PIA - Message Validation, Processing and Provisioning

Att 18 - MVPS PIA.pdf

National Notifiable Diseases Surveillance System (NNDSS)

PIA - Message Validation, Processing and Provisioning

OMB: 0920-0728

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-86426

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-4278294-258144

2a Name:

3/30/2017 1:15:11 PM

Message Validation, Processing, and Provisioning System
(MVPS)
General Support System (GSS)
Major Application

3

Minor Application (stand-alone)

The subject of this PIA is which of the following?

Minor Application (child)
Electronic Information Collection
Unknown

3a

Identify the Enterprise Performance Lifecycle Phase
of the system.

Operations and Maintenance
Yes

3b Is this a FISMA-Reportable system?

4

Does the system include a Website or online
application available to and for the use of the general
public?

5

Identify the operator.

6

Point of Contact (POC):

7

Is this a new or existing system?

8

Does the system have Security Authorization (SA)?

8a Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Business Steward

POC Name

Indira Srinivasan

POC Organization CDC/OPHSS/CSELS
POC Email

[email protected]

POC Phone

404-498-6619
New
Existing
Yes
No

Sep 28, 2018

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11 Describe the purpose of the system.

Message Validation, Processing, and Provisioning System
(MVPS) is a multifaceted public health disease surveillance
system that gives public health officials powerful capabilities
to monitor the occurrence and spread of diseases. Facets of
MVPS will be used by numerous state, territorial, tribal, and
local health departments as well as by partner organizations.
The primary goal of MVPS is to develop a common
infrastructure for public health agencies that allows the
Federal, state, and local level public health agencies to store
and exchange data using a common set of business
procedures, metadata, and capabilities that can be defined
from the start.

The information stored in the system supports the MVPS
mission to monitor the occurrence and spread of diseases by
providing data from participating health agencies/providers to
be used for disease surveillance by the CDC. The data includes
information on patients and patient appointments (e.g.,
names, mailing address, email addresses, phone numbers,
medical notes, date of birth, sex/race, county, marital status
Describe the type of information the system will
and census tract), and the healthcare facilities where the
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask patient appointments occur.
about the specific data elements.)
External non-CDC users from participating health agencies
accessing the system are identified and authenticated via
CDC's Secured Access Management System (SAMS), a separate
authentication tool with its own Privacy Impact Assessment
(PIA). Internal CDC users accessing the system are identified
and authenticated via CDC's Active Directory (AD); AD is also a
separate system with its own PIA.
The primary goal of the Message Validation, Processing, and
Provisioning System (MVPS) is to develop a common
infrastructure for public health agencies that allows the
Federal, state, and local level public health agencies to store
and exchange data using a common set of business
procedures, metadata, and capabilities that can be defined
from the start and not be introduced ad-hoc.
The MVPS system is a message processing system. Messages
are received and are then validated.
Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

MVPS system data contains information on patients and
conditions presented during healthcare visits. This data
includes patient name (only for case records with specific
conditions); patient mailing address (including county and
census tract); patient email address and phone number;
medical notes; patient date of birth; and patient gender, race,
marital status, and citizenship/nationality. Non-identifiable
information collected includes date and time of patient
observation, facility information, and case reports on observed
conditions. The data is used to associate disease trends among
groups like people within a certain age bracket, gender,
geographic location, nationality, or race; such information is
often of interest to public health officials.

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Yes

14 Does the system collect, maintain, use or share PII?

15

No

Indicate the type of PII that the system will collect or
maintain.

Social Security Number

Date of Birth

Name

Photographic Identifiers

Driver's License Number

Biometric Identifiers

Mother's Maiden Name

Vehicle Identifiers

E-Mail Address

Mailing Address

Phone Numbers

Medical Records Number

Medical Notes

Financial Account Info

Certificates

Legal Documents

Education Records

Device Identifiers

Military Status

Employment Status

Foreign Activities

Passport Number

Taxpayer ID

Employees
Public Citizens
16

Business Partners/Contacts (Federal, state, local agencies)

Indicate the categories of individuals about whom PII
is collected, maintained or shared.

Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?
18 For what primary purpose is the PII used?

19

Describe the secondary uses for which the PII will be
used (e.g. testing, training or research)

100,000-999,999
The PII data is strictly used for research purposes only.
PII in the system is used for disease surveillance and reporting.
The system needs to be able to associate disease trends
among groups like people within a certain age bracket,
gender, geographic location, nationality, or race in order to
attempt to provide useful information to public health officials.

20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

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Public Health Service Act, Section 301, "Research and
Identify legal authorities governing information use Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
21
which discuss authority to maintain data and provide
and disclosure specific to the system and program.
assurances of confidentiality for health research and related
activities (42 U.S.C. 242 b, k, and m(d)).
22

Yes

Are records on the system retrieved by one or more
PII data elements?

No
Directly from an individual about whom the
information pertains
In-Person
Hard Copy: Mail/Fax
Email
Online
Other
Government Sources

23

Within the OPDIV
Other HHS OPDIV
State/Local/Tribal
Foreign
Other Federal Entities
Other

Identify the sources of PII in the system.

