Be Careful About Identity Theft When Choosing Patient Identifiers

Accreditation Monthly, April 9, 2005

Dear Colleague,

Some of you may have seen this story reported first in The Wall Street Journal in February concerning the problem of identity thieves obtaining social security numbers of patients treated in a number of hospitals across the United States (a link to the story carried also in the Pittsburgh Post-Gazette is available here). News of this occurrence should not surprise us I suppose, yet hospitals have an obligation to protect the confidentiality and privacy of their patients. Indeed, JCAHO standard RI.2.130 Element of Performance numbers 1 and 2 speak to this requirement as does IM 2.10. In IM 2.10 the Commission defines the terms privacy and confidentiality as follows:

  • Privacy: An individual's right to limit the disclosure of personal information.
  • Confidentiality: The safekeeping of data/information so as to restrict access to individuals who have need, reason, and permission for such access.

The rationale and elements of performance for this standard go on to specify how the hospital should try to balance the need for information about the patient being available to staff while at the same time providing for the patient's right to privacy and confidentiality of the information. It is also clear the Commission has written the EPs in this standard to be in conformance with applicable HIPAA law and regulation.

I think IM 2.10; EP 6 is germane to the concern raised in the WSJ article. It states, "for uses and disclosures of health information, the removal of personal identifiers is encouraged to the extent possible, consistent with maintaining the usefulness of the information." In light of news of identity theft occurring based on stolen social security numbers is would seem wise that organizations design systems to safeguard the patient's social security number and relegate its use within the patient's record to only those purposes for which there is no alternative identifier.

As a case in point, if you are using the social security number as one of your two patient identifiers when administering medication or blood, or collecting specimens or prior to providing any exam or treatment as is required by PC.5.10; EP4, I strongly suggest you adopt an alternative identifier such as the medical record number. If you are using the social security number because in your system it doubles as the medical record number, then I suggest you consider changing your system to create a unique patient-specific medical record number different than the social security number.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

For more information on our accreditation and regulatory compliance consulting services, click here or contact Sandi Reen, Practice Manager, at or call 888/749-3054, ext. 3263.

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