then forwards a copy of the email to the patient’s mail server, probably webmail, like Gmail.
  5. A copy of the email languishes on the mail provider’s server.
  6. It then takes the last leg of the journey to land on the patient’s personal computer.

Wide Open for All to See: As you can see, at any of those points, the email (like a postcard) can be read by anyone with access. That means, if any of those computers storing a copy of the emails is compromised, so are the emails. All of them.

Email is by design, unsecure. That is why you should never, (let me repeat, NEVER) include any important, private information in any email, not just the protected health information (PHI) of patients. Unencrypted email is simply the wrong medium for transmitting sensitive data.

PHI Guidance – From the hhs.gov website:

Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.

PHI Handling: Now, I’m not a HIPAA lawyer, and this is not legal advice, but basically, if you are a medical practice, you know that much of your communication with patients is over email. In fact, many prefer it. So as long as you warn the patient that your email communication is over unsecure media, and the patient acknowledges, then you may be absolved of the consequences of a PHI breach … maybe. You can even get patient acknowledgment with (ironically) a simple email waiver form that the patient signs and returns to your office, over email.

Encryption Options: If you only send PHI through your Electronic Medical Records application, it may take care of the encryption for you. But if not, there are email providers that will encrypt your emails. If you use Microsoft Office 365, there is a tier that will allow you to encrypt email. Other email providers like ProtonMail offer encryption capabilities. A Chrome extension even exists allowing you to encrypt Gmail. It can be a little inconvenient because you have to think up a strong password for each email, then you have to deliver the password to your patient by calling or texting them. If emails containing sensitive data are sent infrequently, the risk is lower. You decide whether you’d rather go through the effort or experience a breach.

You don’t have to protect sensitive data forever. Its value degrades over time. Conversely, that little postcard my grandfather hastily scrawled over 100 years ago is ever more precious to me.