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The University of Texas at Dallas

HIPAA Privacy Manual

Section 24: De-identification of PHI

Policy:

UTD has a duty to protect the confidentiality and integrity of PHI as required by law, professional ethics, and accreditation requirements. 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. This policy defines the guidelines and procedures that must be followed for the de-identification of PHI.

Definitions Institutional Review Board (IRB): A committee group comprised of UTD personnel and community representatives with varying backgrounds and professional experience that review and approve the research protocol involving human subjects.

Authorized User: An individual that is granted access to PHI for patients through an authorization, IRB waiver or who is performing an activity related to health care operations.

Health Care Operations: Activities related to UTD’s functions as a health care provider, including general administrative and business functions necessary for UTD to remain a viable health care provider.

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 individual’s 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.

Procedure:

De-identification requires the elimination not only of primary or obvious identifiers, such as the patient’s name, address, date of birth (DOB), and treating provider, but also of secondary identifiers through which a user could deduce the patient’s 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:

  1. Names
  2. 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)
  3. Names of relatives and employers
  4. Telephone numbers
  5. Fax numbers
  6. Email addresses
  7. Social Security Number (SSN)
  8. medical record number
  9. Health beneficiary plan number
  10. Account numbers
  11. Certificate/License Number
  12. Identifier Protocol (IP) addresses
  13. Any other unique identifying number characteristic, or code.

Whenever possible, de-identified PHI should be used for quality assurance monitoring and routine utilization reporting.

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 an authorized user wishes to encrypt PHI when creating de-identified information the authorized user must ensure that:

  1. 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
  2. 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.

If removal of any identifiers is not practical or does not meet your business needs and you still wish to use PHI, you must obtain approval from the UTD Privacy Office.