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Email Usage Policy

Effective: October, 2013

Revised: November 2014

I.     Introduction

Email is an expedient communication vehicle to send messages to the Columbia University community. The University recognizes and
has established the use of email as an official means of communication. However, use of an email system at the University requires adequate security measures to protect the Data (as such term is defined in the Columbia University Information Security Charter (the “Charter”)[http://policylibrary.columbia.edu/information-security-charter]
that is transmitted.

A PDF of this policy is also available to the right.

Capitalized terms used herein without definition are defined in the Charter.

 

II. Policy History

The effective date of this Policy is November 1, 2013. This Policy and other Information Security Policies replace (A) the following University Policies:

  • Electronic Information Resources Security Policy, dated March 1, 2007
  • Email Usage and Retention Policy, dated April 1, 2008, and

(B) the following CUMC Policy:

  • Communicating Protected Health Information via Electronic Mail (Email) at Columbia University Medical Center, dated January 21, 2004, and amended as of September 21, 2012

 

III. Policy Text

A. Approved University Email Systems

All email used to conduct University business must be transmitted via an Approved University Email System.  For purposes of this Policy, an “Approved University Email System” is Cubmail, Lionmail, any CUIT or CUMC IT Email System and any other Email System that has been risk assessed and approved by the applicable Information Security Office.

B. Prohibited Actions

No User of University email may take any of the following actions:

  1. Send or forward an email through a University System or Network for any purpose if such email transmission violates laws, regulations or University policies and procedures;
  2. Use any Email System other than an Approved University Email System, to conduct University business or to represent oneself or one’s business on behalf of the University. Examples of Email Systems that are not approved include a personal email account or a personal Columbia Alumni Association account (i.e., anything@caa.columbia.edu).

  3.  Send nuisance email or other online messages such as chain letters; 
  4.  Send obscene, harassing, offensive or other unwelcome messages;
  5. Send unsolicited email messages to a large number of Users unless explicitly approved by the appropriate University authority;
    or
  6.  Impersonate any other person or group by modifying email header information to deceive recipients.

C. Provisions Relating to Emails Containing Sensitive Data or Confidential Data

Each User shall ensure that Sensitive Data or Confidential Data is transmitted by email only if the following conditions are met:

  1.  Except as provided in Section D below, all email communications of Sensitive Data or Confidential Data are encrypted before being transmitted.
  2.  Sensitive Data or Confidential Data are not transmitted in the “Subject” line of an email.
  3. Before transmitting an email that contains Sensitive Data or Confidential Data, the User double-checks the message and any attachment to verify that no unintended information is included and that the proper document is attached.
  4.  Before transmitting an email that contains Sensitive Data or Confidential Data, the User double-checks the identity of the
    recipients.

D. Provisions Relating to Email Within the Columbia Covered Entity

For purposes of this Policy, the “Columbia Covered Entity” is CUMC and any other operation at the University that has been designated to be included in the University’s Covered Entity.  An “Approved OHCA Email System” is any CUIT Email System other than Lionmail, any CUMC IT Email System and any other Email System used within the CU/Hospital OHCA that has been approved by the CUMC Information Security Office.

The following provisions relate only to email transmitted by Users within the Columbia Covered Entity:

  1. Unencrypted EPHI may be transmitted internally if sent on an Approved OHCA Email System.
  2. No automatic forwarding, redirection or automated delivery of email outside the CU/Hospital OHCA may be used.    
  3. Email messages containing EPHI must include the following confidentiality notice:

    “This electronic message is intended to be for the use only of the named recipient and may contain information that is confidential or privileged.  If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the contents of this message is strictly prohibited.  If you have received this message in error or are not the named recipient, please notify us immediately by contacting the sender at the electronic email address noted above, and delete and destroy all copies of this message. 
    Thank you.”

  4. Any User who is unsure whether an email message or attachment contains Sensitive Data or Confidential Data must contact his/her supervisor or the HIPAA Privacy Officer before initiating the email
    communication.

E. Communicating PHI to Patients

  1. Patients have the right to request that the University communicate with them via email. If a patient requests email communications containing his/her PHI, the individual receiving the request must obtain a completed Patient Request for Email Communications from   http://www.cumc.columbia.edu/hipaa/pdf/Patient_Request_for_Email_Form.pdf  from
    the patient and provide the patient with the Important Information About Provider/Patient Email form http://www.cumc.columbia.edu/hipaa/docs/cumcimptinfo_provider.pdf  prior to processing the patient’s request. 
  2. All email communications with patients must be
    transmitted in encrypted form on an Approved University Email System.
  3. The University reserves the right to deny a patient’s request to communicate with him/her via email.  For example, a patient’s request for email communications may be denied by the University if a provider with an existing clinical relationship with the patient believes email communications with the
    patient should not occur.
  4.  All completed Patient Requests for Email Communications will be maintained by the office processing the patient’s request for a minimum of 6 years. Approved requests are valid regardless of the time period so long as a hard copy of the form is maintained or the signed form is scanned into the patient’s electronic medical record.
  5.  An approved Patient Request for Email Communications will be effective for only the health care provider identified in the Request. The patient must complete a separate Request for each health care provider with whom he/she wants to communicate via email and must revoke each Request to discontinue email communications.

F. Privacy Expectations

 The University observes the Privacy Expectations described in the Columbia University Acceptable Usage of Information Resources Policy http://policylibrary.columbia.edu/acceptable-usage-information-resources-policy with respect to email. 

For reasons relating to compliance, security or legal proceedings (e.g., subpoenas) or in an emergency or in exceptional circumstances, the Office of the General Counsel may authorize the reading, blocking or deletion of Data.  In particular, in the context of a litigation or an investigation, it may be necessary to access Data with potentially relevant information.  Any such action taken must be immediately reported to the Office of the General Counsel and the applicable Information Security Office.

The University may record information about certain data elements of email messages in the course of monitoring or maintaining its email systems. These data include, but are not limited to: (a) the identity and address of the authenticated sender, (b) the address of the recipient, (c) the size of the message, (d) the transmission time, (e) the headers of the email, (f) the subject of the message, (g) the number of attachments and (h) certain features that are used to identify spam.

CUMC uses a Data Loss Prevention (DLP) solution that filters outbound email messages and attachments to identify the presence of character patterns resembling Sensitive Data, examples of which could include social security numbers, credit card numbers, patient record numbers or certain identifiable data elements that constitute EPHI.  Upon detecting a character pattern that might reflect the presence of Sensitive Data, the DLP appliance blocks the email and
automatically sends a message to the sender instructing him/her to re-send the contents in encrypted form or to take comparable appropriate action.  The filtering consists of automatic scanning for prescribed character patterns and does not permit reading the contents of the email.

 

IV. Cross References to Related Policies and Other
Documentation.

The Information Security Policies and certain additional documentation referred to in this Policy are listed in Appendix A hereto.  

Appendix A

Related Policies  

Acceptable Usage of Information Resources Policy -http://policylibrary.columbia.edu/acceptable-usage-information-resources-policy

Important Information about Provider/Patient Email - http://www.cumc.columbia.edu/hipaa/docs/cumcimptinfo_provider.pdf

Information Security Charter - http://policylibrary.columbia.edu/information-security-charter

Patient Request for Email Communications - http://www.cumc.columbia.edu/hipaa/pdf/Patient_Request_for_Email_Form.pdf