Consider this real world case that was reported in the Boston Globe last year.
Incident: A physician in Rhode Island posted details of her emergency room encounters on Facebook.
Penalty: The Rhode Island Board of Medical Licensure found her guilty of unprofessional conduct and issued a reprimand and a fine. According to the board finding, even though the physician did not reveal any patient names, there was sufficient information in her posting, for other people in the community to figure out who the patient was.
So what information is considered as PHI (protected health information) and what information can be freely disclosed? Under the HIPAA privacy rule, a covered entity is free to disclose any health information that has been de-identified, which means that the patient cannot be identified using the information disclosed, either by itself or in combination with other information. De-identified information is no longer considered as a PHI and thus not covered anymore under the HIPAA Privacy and Security rules. So what steps need to be taken by a covered entity to de-identify PHI?
According to the “45CFR §164.514 (b) Implementation specifications: requirements for de-identification of protected health information”, a covered entity can use either of the two following methods:
Method 1( safe harbor method)
The first method is the so called “safe harbor” method. The Privacy Rule allows a covered entity to de-identify data by removing all 18 elements that could be used to identify the individual or the individual's relatives, employers, or household members. The covered entity also must have no actual knowledge that the remaining information could be used alone or in combination with other information to identify the individual who is the subject of the information. Under this method, the 18 identifiers that must be removed are the following:
- All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes, except for the initial three digits of a ZIP Code if, according to the current publicly available data from the Bureau of the Census: (A) The geographic unit formed by combining all ZIP Codes with the same three initial digits contains more than 20,000 people. (B)The initial three digits of a ZIP Code for all such geographic units containing 20,000 or fewer people are changed to 000.
- All elements of dates (except year) for dates directly related to an individual, including birth date, 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.
- Facsimile numbers.
- Electronic mail addresses.
- Social security numbers.
- Medical record numbers.
- Health plan beneficiary numbers.
- Account numbers.
- Certificate/license numbers.
- Vehicle identifiers and serial numbers, including license plate numbers.
- Device identifiers and serial numbers.
- Web universal resource locators (URLs).
- Internet protocol (IP) address numbers.
- Biometric identifiers, including fingerprints and voiceprints.
- Full-face photographic images and any comparable images.
- Any other unique identifying number, characteristic, or code, unless otherwise permitted by the Privacy Rule for re-identification.
Method 2(statistical method with expert certification)
The second method involves the use of statistical methods to establish de-identification instead of removing all 18 identifiers. A covered entity may determine that health information is not individually identifiable health information if “ A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable” (i) determines that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is a subject of the information; and (ii) Documents the methods and results of the analysis that justify such determination.
As you can see the there are strict requirements under HIPAA for de-identification of PHI. As the Rhode Island case illustrates, just because no patient names are used, doesn’t mean that the individual cannot be identified from other information. Care should be taken to ensure that the PHI is de-identified before being disclosed publicly. It is imperative that all covered entities have well documented policies and procedures as well as training to ensure that all employees understand the HIPAA Privacy and Security rule compliance requirement.