Skip to main content

Data Security

Libraries, Fax Machines, and Data Security Obligations

Submission Date

Question

Outside of best practices for staff handling of sensitive documents, are public libraries otherwise bound by HIPAA, FERPA and SOX when sending faxes for patrons, in terms of the privacy protections provided (or not) by the type of fax technology?

Our library currently uses a traditional standalone fax machine (staff mediated) to send and receive public faxes across a dedicated copper phone line, so there’s a direct connection between receiver and sender, maintaining privacy during transmission. Faxing remains a popular service here largely for that reason -- patrons are often told by the fax destination that documents must be sent via fax and not scanned to email.

We’ve been told that copper phone lines will soon be eliminated, so we’re investigating fax-to-email services, which are cheaper than our current method and can use our public copier as the faxing device. However, the Forbes article linked below says faxing by email does not offer privacy protections: “Virtual fax introduces an intermediary into the fax process; there’s no direct connection between the sending and receiving parties. This can be problematic if your business has certain regulatory compliance requirements to support (for example, HIPAA, FERPA and SOX).” The article cites an encrypted kind of fax by IP, “T.38 Fax Lines,” which we suspect would not be cost effective for us.

Are libraries bound by HIPAA et al in the type of faxing technology they can use?

Answer

This is a great question. Before we jump into it, let’s summarize the three types of faxing set out in the referenced article:

  1. “Walk-up Faxing” (on a copper line)
  2. “Virtual Fax” (it’s really email![1])
  3. “Real-Time T.38 Fax Lines” (still e-mail, but with a better connection)

The “T.38” as a “best practice” intrigued me, so I dug in to see if there was any case law featuring it.

There is! And it digs into the capability of the T.38: [2]

Defendant further attacks Richard’s credibility by claiming that his testimony reveals his failure to understand the intricacies of fax technology. These critiques are frivolous. For example, defendant claims Richard’s credibility is undermined by his allegedly inaccurate testimony that: (1) MessageVision used only the T.30 protocol; and (2) a device such as MessageVision’s that uses the T.38 protocol cannot use the T.30 protocol. Even if defendant is correct that Richard’s testimony reflects his limited comprehension of fax technology—a proposition that appears to be dubious at best—defendant’s argument is contradicted by the fact that his own expert admits that T.38 converts to T.30 when a fax is sent using APX 1000.

Well then.[3]

So, with “the intricacies of fax technology” now established as a legal niche, let’s take the questions about faxing and regulatory compliance acronym-by-acronym.

  • FERPA
  • HIPAA
  • SOX[4]

1. Libraries, Fax Lines, and FERPA

FERPA does not apply to public libraries, so we’ll discuss it in the context of school libraries.

Academic libraries at institutions that receive federal assistance have to follow the “Family Education Rights Privacy Act,” which (among many other things) restricts third-party access to education records.[5]

As an example: if I am a student at ABC College, I need to borrow something via an inter-library loan, and (for some odd, steampunky reason) the lending library will only receive loan requests by fax, FERPA could restrict third-party access to the request, if the request lists me (the student) by name as the borrower.[6]

In this case, the manner in which the fax is sent (copper, email, fancy T.38) does not matter. What matters is that either a) I consented for my FERPA-protected education record to be shared with a third party or b) inter-library lending is set up in a way that makes lending libraries (sorta) part of the institution under 34 CFR § 99.31.[7]

After that, the fax simply has to be sufficiently secure to get it from point A (the library) to point B (the other library) without disclosure to a third party.[8]

So that’s FERPA.

2. Libraries, Fax Lines, and HIPAA

HIPAA and other laws related to medical privacy are important and high-stakes; the fine for a HIPAA violation is $50,000 dollars.

Before we delve into this, aside from a hospital librarian or librarian serving a program providing health services, there is NO CIRCUMSTANCE under which a public, academic or public library should be engaging in a HIPAA-governed communication.[9]

What do I mean by “HIPAA-governed communication?” Here’s the type of information governed by HIPAA:[10]

Individually identifiable health information

The term “individually identifiable health information” means any information, including demographic information collected from an individual, that—

(A) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and

(B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and—

(i) identifies the individual; or

(ii) with respect to which there is a reasonable basis to believe that the information can be used to identify the individual.

