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Health Insurance Portability and Accountability Act (HIPAA)

As stated on the Johns Hopkins Medicine intranet page regarding HIPAA strategy, it has been decided to use a Hopkins-wide approach to assure compliance with the HIPAA Act and Regulations. For this reason, a HIPAA coordinating council has been formed to assure that all Hopkins organizations will be in compliance.

The HIPAA Regulations will have an impact on those who collect information via the Web, such as with forms, and for those who engage in any type of marketing activities (including emailed newsletters, for example). For this reason, and for further information, please see the HIPAA pages on the Johns Hopkins Medicine intranet site.

If you have questions about HIPAA and compliance, please contact the following before proceeding with your project:

Carol Richardson, HIPAA Administrative Coordinator & Privacy Officer, Johns Hopkins, 410-502-7983 [hipaa@jhmi.edu]

What Is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 governs health-related companies and doctors who handle patient information. HIPAA specifically addresses health care providers who transmit health information, such as patient records, in electronic form.

Protected health information (PHI) under HIPAA means individually identifiable health information. Identifiable refers not only to data that is explicitly linked to a particular individual (i.e. identified information), it also includes health information with data items which reasonably could be expected to allow individual identification.

Health information is not individually identifiable health information only if:

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

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
2. documents the methods and results of the analysis that justify such determination.

OR

1. The following identifiers of the individual or of relatives, employers, or household members of the individual, are removed:
   • Names;
   • All geographic subdivisions smaller than a state, including street 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:
     • 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 such geographic units containing 20,000 or fewer people is 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;
   • Fax 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 finger and voice prints;
   • Full face photographic images and any comparable images; and
   • Any other unique identifying number, characteristic, or code; and
2. The covered entity 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.