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11-De-Identification

Approved by: William Voss Effective: April 1, 2024
Review: Annual Revised:
Renewed By: Renewed:

De-Identification

Policy Statement

River City TMS, PLLC uses the process of de-identification to help protect the confidentiality of Protected Health Information (PHI), when information based off PHI must be shared in a way that would be an unauthorized use or disclosure. The process of de-identification is a method of removing any identifiable information from an individual’s record to eliminate the potential for privacy breaches of a specific information set.

De-identification is defined by the Department of Health and Human Services (HHS) as “Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.”

Procedure

  • Non-Individually Identifiable Information

    Health Information that is created, stored, or transmitted by River City TMS, PLLC is maintained in a manner that does not violate the HIPAA Privacy and Security rules. In line with the above statement, River City TMS, PLLC will apply generally accepted statistical and scientific methods to ensure that information, that is deemed de-identified, introduces an extremely low risk of any third party identifying the subject of the information. The methods and results that are used for the purpose of analyzing the associated risks of the contained information will be documented, and a note that this has been performed will be placed into any involved medical records. 

  • Identifiers §164.514(b)(2)

    River City TMS, PLLC maintains a view consistent with the HHS that all the following information may be an identifier and must be removed when de-identifying PHI. These include identifiers about the individual or of relatives, employers, or household members of the individual.

    • Names.

    • All geographic subdivisions smaller than a State, including street address, zip code, city, county, precinct, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census:

      • The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and

      • The initial three digits of a zip code for all geographical units containing fewer than 20,000 people is changed to 000.

    • All elements of dates (except year) 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 may be aggregated into a single category of age 90 or older. 

    • Telephone numbers.

    • Fax numbers.

    • Electronic mail addresses.

    • Social security numbers.

    • Medical record numbers.

    • Health plan beneficiary numbers.

    • Account numbers.

    • Certificate/license.

    • 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 finger and voice prints.

    • Full face photographic images and any comparable images.

    • Any other unique identifying number, characteristic, or code, except as permitted by Re-identification specifications (§ 164.514(c)).

    River City TMS, PLLC may also determine information is not individually identifiable if they hold no knowledge that the included information could reasonably be used alone or in combination with other information to identify the individual it describes. 

  • Re-Identification

    River City TMS, PLLC may have a need to temporarily de-identify information for specific purposes where they must later be able to add the identifiers back. In these cases, River City TMS, PLLC may assign codes or various identifiers that do not disclose the private information that is held in the records but allows for the information to be reloaded when the information no longer needs to be de-identified.

    The Privacy Officer is responsible for associating records to identifiers in a manner consistent with this policy and the HIPAA Privacy Rule. These codes or record identifiers should not be made in way that enables others to translate the codes to identify individuals. Additionally, the record identifiers will not include components of an individual’s personal identifiers that disclose the mechanism of de-identification.