If your library is not transmitting this type of information,[11] you can stop sweating about HIPAA, even if patrons are using your fax to send it, or (at an academic library) the health center on campus has to abide by it.

Now, if you are a library in a teaching hospital, etc., here is the deal: your institution needs to step up and provide you with 100% assurance that you have the right policies, technology, and practices to be compliant.[12] This includes assurance of a fax line that is secure, which can be any of the three solutions, so long as it is set up right and maintained properly.[13]

So that’s HIPAA.

3. Libraries, Fax Lines, and SOX

While the accountants who audit your library or larger institution may (rightly) hold themselves to the standard set by “Sarbanes-Oxley” (SOX), which was passed in 2002 to protect investors in publicly traded companies, SOX does not govern the data transmission practices of a public or academic library.

But the mention of SOX in the Forbes article referenced in the question intrigued me—it says, “Virtual fax... can be problematic if your business has certain regulatory compliance requirements to support (for example, HIPAA, FERPA and SOX).”

So, I took a look to see if there has been a SOX case involving an insecure fax... and there is!

Here is what happened as told by Judge Denise Cote in Seybold v. Groenink:[14]

In October 2004, while the chairman of ABN’s Managing Board, defendant Rijkman Groenink, met with Federal Reserve Bank regulators in New York over the Eastern European transactions, he received a fax at the Ritz-Carlton Hotel concerning the results of an internal ABN investigation regarding Iran-Libya transactions. Groenink allegedly ordered his aides to destroy the report and to stop sending sensitive documents to the United States.

So, if you are at a library near a business school prepping students for stellar careers in international business... it may be helpful to show that we must all fax wisely.

Does this mean your library needs a T.38? No, but it does mean that asking questions and developing secure systems is important.

You may even want to do the research and see if you can fight to keep at least one copper line.[15] There is strength in having a diversity of technology.[16]

Thank you for an excellent question!

Update 7/23/2025: We received a followup question on this topic; read our answer here.


[1]^ For this question, I will assume that the academic library is using the institutionally assigned and controlled email, which is generally either an in-house service or a third-party provider with a contract that addresses privacy/security.

[2]^ This tech-takedown was issued by U.S. District Judge Robert Gettleman in Ira Holtzman, C.P.A., & Assocs. v. Turza in 2011. Citation: U.S. Dist. LEXIS 97666, 2011 WL 3876943.

[3]^ This paragraph is the judicial equivalent of what in videogames is called “pwnage.”

[4]^ FAX in FERPA, HIPAA in SOX... HIPPA with FERPA on FAX in SOX!

[5]^ Ask the Lawyer has tackled FERPA elsewhere, see: FERPA and NYS Privacy Laws and Patron Confidentiality in School Libraries for two examples.

[6]^ Why this would happen outside a hypothetical situation eludes me, but if you are at an academic library that includes patron names in ILL requests (aside from those enabled by an interconnected/automated ILS), please write adams@losapllc.com, because I am curious how that works.

[7]^ This section of FERPA is how institutions do things like use outside providers to held run residence halls, consult on student outcomes, and in general assist with institutional functions that require access to education records.

[8]^ This means the email used to send the virtual fax needs to be a secure, institutionally-controlled email on both ends, but one would hope that is not a heavy lift.

[9]^ A good resource to assess if you are at a HIPAA “covered entity” is at https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html.

[11]^ What your patrons are doing is their own business. Of course, if they have stolen the health information of a person and are now using your fax machine to engage in identity theft, the might a violation of your Code of Conduct (and about three laws), but it is still not an illegal act by the library.

[12]^ Seriously... this cannot be self-diagnosed. The lawyer for your institution should sign off on it.

[13]^ And with that, we have hit the threshold of my techy savvy.

[14]^ 2007 U.S. Dist. LEXIS 16994, 2007 WL 737502.

[15]^ I did. And yes, my law office still faxes. Like the article said, it’s still very much a thing.

[16]^ Look, sir. Look, sir. It’s our fax, sir. Let’s do tricks with lines and wires, sir. Let’s do tricks with code and lines, sir.

