1. Purpose

1.1. East Carolina University Health Care Components ("ECU Health Care Components") have a legal duty to maintain the security and confidentiality of protected health information ("PHI"). The purpose of this regulation is to provide guidance on the de-identification of PHI.

2. Definitions

2.1. Protected Health Information means:

2.1.1. Individually identifiable information, that is a subset of health information, including demographic information collected from an individual, and:

2.1.1.1. Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and

2.1.1.2. Relates to the past, present, or future physical or mental health or condition of a subject; the provision of health care to a subject, or the past, present, or future payment for the provision of health to a subject; and

2.1.1.2.1. That identifies the subject; or

2.1.1.2.2. With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

2.1.2. PHI can be:

2.1.2.1. Transmitted by electronic media;

2.1.2.2. Maintained in electronic media; or

2.1.2.3. Transmitted or maintained in any other form or medium.

2.1.3. PHI excludes individually identifiable information that is:

2.1.3.1. In education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g;

2.1.3.2. In records described at 20 U.S.C. 1232g(a)(4)(B)(iv);

2.1.3.3. In employment records held by a covered entity in its role as employer; and

2.1.3.4. Regarding a person who has been deceased for more than 50 years.

3. Policy

3.1. ECU Health Care Components will consider all individually identifiable health information as PHI unless this information is appropriately de-identified in accordance with this policy. De-identified health information will not be subject to ECU's HIPAA Privacy Policies.

3.1.1. 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.

3.2. De-identification.

ECU Health Care Components may determine that health information is not individually identifiable health information only if:

3.2.1. A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable:

3.2.1.1. Applying such principles and methods, 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

3.2.1.2. Documents the methods and results of the analysis that justify such determination ; or

3.2.2. The following identifiers of the individual or of relatives, employers, or household members of the individual, are removed and an ECU Health Care Component does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information:

3.2.2.1. Names;

3.2.2.2. All geographic subdivisions smaller than a State including address, city, county, precinct, zip code, 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:

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

3.2.2.2.2. The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.

3.2.2.3. 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;

3.2.2.4. Telephone numbers;

3.2.2.5. Fax numbers;

3.2.2.6. Email addresses;

3.2.2.7. Social security numbers;

3.2.2.8. Medical record numbers;

3.2.2.9. Health plan beneficiary numbers;

3.2.2.10. Account numbers;

3.2.2.11. Certificate/license numbers;

3.2.2.12. Vehicle identifiers and serial numbers, including license plate numbers;

3.2.2.13. Device identifiers and serial numbers;

3.2.2.14. Web Universal Resource Locators (URLs);

3.2.2.15. Internet Protocol (IP) address numbers;

3.2.2.16. Biometric identifiers, including finger and voice prints;

3.2.2.17. Full face photographic images and any comparable images; and

3.2.2.18. Any other unique identifying number, characteristic, or code, except as permitted by paragraph 3.3.

3.3. Re-identification.

ECU Health Care Components may assign a code or other means of record identification to allow de-identified information to be re-identified by the Component, provided that:

3.3.1. The code or other means 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

3.3.2. The ECU Health Care Component does not use or disclose the code or other means of record identification for any other purpose and does not disclose the mechanism for re-identification.

4. Procedure

4.1. ECU Health Care Components must contact the ECU HIPAA Privacy Officer prior to the use or disclosure de-identified information by calling 252-744-5200 or by email at healthcareprivacy@ecu.edu.