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1.4 · HIPAA Basics

What Counts as Protected Health Information

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Protected Health Information is the type of data HIPAA actually protects. Knowing exactly what counts and what does not is essential, because everything else in compliance hinges on this question. The same field can be regulated or unregulated depending on what else sits next to it on the page.

The definition

Protected Health Information is any information that satisfies both of the following:

  1. It identifies a specific person.
  2. It relates to that person’s past, present, or future physical or mental health, the provision of healthcare to them, or the payment for that care.

The identifying part is the trigger. A diagnosis on its own, with no name attached, is not Protected Health Information. A diagnosis on a page that also carries a name, a date of birth, or any of the other identifiers below becomes Protected Health Information the moment those two things appear together. Strip every identifier and what remains is no longer regulated.

The eighteen identifiers (HIPAA Safe Harbor)

HIPAA enumerates eighteen specific identifiers in its Safe Harbor de-identification rule. If a piece of data carries any of these and is tied to health information, it is Protected Health Information. If you remove all eighteen, the remainder is considered de-identified and can be used freely.

#IdentifierWhat it covers
1NamesFirst, last, nickname, family member names.
2Geographic detail smaller than a stateStreet, city, county, ZIP code under specific conditions.
3Dates tied to an individualBirth, admission, discharge, death, and all ages over 89.
4Phone numbersMobile, landline, fax.
5Email addressesParent, learner, caregiver.
6Social Security numbersAny portion.
7Medical record numbersMRN, chart number, intake number.
8Health plan beneficiary numbersMedicaid recipient ID, commercial member ID.
9Account numbersBilling account, payment plan.
10Certificate or license numbersDriver license, professional license tied to a patient.
11Vehicle identifiersPlate numbers, VIN if tied to a patient.
12Device identifiers and serialsCommunication device, AAC device, sensor.
13Web URLsPatient portal links containing identifiers.
14IP addressesLogged sessions tied to a patient.
15Biometric identifiersFingerprints, voiceprints, facial geometry.
16Full-face photos and comparable imagesTherapy photos, intake photos.
17Any other unique identifierInternal codes that, with effort, point back to a person.
18Genetic informationFamily history, genetic test results.

A working test

Before you put anything into this software, ask two questions:

  1. Does this identify a specific person?
  2. Does this relate to their care or its payment?

If both answers are yes, treat the data as Protected Health Information. If you are uncertain about either, treat it as Protected Health Information until proven otherwise. The cost of being too cautious is small. The cost of being wrong in the other direction is a breach.

Examples that matter for ABA

These come up often in ABA consulting and they are not always obvious.

ExampleVerdictWhy
Photo of a child on a clinic’s social mediaProtected Health InformationIdentifying (face) plus context (the clinic provides ABA care). Allowed only with a specific HIPAA-compliant release on file.
Parent email mentioning the child by name and describing a behaviorProtected Health InformationIdentifying (name) plus relation to care (the behavior is the subject of therapy).
Spreadsheet of learners by initials and progress scoreTreat as Protected Health InformationInitials can identify when paired with other context (clinic location, dates).
De-identified case study used for trainingNot Protected Health InformationEvery identifier on the list has been removed and the case cannot be re-identified through context.