"prompt","response" "Date Signed:","03/08/2024" "OPDIV:","NIH" "Name:","CC CRSS VALET" "PIA Unique Identifier:","P-5538190-350397" "The subject of this PIA is which of the following?","Minor Application (stand-alone)" "Identify the Enterprise Performance Lifecycle Phase of the system.","Operations and Maintenance" "Is this a FISMA-Reportable system?","No" "Does the system include a Website or online application available to and for the use of the general public?","No" "Identify the operator.","Agency" "Is this a new or existing system?","New" "Does the system have Security Authorization (SA)?","Yes" "Describe the purpose of the system.","The Validate Addresses, Letters, and labels Efficiently Tool (VALET) is an application used in the NIH Clinical Center (CC) Health Information Management Division (HIMD) to verify referring clinicians' and other outside clinicians' names, addresses and contact information. This contact information ultimately serves as the authoritative source when adding outside clinicians as Referring Providers and/or MDReport providers. (MDReport providers are outside physician care providers that the patient has authorized to receive their information permanently. It is an internal name for a type of patient doctor and not a corporation or acronym.) " "Describe the type of information the system will collect, maintain (store), or share.","The system displays a patient's name, medical record number (MRN), and the patients outside physician information (name, phone number and business mailing address) and National Provider Identifier (NPI). The software connects to a publicly available database, and using the NPI, ensures that the CC captures the most current information for a patient's physician. Users requiring access log in to this system using the NIH Identity, Credential, and Access Management (IAM) Services which maintains its own unique privacy impact assessment (PIA) on record, including all legal authorities documented. The purpose of IAM Services is to authenticate and authorize all users and computers in a Windows domain type network, assigning and enforcing information security policies for all computers and installing or updating software. The IAM Services collect unique user credentials and stores them in an encrypted format. The IAM Services are an essential service which facilitates and governs network access to various resources. " "Provide an overview of the system and describe the information it will collect, maintain (store), or share, either permanently or temporarily.","VALET is an application used in HIMD to verify referring clinicians' and other outside clinicians' names, addresses and contact information. This contact information ultimately serves as the authoritative source when adding outside clinicians as Referring Providers and/or MDReport providers. MDReport providers are outside physician care provider that the patient has authorized to receive their information permanently. The system displays a patient's name, MRN, and the patients outside physician information (name, phone number and business mailing address) and NPI. The software connects to a publicly available database, and using the NPI, ensures that the CC captures the most current information for a patient's physician. Users requiring access log in to this system using the NIH IAM Services which maintains its own unique PIA on record, including all legal authorities documented. " "Does the system collect, maintain, use or share PII?","Yes" "Indicate the type of PII that the system will collect or maintain.","Name; Mailing Address; Phone Numbers; Medical Records Number; National Provider Identifier" "Indicate the categories of individuals about whom PII is collected, maintained or shared.","Employees; Public Citizens; Patients" "How many individuals' PII is in the system?","100-499" "For what primary purpose is the PII used?","Validating the contact information of a patients outside physician (external to NIH)." "Describe the secondary uses for which the PII will be used.","No secondary uses have been articulated." "Identify legal authorities governing information use and disclosure specific to the system and program.","The legal authority to operate and maintain this Privacy Act records system is 42 U.S.C. §§ 241, 248, 282 and 284" "Are records on the system retrieved by one or more PII data elements?","Yes" "Identify the number and title of the Privacy Act System of Records Notice (SORN) that is being use to cover the system or identify if a SORN is being developed.","09-25-0099; Clinical Research: Patient Medical Records, HHS/NIH/CC" "Identify the sources of PII in the system.","Directly from an individual about whom the information pertains - Online; Government Sources - Within OpDiv; Non-Governmental Sources - Public; Non-Governmental Sources - Private Sector" "Identify the OMB information collection approval number and expiration date","Public Law 114-255, Section 2035, exempts research conducted by NIH from Paperwork Reduction Act (PRA) requirements." "Is the PII shared with other organizations?","No" "Describe the process in place to notify individuals that their personal information will be collected. If no prior notice is given, explain the reason.","Every patient must voluntarily execute a protocol consent and authorization prior to entry onto an intramural research protocol and treatment at the Clinical Center. In addition, each patient is provided a formal notification of Information Practices at the Clinical Center and must certify that they have been so advised. " "Is the submission of PII by individuals voluntary or mandatory?","Voluntary" "Describe the method for individuals to opt-out of the collection or use of their PII. If there is no option to object to the information collection, provide a reason.","General admission and protocol consent forms are signed by each patient. Additionally, an information practices notification form is reviewed and acknowledged in writing by each patient at the time of initial admission to the CC. Enrollment in a clinical