Ccqas Pia

PRIVACY IMPACT ASSESSMENT (PIA)
PRESCRIBING AUTHORITY: DoD Instruction 5400.16, "DoD Privacy Impact Assessment (PIA) Guidance". Complete this form for Department of Defense
(DoD) information systems or electronic collections of information (referred to as an "electronic collection" for the purpose of this form) that collect, maintain, use,
and/or disseminate personally identifiable information (PII) about members of the public, Federal employees, contractors, or foreign nationals employed at U.S.
military facilities internationally. In the case where no PII is collected, the PIA will serve as a conclusive determination that privacy requirements do not apply to
system.
1. DOD INFORMATION SYSTEM/ELECTRONIC COLLECTION NAME:

Centralized Credentials and Quality Assurance System (CCQAS)
3. PIA APPROVAL DATE:

2. DOD COMPONENT NAME:

Defense Health Agency

SECTION 1: PII DESCRIPTION SUMMARY (FOR PUBLIC RELEASE)
a. The PII is: (Check one. Note: foreign nationals are included in general public.)
From members of the general public

From Federal employees and/or Federal contractors

From both members of the general public and Federal employees and/or
Federal contractors

Not Collected (if checked proceed to Section 4)

b. The PII is in a: (Check one)
New DoD Information System

New Electronic Collection

Existing DoD Information System

Existing Electronic Collection

Significantly Modified DoD Information System
c. Describe the purpose of this DoD information system or electronic collection and describe the types of personal information about individuals
collected in the system.

Centralized Credentials and Quality Assurance System (CCQAS) is a web-based system that contains credentialing, privileging, risk
management, and adverse actions data on Active Duty, National Guard, Coast Guard, Reserve, Public Health Service, Volunteer, Civilian,
and Contractor healthcare providers that work in Medical Treatment Facilities (MTFs) throughout the world.
The system tracks provider training and education through information input and record retention. It also allows healthcare providers to
apply for privileges electronically, allows for the electronic review, routing, and approval of provider privileges, and streamlines the
credentialing and privileging process. It is accessible 24/7 via the Web to users with role based access permissions.
The types of PII collected by CCQAS include personal descriptors, identification numbers (including Social Security Numbers (SSNs)),
education information, health information, employment information, photographs, and information regarding children.
Current product features include the ability to:
-Capture, store, maintain and report on medical malpractice claims, incidents, disability claims and adverse actions. These records include
both the provider's documentation of an incident or event in addition to patient data specific to the incident or event.
-Maintain the credential records of direct-care providers, i.e. medical school records, diplomas, certificates, additional training, and
experience documentation.
-Share providers above mentioned PII between DoD facilities.
-Automate the provider's application for privileges to provide medical healthcare.
-Potentially Compensable Event (PCE) capture and visibility.
-Adverse Action tracking capture and visibility.
CCQAS is owned and operated by DHA and managed and resourced by the Solutions Delivery Division (SDD).
d. Why is the PII collected and/or what is the intended use of the PII? (e.g., verification, identification, authentication, data matching, mission-related use,
administrative use)

The intended use of PII is for verification purposes. Information is used to verify the provider's qualifications to perform the requested
medical/dental procedures and to approve the procedures. This requirement is per The Joint Commission and state licensing agencies, which
require health care organizations to maintain medical provider qualifications.
e. Do individuals have the opportunity to object to the collection of their PII?

Yes

No

(1) If "Yes," describe the method by which individuals can object to the collection of PII.
(2) If "No," state the reason why individuals cannot object to the collection of PII.

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Medical healthcare providers are the primary, individual users of the system. A provider’s submission of personal data is voluntary.
However, failure to provide information may result in an provider's ineligibility to serve at an MTF or within the Military Health System
(MHS). It is necessary to ensure that our healthcare providers have the credentials and training for the privileges they perform and that all
information is documented in claims and adverse actions as necessary. Providers may object to PII collection through face-to-face, E-mail,
paper, or telephone modes of collection.
Patients do not access the system. However, personal patient data may be found in risk management or adverse action data files. A patient’s
personal data recorded in the system is not voluntary. Information stored within risk management or adverse action files reflect the details of
a malpractice claim, incident, disability claim, or adverse event related to the healthcare provider of record, and thus, patient information is
disclosed as part of the known event. There is no process for a patient to object to PII collection as the record is part of a historical, formally
documented known event.
f. Do individuals have the opportunity to consent to the specific uses of their PII?

Yes

No

(1) If "Yes," describe the method by which individuals can give or withhold their consent.
(2) If "No," state the reason why individuals cannot give or withhold their consent.

