Policy Number: IT- 3
Effective Date: May 9, 2008
Responsible Officer: Chief Information Officer/Information Security Officer
To secure sensitive DUCOM data sent by email transmission, DUCOM has licensed for the Drexelmed.edu domain the Voltage™ encryption software for use by DUCOM employees, faculty, contractors and Residents. (“Users”). This is to provide for the secure transmission of protected health information (PHI) and other Sensitive Data when e-mailed to minimize the risk of a breach of confidentiality and the potential misuse, disclosure or theft of such information.
Sensitive Data: Protected Health Information, Social Security Numbers, Credit Card Numbers, Financial Account Numbers, and other information protected by HIPAA, FERPA, Gramm Leach Bliley, Pennsylvania Breach of Personal Information Notification Act and other laws and regulations.
Protected Health Information: Protected health information (PHI) is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.
The 18 Identifiers that render information PHI are the following:
- All geographical 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: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) 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;
- Phone 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 (note this does not mean the unique code assigned by the investigator to code the data)
DUCOM Users shall use the Voltage™ Encryption Software when sending any email (with or without attachments) which contains Sensitive Data. This applies to both sending emails internally to other DUCOM Users and externally to third parties who have a need to know the Sensitive Data. All such use of the DUCOM email system shall be done in accordance with the Acceptable Use Policy http://www.drexel.edu/admin/hr_hs/policies/DU-IT-2.htm in addition to this policy.
- All DUCOM Users must complete the Web-based training program on the use of Voltage Encryption software (”SecureMail”).
- All DUCOM Users must complete the on-line sign-on process prior to use of Voltage Encryption software.
DUCOM Users are to transmit minimum necessary protected health information to covered entities certified to adhere to HIPAA regulations (e.g. insurance plans, research entities).
- Sensitive Data in e-mail transmissions should be limited to minimum necessary and must need information.
- Do not forward sensitive information to personal e-mail accounts on non-Drexelmed.edu domains.
Per the Acceptable Use Policy email communications may be audited on a random basis to ensure compliance with set policies.
Violation of this policy will be reviewed on a case by case basis by the Privacy and Security Committee and Human Resources, with consequences recommended to management of the employee including termination of employment and additional penalties and charges to the full extent of the law applicable to the offense
DUCOM reserves the right to update or revise the Email Encryption Policy or implement additional policies in the future. Users are responsible for staying informed about DUCOM policies regarding the use of computer and network resources and complying with all applicable policies.
Inquiries regarding this policy can be directed to the Information Technology Department of DUCOM.