Does the Rise of AI Mean Public Libraries Should Stop Posting Policies to Ensure Security?

Submission Date

Question

Hello,

We have had a huge increase in AI bots on our member library websites. My concern is that internal policies linked on member websites will be “learned” by AI and linked (cited) back to that member library. I’m concerned that members might have their Emergency Action Plan in their Personnel Policy Manual, and that financial controls could be used by ransomware hackers. We go by the following list to define internal and external policies: https://nyslibrary.libguides.com/Handbook-Library-Trustees/policy-checklist

Would it be a “good practice” to not post internal policies online? If there are a few internal policies that you feel should be posted online, would it be best to say online that you have the policy, but please contact the director (or library) for the file/print copy? That way, AI won’t be trained on the policy.

Thank you!

Answer

The concerns raised by the member are valid: absolutely, Artificial Intelligence (AI) OR real people can use published documents, including policies, to exploit a target.

What’s interesting is that this issue actually pre-dates AI; it emerged early in the Internet era, when (often nefarious) people would use information published on websites—along with other techniques—to exploit targets.

Here is a fictional example:

A business’s website includes its protocol for visitors, photos of the interior of its office, and its fiscal policy. A would-be thief we’ll call “Cooper” reviews the protocol, assesses the office interior, and uses the information to gain access to a manager’s office, where Cooper acquires the serial number of a computer. Coopers then calls that office, pretending to be IT (the serial number aids this impersonation) and gets a username and password for the business’s online banking system, which Cooper uses to access accounts described in the fiscal policy.

Poof! Money gone.

To guard against this, many businesses take a careful risk management approach to what they publish (and hopefully admonish people who put their passwords on Post-its).

However, anyone who reads the news knows that financial fraud based on social engineering and computer intrusion is only going up and artificial intelligence is helping with those attacks.

So, is it time to stop publishing public library policies and other documents?

No.

Published policies—even fiscal controls that set out the process for validating checks and the maximum amount of cash to keep in a safe—are not a skeleton key for hackers (AI or otherwise).

Of course, public institutions have always had to be careful about what information they make available. Staging areas and other resources for responding to terrorism and active shooters must be restricted to avoid exploitation by would-be attackers. Bank account numbers and other account-specific information should not be published. Computer passwords, the location of servers, and other sensitive information should be restricted. These considerations should be made in the drafting phase, not when the policy is ready for publication.

That said, because many of their records are FOILable,[1] public libraries should not rely on restricting access to them for security.

Rather, all public library workers and trustees with any part to play in data, financial, and physical security should be trained in the following:[2]

  • Never to provide their password to anyone;
  • Follow fiscal controls at all times;
  • Follow all IT security rules at all times;
  • Notify the IT provider in the event of a suspected data breach, virus, or attack;
  • Never allow unauthorized people into restricted areas;
  • Report lost keys immediately;
  • Secure password lists;
  • Never access sensitive information on personally owned devices (like the bank accounts username and password on a director’s cell phone);
  • Immediately report and document all outside requests for system and/or fiscal information (passwords, location of servers, banking information);
  • Remember that big hacks/ransomware attacks usually start with human failure (giving a password, leaving things logged in, loss of device).

So, are the member’s concerns valid? YES. Exploitive people can use AI to find, copy, and use your library’s policies in attempt to gain access to critical systems.

BUT, if the policies are not published, such people can look up public grant information, building records, or meeting minutes to make themselves sound legitimate for a different social engineering scheme. And if your policies are not available to your community, your library runs the risk of being accused of a lack of transparency.

Instead of restricting access to policies, libraries should develop policies that help prevent the library’s financial exploitation.

For example, a public library’s financial policies should prescribe appropriate internal controls and appropriate use of technology to verify transactions prior to them being irrevocable. For this, the newly released (2025) local government guidance from the New York State Comptroller is excellent.[3] This is mandatory reading for all public library treasurers, controllers, CFOs, accountants, bookkeepers, and directors.

In the same vein, IT policy should include either adequate internal resources to routinely update security and train employees, or a contract with a provider that provides the same assurance (for many public libraries, this is the role of the library system, and it is an increasingly complex and costly role).

