Privacy Impact Assessment 18NOV2020

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-37361

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-4490559-562460

2a Name:

1/22/2020 10:17:16 AM

National Healthcare Safety Network (NHSN)
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)?

8b Planned Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Branch Chief

POC Name

Daniel Pollock

POC Organization NCEZID/DHQP
POC Email

[email protected]

POC Phone

404-639-4237
New
Existing
Yes
No
April 2, 2020
Not Applicable

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11 Describe the purpose of the system.

NHSN allows participating healthcare facilities to enter data
associated with healthcare safety events, such as surgical site
infections, antimicrobial use and resistance, bloodstream
infections, and healthcare worker vaccinations. NHSN provides
analysis tools that generate reports using the aggregated data
(reports about infection rates, national and local comparisons,
etc). Participating NHSN healthcare facilities can access webbased screens that allow them to enter data associated with
healthcare safety events. These data are captured in a
relational database at the CDC. Participants can then use
NHSN analysis tools to generate reports that are displayed on
their web browser.

NHSN is a voluntary surveillance system. The system requires
reporting of the following information:
Patients: patient identification number (may be a medical
record number), gender and date of birth. For some patients,
birth weight is required.
Healthcare workers: healthcare worker identification number,
gender, date of birth, work location, and occupation.
Facilities: facility name, address, county, city, state , zip code,
telephone number, identifying number (i.e., CMS provider
number and/or American Hospital Association identification
number and/or Veterans Administration station code), type,
Describe the type of information the system will
ownership category, affiliation with a medical school (y/n), and
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask bed-size characteristics.
Users: name, address (if different from facility), telephone
about the specific data elements.)
number, and email address.
Optional information that may be reported to NHSN:
Patients: Social security number, secondary identification
number, name, ethnicity, and race.
Healthcare workers: name, address, work and home phone
numbers, email address, born in United States (y/n), ethnicity,
race, and date of employment.
Users: fax number, pager number, and title.
NHSN users are authenticated through CDC Secure Access
Management System (SAMS), which is covered by a separate
PIA.

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Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

NHSN is the nation’s most comprehensive medical event
tracking system used by more than 22,000 U.S. healthcare
facilities in all 50 states, Washington, D.C., and Puerto Rico.
Data from NHSN is used for tracking of healthcare-associated
infections and guides infection prevention activities that
protect patients. CMS and other payers use these data to
determine incentives for performance and members of the
public may use the data to select among available providers.
Each of these parties relies on the completeness and accuracy
of the data.
NHSN allows participating healthcare facilities to enter data
associated with healthcare safety events, such as surgical site
infections, antimicrobial use and resistance, bloodstream
infections, and healthcare worker vaccinations. NHSN provides
analysis tools that generate reports using the aggregated data
(reports about infection rates, national and local comparisons,
etc). NHSN also provides links to best practices, guidelines,
and lessons learned. Participating NHSN healthcare facilities
can access web-based screens that allow them to enter data
associated with healthcare safety events.
Any U.S. healthcare institution including hospitals, outpatient
centers, and long-term care facilities may enroll in NHSN
provided they have access to the Internet. Along with NHSN
there is an NHSN Registration server that provides healthcare
administrators with a way to register their facility in NHSN
without having a digital certificate. After registering their
facility they will be given instructions on how to get a digital
certificate and begin using the main NHSN application. This
registration application also provides a way for users to accept
the NHSN Rules of Behavior before accessing the main NHSN
application.
NHSN is a voluntary surveillance system. The system requires
reporting of the following information:
Patients: patient identification number (may be a medical
record number), gender and date of birth. For some patients,
birth weight is required.
Healthcare workers: healthcare worker identification number,
gender, date of birth, work location, and occupation.
Facilities: facility name, address, county, city, state , zip code,
telephone number, identifying number (i.e., CMS provider
number and/or American Hospital Association identification
number and/or Veterans Administration station code), type,
ownership category, affiliation with a medical school (y/n), and
bed-size characteristics.
Users: name, address (if different from facility), telephone
number, and email address.
Optional information that may be reported to NHSN:
Patients: Social security number, secondary identification
number, name, ethnicity, and race.
Healthcare workers: name, address, work and home phone
numbers, email address, born in United States (y/n), ethnicity,
race, and date of employment.
Users: fax number, pager number, and title.
NHSN users are authenticated through CDC Secure Access
Management System (SAMS), which is covered by a separate
PIA.

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Yes

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

15

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

No
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
Birth weight
Ethnicity
Race
Titles
Gender
Work Identification Number
Certificates
Employees
Public Citizens
16

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

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

20 Describe the function of the SSN.

1,000,000 or more
Data from NHSN is used for tracking of healthcare-associated
infections.
Data from NHSN is also used as a guide for infection
prevention activities that protect patients.
SSNs are vital to the overall operation of NHSN because
hospitals whose data is entered into NHSN may use NHSN to
track a patient by SSN. Also state public health officials who
have been granted access to the data in their state by their
constituent hospitals may require access to patient SSNs. The
state of Pennsylvania for example requires by law the
reporting of Healthcare Associated Infections using NHSN and
as part of the state mandate requires the records to be
identified by SSNs. This allows Pennsylvania to download data
from NHSN about patients in their state and link that data to
payment information.

