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Protected Health Information (PHI):
Individually identifiable health information transmitted or maintained in any form or medium, including oral, written, and electronic communications. Individually identifiable health information relates to an individuals health status or condition, furnishing health services to an individual or paying or administering health care benefits to an individual. Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individual.
Heathcare professionals have a duty to protect the confidentiality and integrity of PHI as required by law and professional ethics. Whenever possible, de-identified PHI should be used. De-identified PHI is rendered anonymous when identifying characteristics are completely removed. PHI must be de-identified prior to disclosure to non-authorized users.
De-Identification of PHI Guidelines:
All personnel must strictly observe the following guidelines relating to the de-identification of PHI:
De-identification requires the elimination not only of primary or obvious identifiers, such as the patients name, address, date of birth (DOB), and treating physician, but also of secondary identifiers through which a user could deduce the patients identity. For information to be de-identified the following identifiers of the individual (or of relatives, employers, or household member of the individual) must be removed:
Names
Address information smaller than a state, including street address, city, county, zip code (except if by combining all zip codes with the same initial three digits, there are more than 20,000 people)
Names of relatives and employers
All element of dates (except year), including DOB, admission date, discharge date, date of death; and all ages over 89 and all elements of dates including year indicative of such age except that such ages and elements may be aggregated into a single category of age 90 or older;
Telephone numbers
Fax numbers
Email addresses
Social Security Number (SSN)
Electronic Medical Record number (EMR)
Health beneficiary plan number
Account numbers
Certificate/License Number
Vehicle identifiers, including license plate numbers
Device ID and serial number
Uniform Resource Locator (URL)
Identifier Protocol (IP) addresses
Biometric identifiers
Full face photographic images and other comparable images
Any other unique identifying number, characteristic, or code.
Whenever possible, de-identified PHI should be used for quality assurance monitoring and routine utilization reporting. If de-identified PHI cannot be used, a limited data set should be used whenever possible.
PHI used for research, including public health research, should be de-identified at the point of data collection for research protocols approved by the IRB, unless the participant voluntarily and expressly consents to the use of his/her personally identifiable information or an IRB waiver of authorization is obtained. If de-identified PHI cannot be used for research, a limited data set should be used whenever possible.
If an authorized user wishes to encrypt PHI when creating de-identified information the authorized user must ensure that:
The code or other means of record identification is not derived from or related to information about the individual and is not otherwise capable of being translated so as to identify the individual; and
Anyone involved in the research project does not use or disclose the code or other means of record identification and does not disclose the mechanism to accomplish re-identification.
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