research trial is voluntary and the collection of personally identifiable information (PII) and medical notes is necessary to conduct research and provide clinical care. Therefore, a patient may not opt out of the collection or use of their PII while participating in research at the CC. " "Process to notify and obtain consent from individuals whose PII is in the system when major changes occur to the system.","All patients are notified of information practices upon admission. Each patient would be advised at the time of the next admission about major system changes and the CC Information Practices Notice would be revised and provided to each patient again. " "Describe the process in place to resolve an individual's concerns when they believe their PII has been inappropriately obtained, used, or disclosed, or that the PII is inaccurate.","A Privacy Rights Complaint Form is available to individuals when they believe that their PII has been inappropriately used or disclosed. The CC Department of Clinical Research Informatics (DCRI) Privacy Office will review the complaint and coordinate with the NIH Office of the Senior Official for Privacy (OSOP) to respond to the concern. Complaints could also be submitted to the System Manager, who would investigate and share findings with CC Information Systems Security Officer (ISSO) and CC DCRI Privacy Office." "Describe the process in place for periodic reviews of PII contained in the system to ensure the data's integrity, availability, accuracy and relevancy.","Modifications to physician data are sent electronically to the NIH CC Clinical Research Information System (CRIS). CRIS is the authoritative source for NIH CC patient care and maintains its own unique PIA, with all legal authorities documented." "Identify who will have access to the PII in the system and the reason why they require access.","Users: Users in the medical records department (HIMD) use the system to verify the address of a given patient's physician.; Contractors: Direct Contractors may be users." "Describe the procedures in place to determine which system users (administrators, developers, contractors, etc.) may access PII.","Access to PII is assigned to personnel based upon current job responsibilities. An NIH IAM Services account login is required to gain access to the stored PII data. (The availability of PII data is based on file system permissions and the access rights of the user's IAM account determines whether PII may be accessed.)" "Describe the methods in place to allow those with access to PII to only access the minimum amount of information necessary to perform their job.","Appropriate access is granted to the system based on predefined roles and job descriptions, and administrative access is limited to authorized employees based on current roles. Dual factor authentication with NIH Personal Identity Verification (PIV) card and NIH IAM will occur at time of login to the NIH Network. System owners are responsible for creating the proper security groups within their systems with the applicable permissions for group members to enforce least privilege. " "Identify training and awareness provided to personnel (system owners, managers, operators, contractors and/or program managers) using the system to make them aware of their responsibilities for protecting the information being collected and maintained.","According to NIH policy, all personnel who manage or operate NIH applications must successfully complete annual security awareness training. There are five categories of mandatory information technology (IT) training (Information Security, Counterintelligence, Privacy Awareness, Records Management and Emergency Preparedness). " "Describe training system users receive (above and beyond general security and privacy awareness training).","Application specific ""sit next to me while I show you"" peer training is provided." "Do contracts include Federal Acquisition Regulation and other appropriate clauses ensuring adherence to privacy provisions and practices?","Yes" "Describe the process and guidelines in place with regard to the retention and destruction of PII.","Records are retained and disposed of under the authority of the NIH Records Retention Schedule. Item 03-001: Clinical Care Services Records These records consist of clinical care services and clinical care department operational records that are consolidated under this one common temporary retention item. Exclusions and exceptions are noted and cross referenced to their appropriate item numbers within this schedule. Disposition: Cut off annually at end of fiscal year. Destroy 7 years after cutoff. DAA-0443-2019-0001-0001" "Describe, briefly but with specificity, how the PII will be secured in the system using administrative, technical, and physical controls.","Physical Controls: The information technology (IT) hardware used to host protected information is located in a secured datacenter facility. The facility is only open to authorized personnel whose access is monitored by locking doors with badge readers for both ingress and egress. Each discrete ingress and egress event is logged. The facility is under 24-hour surveillance by facilities security for security and environmental hazards. Technical Controls: IT hardware and software is segregated from default commodity public networks to prevent unauthorized or malicious access. Access controls lists and event logs are maintained and monitored to detect unauthorized, suspicious or malicious activity. Access lists are restricted to approved IT technical personnel. Two factor authentication must be used for access. File integrity and auditing software are employed on hardware. Administrative Controls: All technical personnel who access IT systems which contain protected information have met background investigation criteria for Public Trust positions. All personnel have taken mandatory security and privacy training classes and annual refreshers. Administrative personnel accessing these systems use privileged and separate accounts for administrative access. "