While care in drafting policy is important, the essential elements of avoiding ransomware and other attacks are routine updates to security measures and routinely training of people to NOT BE FOOLED.

With the right training and adequate security, AI-powered or good ol’-fashioned hackers will have a tough time getting through, even if they try to use your own policy against you.[4] Train your people, and you don’t have to worry (too much) about training AI.

Now, if we want to talk about putting things behind a log-in to avoid misappropriation of content for the general good of society, that’s another story…

… for another “Ask the Lawyer.”[5]

Thanks for a great question!


[1] And yes, hackers know how to use the Freedom of Information Law.

[2] This is not an exhaustive or professionally phrased list, but it’s the gist of things.

[3] Cash Management Technology, Office of the State Comptroller (https://www.osc.ny.gov/files/local-government/publications/pdf/cash-management-technology.pdf).

[4] Nothing is fool proof, however, so the board should also annually verify that there is adequate insurance for loss due to ransomware and other cyber-attacks or failures.

[5] It is possible we are long past the end of the “open internet,” and more things need to be restricted, both for legal and operational reasons. Hopefully we’ll get a question about that soon, because I have a lot to say.

The Legalities of Patron Data on a Shared ILS

Submission Date

Question

According to the RAQ: Using Emails from ILS Patron Database: “Although a member library contributes information to an ILS, unless system bylaws or policies say otherwise, that information belongs to the system, who is just as ethically and legally bound to protect the information as a member library.”

However, there was a question during a session at NYLA regarding system ownership of library records that seemed to contradict this.

If the system owns the ILS and therefore the library records, wouldn’t that mean that policies pertaining to accessing/creating/modifying/deleting records for the ILS should be governed by system policies that are also approved by each member library board?

I’m specifically thinking of such policies as Confidentiality of Library Records / Inquiries from Law Enforcement - where if the system owns the records then wouldn’t both these policies just be a system one? Also with having consistency for Library Card Applications. A patron can go to one of our libraries and have to show many forms of identification - but the same patron could see us at an outreach event and not even have to show their ID to get a card.

Answer

This submission has it all—attention to detail, a blend of law and policy, and a reference to a past ATL.[1]

It also shows what’s at stake for libraries when we ask these two questions: who “owns” all that data on an ILS? Who sets the terms of cardholder access?

As the members questions point out, uncertainly about these issues can cause complications

Before we jump into the details, there is a critical take-away: while there is no one right answer to these questions, every library and every system should know their particular answers.

To make this answer as helpful as possible, we’ll spend a little time on why there is no single right answer to this issue. After we review the “why,” we’ll review the spectrum of approaches. And after all that, I’ll provide a diagnostic form so your library or system can assess where it stands.

The “Why”

Why is there “no one right answer” to who owns ILS data and who sets the terms of cardholder access? Because the law and its regulations give library systems and members infinite flexibility on those topics.

That flexibility means there is no prescribed model of ILS.[2] Instead, the law[3] simply conditions certain state aid on a system having “an automation program to support bibliographic control and interlibrary sharing of information resources of member libraries, and to coordinate and integrate the automated system or systems of such member libraries consistent with regulations of the commissioner.”

Those “regulations of the commissioner” state: “The plan of each public library system shall provide for coordination of the reference and interlibrary loan programs and functions of the public library system with the approved plan of the reference and research library system of which it is a member.”[4]

That’s it. There are no laws or regulations saying how that must be done.

Because of that, the “rules” of an ILS and its impact on cardholder access come from charters,[5] bylaws, contracts, and policy—all of which are set by a system’s board of trustees and then accepted by the member libraries.

This approach has led to there being a spectrum of ILS policies in New York State.[6]

Let’s explore this spectrum.

The ILS Spectrum

Library systems are formed to offer “improved and expanded”[7] library service.