Medical healthcare providers are the primary individual users of the system. Upon the completion of system registration, providers must read
and verify the CCQAS Privacy Act Statement by selecting the "Yes" radio button. The system does not allow prospective registrants to
continue unless they select this radio button. Providers consent to the specific uses of PII in accordance with DoD 5400.11-R, DoD Privacy
Program, C4.1.3.
g. When an individual is asked to provide PII, a Privacy Act Statement (PAS) and/or a Privacy Advisory must be provided. (Check as appropriate and
provide the actual wording.)
Privacy Act Statement

Privacy Advisory

Not Applicable

Privacy Act Statements are included on every form completed by an individual provider. Privacy Act, HIPAA, and 10 U.S.C. 1102
statements all appear on the login screen and must be acknowledged before a user can access CCQAS.
AUTHORITY: 10 U.S.C. 1102, Confidentiality of Medical Quality Assurance Records: Qualified Immunity for Participants; 42 U.S.C.
11112, Encouraging Good Faith Professional Review Activities; DoD Instruction 6025.13, Medical Quality Assurance (MQA) and Clinical
Quality Management in the Military Health System (MHS); DHA-PM 6025.13, Clinical Quality Management in the Military Health System;
and E.O. 9397 (SSN), as amended.
PURPOSE: To obtain information necessary to credential a health care provider and determine whether that individual should have
privileges to work or continue working in a military treatment facility (MTF) or within the Military Health System (MHS). Data in the
system may contain medical records information including patient care assessments and treatment procedures which may be used to assess
malpractice claims and adverse privilege actions filed against a health care provider at an MTF within the MHS.
ROUTINE USES: Your records may be disclosed outside of DoD in accordance with the DoD Blanket Routine Uses published at http://
dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a
(b)).
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45
CFR Parts 160 and 164), as implemented within the DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment,
payment, and healthcare operations.
Collected information may be shared with government boards, agencies, professional societies, civilian medical institutions, or organizations
if needed to apply for privileges, licenses, or to monitor professional standards of health care practitioners. Information may also be used to
conduct trend analysis for medical quality assurance programs.
DISCLOSURE: Voluntary. However, failure to provide information may result in an individual’s ineligibility to serve at an MTF or within
the MHS.
h. With whom will the PII be shared through data exchange, both within your DoD Component and outside your Component? (Check all that apply)

Within the DoD Component

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Defense Healthy Agency - Healthcare providers at MTFs
and/or administrators may need to review or approve a
provider's privilege application at each location a provider
Specify.
will provide medical health services. PII is shared to verify
the provider during the credentialing and privileging
processes.

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Army Reserve, Navy Reserve, Marine Corps Reserve, Air
Force Reserve, Army National Guard, Air Force National
Guard, and Public Health Service - Healthcare providers at
MTFs and/or administrators may need to review or approve
Specify.
a provider's privilege application at each location a provider
will provide medical health services. PII is shared to verify
the provider during the credentialing and privileging
processes.
Coast Guard, Coast Guard Reserve - Healthcare providers at
MTFs and/or administrators may need to review or approve
a provider's privilege application at each location a provider
Specify.
will provide medical health services. PII is shared to verify
the provider during the credentialing and privileging
processes.

Other DoD Components

Other Federal Agencies

State and Local Agencies

Specify.

Contractor (Name of contractor and describe the language in
the contract that safeguards PII. Include whether FAR privacy
clauses, i.e., 52.224-1, Privacy Act Notification, 52.224-2,
Privacy Act, and FAR 39.105 are included in the contract.)

Code Maintenance Contract - Tier III System Maintenance
Personnel with Public Trust or higher security clearance.
"The Contractor shall establish appropriate administrative,
technical, and physical safeguards to protect any and all
Government data. The Contractor shall also ensure the
confidentiality, integrity, and availability of Government
data in compliance with all applicable laws and regulations,
including data breach reporting and response requirements,
in accordance with DFAR Subpart 224.1 (Protection of
Individual Privacy), which incorporates by reference DoDD
5400.11, “DoD Privacy Program,” May 8, 2007, and DoD
5400.11-R, “DoD Privacy Program,” May 14, 2007. The
contractor shall also comply with federal laws relating to
Specify. freedom of information and records management."
DSA #12-884F – for PSI Code Maintenance Contract
#HT0015-20-F-0078.
DSA #18-1971 – for Institute for Defense Analyses (IDA).
DSA #15-1383 – for TRICARE Pharmacy Program, Fourth
Generation (TPharm4) Contract #HT9402-14-D-0002.
Renewal request, DSA #15-1383B, is currently being
processed by the Data Sharing team supporting the DHA
Privacy and Civil Liberties Office as of Dec 2018.
Note: DoDD 5400.11 was reissued as and canceled by DoD
Instruction 5400.11, "DoD Privacy and Civil Liberties
Programs," January 29, 2019.

Other (e.g., commercial providers, colleges).