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20a Cite the legal authority to use the SSN.

E.O. 9397, November 22, 1943 (as Amended by E.O. 13478, 18
November 2008)

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
Published:

Identify the number and title of the Privacy Act
System of Records Notice (SORN) that is being used
22a
to cover the system or identify if a SORN is being
developed.

09-20-0136: Epidemiologic Studies and
Surveillance of Disease Problems. HHS/CDC.

Published:

Published:
In Progress
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?

OMB No. 0920-0666, expiration Date: 01/31/2021
Yes
No

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Within HHS

24a

Identify with whom the PII is shared or disclosed and
for what purpose.

Other Federal
Agency/Agencies
State or Local
Agency/Agencies
Select Healthcare facilities in the U.S. These facilities may
track a patient using SSN. Specifically PA requires by law the
reporting of healthcare associated infections using NHSN
and as part of the state mandate requires the records to be
identified by SSNs.
Private Sector

Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
Understanding (MOU), or Information Sharing
Agreement (ISA)).

24c

Describe the procedures for accounting for
disclosures

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.
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.
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.
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.

Information and the NHSN Data Use Agreement document can
be found at http://www.cdc.gov/hai/surveillance/DUAannouncment.html. So far we have agreements with AZ, KY,
LA, MN, and NY. Each state has requested access to different
data—you can read each state’s specifics by clicking on the
state at http://www.cdc.gov/HAI/state-based/index.html. Each
facility can only see it's own data.
The NHSN User Support Helpdesk currently tracks for
accounting for disclosures via management of an organized
email folder system.
NHSN is a public health surveillance system and does not
require obtaining consent from individuals whose data are
submitted and stored in the system.
Voluntary
Mandatory
There is no option to object to the information collection
because NHSN is a public health surveillance system that
requires healthcare facilities to submit patient data for
Antimicrobial Resistance surveillance.

Facilities that participate in NHSN are responsible for letting
individuals know if their PII is being used and as such any
concerns regarding this should be directed to the facility.

Facilities that participate in NHSN are responsible for letting
individuals know if their PII is being used and as such any
concerns regarding this should be directed to the facility.
No umbrella process is in place to ensure the accuracy of the
PII contained in the system. Facilities participating in NHSN are
responsible for the submission and verification of PII in NHSN.

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31

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

Users

Epidemiologic Analysis

Administrators

Database Management

Developers
Contractors

Direct Contractors need access to
perform Epidemiologic Analysis.

Others

Epidemiologic Analysis by approved
CDC staff and guest researchers

All users must be approved by the Business Steward based on
Describe the procedures in place to determine which their role, duties and responsibilities prior to gaining access to
32 system users (administrators, developers,
the data. Role Based Access Control (RBAC) is utilized. The roles
contractors, etc.) may access PII.
are predefined and users are assigned those roles as
appropriate.
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.

The least privilege model is utilized to allow those with
access to PII to only access the minimum amount of
information necessary to perform their job.

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 complete annual Security
and Privacy Awareness training.

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

Users are required to acknowledge a Rules of Behavior
attesting to their understanding of the privacy requirements.

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
CDC Records Control Policy applies. Records are retained and
disposed of in accordance with the CDC Records Control
Schedule for NHSN records. Records are retained for various
periods of time depending upon how useful they are
considered to be, in accordance with NHSN policy. Some
records of users may be maintained indefinitely. Disposal
methods include burning or shredding hard copy and erasing
computer tapes and disks, N1-442-09-1, item 1 ()
NHSN adheres to GRS 20.2a.4, 20.2d, 20.6 and RCS B-321, 2.

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Administrative controls include Federal, HHS, and CDC specific
Privacy, Risk Assessment, and Incident Management Policies,
annual system privacy impact assessments; and mandatory
annual security & privacy awareness training.

Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

Technical controls include application level role based access
controls; encryption of PII at rest and in transit; standard
baseline configurations for IT assets; server audit and
accountability measures; and continuous monitoring of system
resources to identify vulnerabilities and ensure adherence to
organizationally defined minimum security requirements. In
addition, the system is protected by residing within SAMS and
requires each user to have CDC-approved identity proofing in
order to access the system.
Physical controls surrounding the system's data centers
include gated campuses with 24-hour security guards to
enforce access restriction; key card access to campus buildings;
and access control lists further limiting physical access to
sensitive areas such as the data centers.

General Comments

OPDIV Senior Official
for Privacy Signature

signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2020.02.26 11:06:21
-S
-05'00'

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