To qualify for certain state aid under Education Law Section 273(d), systems must implement an “automation program to support bibliographic control and interlibrary sharing of information resources of member libraries, and to coordinate and integrate the automated system or systems of such member libraries consistent with regulations of the commissioner…”

How a system meets those requirements is up to the system. To illustrate how differently systems can do that, here is a range of solutions:[8]

One system puts major rules for ILS right in its bylaws, including that all ILS contracts and policy must be approved by the board. This is an “ILS by Bylaws and Board” model.[9]

Another system has bare-bones bylaws, but ILS policy, pricing, and contracts can only be approved by the board of trustees. This is an “ILS by Board Only” model.

Another system wants more “on the ground” input, and it wants that input to have power. It creates a council to assess ILS policy, pricing, and contracts, and those things can only be changed by the board of trustees after approval by the council. This is a “Two-Step Approval ILS Policy” model.

Another system finds bylaws and policy revision cumbersome and puts all the terms for the ILS in an “ILS Participation Contract” that must be approved by the system board and then by the board of each participating library. This is an “ILS by Contract” model.[10]

Another system wants to have ongoing stability, so it puts part of the ILS process in the bylaws, some in board-approved policy, and then outsources more mutable aspects (like pricing and desired tech functions) to a committee (or committees). The system believes in the power of shared governance, so it asks another group (usually of directors) to assess ALL changes to policy before approval by the board. And finally, it uses an annual contract process to confirm pricing and updated security measures. This is an “ILS By Everything” model.

See what I mean about diversity?[11] And these five models only illustrate a broad range of approaches; within this range, any number of permutations exist.[12]

Where your Library/System Stands

All this diversity and flexibility means it can be tough to sort out answers to the questions raised by the member:

  • Who “owns” all that data on an ILS?
  • Who sets the terms of cardholder access?

To answer them—because as was said at the beginning, no matter what the answer is, it must be clear—it is helpful to review certain documents while asking certain questions.

Here they are:[13]

QuestionWhy it’s important

Does your library have a policy governing the terms of getting a library card?

NOTE: Libraries can have a policy of issuing cards only to “resident” borrowers, even though they must honor the cards of nonresident borrowers issued by other member libraries and the library system.

If so, attach the policy.

If your library doesn’t have a policy, the only terms will be those on the application form and those in the policy of the system.

Does your library have an application form governing the terms of getting a library card?

NOTE: Libraries can have a policy of issuing cards only to “resident” borrowers, even though they must honor the cards of nonresident borrowers issued by other member libraries and the library system.

If so, attach the form.

If your library doesn’t have a form, you might not be informing the patron of your library’s conditions for getting a card.

 

Does your system have a policy governing the terms of getting a library card?

If so, attach the system’s policy.

The system’s policy should be a “floor” that sets the base terms. Your library can add additional terms, so long as they don’t restrict the direct access of non-resident borrowers.

Does your system have an application form governing the terms of getting a library card?

NOTE: Unless a charter, bylaws, or policy says otherwise, systems can issue cards without the person being served by a member library.

If so, attach the form.

The system’s policy should be a “floor” that sets the base terms. Your library can add additional terms, so long as they don’t restrict the direct access of non-resident borrowers.
Attach the system’s charter and bylaws.They most likely don’t address the issue of ILS, but never say never in Libraryland!
If the system has an ILS Policy, attach the system’s ILS policy.NOTE: Some systems have multiple policies that address different aspects of ILS (operations, privacy, security, costs, routine assessment, etc.). Attach them all.

Is there a contract (or other written agreement) between the system and the Library governing ILS services provided by the system?

If yes, attach the contract.

NOTE: While a contract approved or acknowledged by the board of a member library is the most formal method, some systems may use an “MOU” or other less formal instrument.

Looking at the documents you’ve assembled, answer this question:

Whose privacy policy governs a cardholder’s data?

The answer must be:

1. Both the library’s and the system’s

2. Only the library’s

3. Only the system’s

If the answer is “both,” that’s okay! Privacy can stack. Just make sure that the library and system are actually doing what has been assured by the policies and that they don’t contradict each other.

Looking at the policies and forms, answer this question:

Whose data security policy governs the cardholder’s data?

The answer must be:

1. Both the library’s and the system’s

2. Only the library’s

3. Only the system’s

If the answer is “both,” that’s okay! Security can stack. Just make sure that the library and system are actually doing what has been assured by the policies and that they don’t contradict each other.