Non-Government Sources
Members of the Public
Commercial Data Broker
Public Media/Internet
Private Sector
Other
23a

Identify the OMB information collection approval
number and expiration date.

24 Is the PII shared with other organizations?

Describe the process in place to notify individuals
25 that their personal information will be collected. If
no prior notice is given, explain the reason.

26

Is the submission of PII by individuals voluntary or
mandatory?

Describe the method for individuals to opt-out of the
collection or use of their PII. If there is no option to
27
object to the information collection, provide a
reason.

0920-0728, Exp. 02/28/2021
Yes
No
No prior notice is given by CDC because MVPS does not collect
information directly from any individuals. The actual collection
of MVPS data is done by participating state public healthcare
agencies. As the original collectors of data, obtaining consent
from individuals and notifying individuals about data
collection and use are the responsibility of those participating
agencies.
Voluntary
Mandatory
The MVPS platform is a "downstream" recipient of data that
has already been collected by healthcare agencies at the point
of service in their healthcare facilities. Individuals requesting to
opt-out must do so according to the policies and procedures in
place at those facilities.

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Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.

The MVPS platform does not have a process to obtain consent
from or notify individuals about data collection and use. MVPS
is a "downstream" recipient of data that has already been
collected by healthcare agencies at the point of service in their
healthcare facilities; obtaining consent from and notification of
individuals about data use is the responsibility of the agencies
that collect it. As a public health authority, the healthcare
agencies can exchange the information with CDC to perform
health activities without obtaining the individual's consent.

Describe the process in place to resolve an
individual's concerns when they believe their PII has
29 been inappropriately obtained, used, or disclosed, or
that the PII is inaccurate. If no process exists, explain
why not.

The MVPS system does not have a process in place to work
with individuals regarding concerns about their PII stored in
the system because the records in the system are not subject
to the Privacy Act. Further, consent, notification, and such
interactions are conducted between individuals and the
healthcare agencies collecting the PII, and are out of scope of
the MVPS project and system.

Describe the process in place for periodic reviews of
PII contained in the system to ensure the data's
30
integrity, availability, accuracy and relevancy. If no
processes are in place, explain why not.

31

Identify who will have access to the PII in the system
and the reason why they require access.

There is an annual review process between the MVPS program
and the sending jurisdictions to reconcile and confirm the
integrity of case data sent from participating healthcare
agencies and data received by the MVPS system. This is
conducted with each participating agency at least once every
365 days, and can be done more frequently if a need to do so is
determined.

Users

Access for data analysis, reporting
activities.

Administrators

General access for management of
system resources and users.

Developers
Contractors
Others

Describe the procedures in place to determine which MVPS program management review, on a case-by-case basis,
32 system users (administrators, developers,
which system users may access PII. The decision is based on
contractors, etc.) may access PII.
the users' job requirements consistent with Role Based Access.

Describe the methods in place to allow those with
33 access to PII to only access the minimum amount of
information necessary to perform their job.

Users are given access according to their jurisdiction and/or
program only has access to that information after proofing and
approval. The data steward oversees the approval process and
determines who gets access to the information for which he or
she is responsible. The Least Privilege model is used for all
grants of access, and enforced with row-level security in the
database.

Identify training and awareness provided to
personnel (system owners, managers, operators,
contractors and/or program managers) using the
34
system to make them aware of their responsibilities
for protecting the information being collected and
maintained.

All CDC personnel are required to take annual Privacy and
Security Awareness Training (SAT).

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Describe training system users receive (above and
35 beyond general security and privacy awareness
training).

All personnel are required to acknowledge HHS Rules of
Behavior annually during the SAT.

Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?
Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

Yes
No
MVPS data is kept by the CDC as a historical public health
record, per CDC's "Scientific and Research Project Records
Control Schedule", section 1a ("Authorized Disposition:
PERMANENT"). Records Schedule N1-442-09-1.

PII will be secured using a layered approach of Administrative,
Technical, and Physical Controls, as follows:
Administrative:
Users are assigned roles and privileges depending on their job
requirements. MVPS program management approves all CDC
user access on a case-by-case basis according to the leastprivilege principle. MVPS program management also vets and
approves access for non-CDC users (“Jurisdictional” Users and
Data Managers) also according the principle of least privilege.
Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

Technical:
MVPS data is protected by restricting access to two points: via
CDC’s SAMS Authentication platform for external non-CDC
users, and via CDC's Active Directory infrastructure for internal
CDC users. Once authenticated, users’ access to system PII is
limited by Role-Based Access Control (RBAC) features built into
the MVPS platform. System data is also protected by firewalls,
intrusion detection systems, anti-malware systems, and
encryption methods provided by CDC’s Applied Hosting
Branch.
Physical Controls:
Production and test servers are stored in a server room secured
by the CDC. Access tools are in place to secure entry into CDC
buildings (Guards, ID Badges, Key Card, Cipher Locks, Closed
Circuit TV).

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2018.09.25 16:52:10
-04'00'

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