Looking at the policies and forms, answer this question:

Whose policies did the cardholder agree to follow to get a card?

The answer must be:

1. Both the library’s and the system’s

2. Only the library’s

3. Only the system’s

4. Every participating library’s

If the answer is “both” or “every participating library’s,” that’s okay, unless the terms don’t harmonize.

For instance, if a library’s policy says that cardholder privileges will be suspended due to a Code of Conduct violation, is there clarity about how that suspension will impact system access or access at member libraries?[14]

Looking at the bylaws, policies, and contracts, answer this question:

Who sends the patron a notice if there is a data breach at the library involving their patron data?

The answer should be “the library”, although the system (which may have more technical capacity) can agree to help (up to and including doing it).

Looking at the bylaws, policies, and contracts, answer this question:

Who sends the patron a notice if there is a data breach at the system involving their patron data?

The answer should be “the system,” and there should be a clear process for the Library to get notified about the impact on it patrons.

Looking at the bylaws, policies, and contracts, answer this question:

Who must preserve evidence on the ILS if there is a directive to do so?

The answer must be:

1. Both the library and the system

2. Only the library

3. Only the system

Looking at the bylaws, policies, and contracts, answer this question:

Who must disclose patron data on the ILS if there is a proper subpoena, warrant, or court order?

The answer must be:

1. Both the library and the system

2. Only the library

3. Only the system

Looking at the bylaws, policies, and contracts, answer this question:

Whose insurance covers loss of a library’s data on the ILS due to natural disaster, negligence, or criminal activity?

The answer must be:

1. Only the library’s

2. Only the system’s

What record retention policy governs the retention of the patron’s records on the ILS?

Follow-up question: How are the records disposed of when the retention period is over?

The answer must be:

1. Only the library’s

2. Only the system’s

Public libraries are obligated to retain certain records for prescribed periods (See the LGS-1).

Are there any technical functions of the current ILS system that complicate the above factors or make them impossible to sort out?

The answer will be:

1. No

2. Yes

If “no,” that is great news, because such complications are a true pain.

If “yes,” the complications should be continuously documented and then addressed when the ILS contract is next assessed for renewal or termination.

And that’s it!

Who “owns” all that data on an ILS? It depends, but the rights and obligations of ownership should be clear between a system and its members.

Who sets the terms of cardholder access? It depends, but the rights and obligations of cardholders, member libraries, and the system should be clearly set in guidance, forms, contracts, and policies.

Thank you for submitting such a great question.


[1] If I was “Stefon” from SNL, I’d add “library cart axle grease, book club groupies, and book signings in a hot tub,” but I am not.

[2] Flexibility means diversity! This is a strength, unless the lack of prescription leads to uncertainty.

[3] Education Law Section 273

[4] 8 NYCRR 90.3(k)

[5] Charters don’t typically speak to ILS terms, but they are so fundamental, it feels wrong to omit them from this list. Like a grumpy fairy, if they are left out, it could result in mischief.

[6] And when I say “spectrum”...we are talking triple rainbow.

[7] Education Law 255 (2).

[8] None of the models in this answer are from particular systems I am familiar with. So, if you are at a system and feel seen, that’s great, but I am painting with a broad brush here!

[9] I don’t know of any system that does this, but it is feasible.

[10] Such models can be annual or for longer terms. Generally, at least one fiscal year’s worth of notice is needed to leave.

[11] Further complicating things is that ILS is often lumped in with web services, e-mail, delivery, and other services systems offer to help libraries maximize services.

[12] A mathematician, a lawyer, and Library IT manager all walk into a bar…

[13] It is none of my business how a library or system does this, but I advise using a buddy system. While the friendly table above makes this look simple, much of this requires a “search” function, a highlighter, and a calming herbal tea.

[14] This is especially important to coordinate when it comes to public safety. A system should have a policy to ensure that if a person loses privileges at one library, there is clarity about how that impacts access to other member libraries. Simply posting an unofficial warning via an ILS puts you at risk of a civil rights violation claim by the barred patron. This is also a priority to ensure worker safety.