Specify.

i. Source of the PII collected is: (Check all that apply and list all information systems if applicable)
Individuals

Databases

Existing DoD Information Systems

Commercial Systems

Other Federal Information Systems

Existing DoD Information System: CCQAS receives the National Provider Identifier (NPI) number from the Defense Medical Human
Resources System-internet (DMHRSi).
Other Federal Information Systems: CCQAS users query the National Practitioner Data Bank (NPDB) web-based repository from the U.S.
Department of Health and Human Services (HHS) and manually enter data into CCQAS. CCQAS also receives the List of Excluded
Individuals/Entities from HSS-Office of the Inspector General; this data is entered manually by system administrators.
j. How will the information be collected? (Check all that apply and list all Official Form Numbers if applicable)
E-mail

Official Form (Enter Form Number(s) in the box below)

Face-to-Face Contact

Paper

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Fax

Telephone Interview

Information Sharing - System to System

Website/E-Form

Other (If Other, enter the information in the box below)

E-mail, Face-to-Face Contact, Telephone Interview: DoD Service credentialers may collect PII from providers and enter the information
into the system as modular users.
Paper: Each DoD Service may maintain an inventory of paper documentation that can be used to collect information about the provider's
qualifications.
Information Sharing: DMHRSi interface provides NPI.
Website/E-Form: Information is collected electronically from the individual via a secure Internet or network interconnection. (https://
ccqas.csd.disa.mil/)
k. Does this DoD Information system or electronic collection require a Privacy Act System of Records Notice (SORN)?
A Privacy Act SORN is required if the information system or electronic collection contains information about U.S. citizens or lawful permanent U.S. residents that
is retrieved by name or other unique identifier. PIA and Privacy Act SORN information must be consistent.
Yes

No

If "Yes," enter SORN System Identifier

EDHA 09

SORN Identifier, not the Federal Register (FR) Citation. Consult the DoD Component Privacy Office for additional information or http://dpcld.defense.gov/
Privacy/SORNs/
or
If a SORN has not yet been published in the Federal Register, enter date of submission for approval to Defense Privacy, Civil Liberties, and Transparency
Division (DPCLTD). Consult the DoD Component Privacy Office for this date
If "No," explain why the SORN is not required in accordance with DoD Regulation 5400.11-R: Department of Defense Privacy Program.

l. What is the National Archives and Records Administration (NARA) approved, pending or general records schedule (GRS) disposition authority
for the system or for the records maintained in the system?
(1) NARA Job Number or General Records Schedule Authority.

N1-330-11-3

(2) If pending, provide the date the SF-115 was submitted to NARA.

(3) Retention Instructions.

TEMPORARY cut off annually Delete/Destroy when 10 years old.
m. What is the authority to collect information? A Federal law or Executive Order must authorize the collection and maintenance of a system of
records. For PII not collected or maintained in a system of records, the collection or maintenance of the PII must be necessary to discharge the
requirements of a statue or Executive Order.
(1) If this system has a Privacy Act SORN, the authorities in this PIA and the existing Privacy Act SORN should be similar.
(2) If a SORN does not apply, cite the authority for this DoD information system or electronic collection to collect, use, maintain and/or disseminate PII.
(If multiple authorities are cited, provide all that apply).
(a) Cite the specific provisions of the statute and/or EO that authorizes the operation of the system and the collection of PII.
(b) If direct statutory authority or an Executive Order does not exist, indirect statutory authority may be cited if the authority requires the
operation or administration of a program, the execution of which will require the collection and maintenance of a system of records.
(c) If direct or indirect authority does not exist, DoD Components can use their general statutory grants of authority (“internal housekeeping”) as
the primary authority. The requirement, directive, or instruction implementing the statute within the DoD Component must be identified.

10 U.S.C. 1102, Confidentiality of Medical Quality Assurance Records: Qualified Immunity for Participants; 42 U.S.C. 11112, Encouraging
Good Faith Professional Review Activities; DoDI 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the
Military Health System (MHS); DHA-PM 6025.13, Clinical Quality Management in the Military Health System; and E.O. 9397 (SSN), as
amended.
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n. Does this DoD information system or electronic collection have an active and approved Office of Management and Budget (OMB) Control
Number?
Contact the Component Information Management Control Officer or DoD Clearance Officer for this information. This number indicates OMB approval to
collect data from 10 or more members of the public in a 12-month period regardless of form or format.
Yes

No

Pending

(1) If "Yes," list all applicable OMB Control Numbers, collection titles, and expiration dates.
(2) If "No," explain why OMB approval is not required in accordance with DoD Manual 8910.01, Volume 2, " DoD Information Collections Manual:
Procedures for DoD Public Information Collections.”
(3) If "Pending," provide the date for the 60 and/or 30 day notice and the Federal Register citation.

CCQAS does not currently have an OMB control number. However, the CCQAS team is currently working with Information Management
Control Office (IMCO) to create new OMB package. Anticipated approval is FY21 Q2.

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SECTION 2: PII RISK REVIEW
a. What PII will be collected (a data element alone or in combination that can uniquely identify an individual)? (Check all that apply)
Biometrics

Birth Date

Child Information

Citizenship

Disability Information

DoD ID Number

Driver's License

Education Information

Emergency Contact

Employment Information

Financial Information

Gender/Gender Identification

Home/Cell Phone

Law Enforcement Information

Legal Status

Mailing/Home Address

Marital Status

Medical Information

Military Records

Mother's Middle/Maiden Name

Name(s)

Official Duty Address

Official Duty Telephone Phone

Other ID Number

Passport Information

Personal E-mail Address

Photo

Place of Birth

Position/Title

Race/Ethnicity

Rank/Grade

Protected Health Information (PHI)1
Religious Preference

Records

Security Information

Work E-mail Address

If Other, enter the information in the box below

Social Security Number (SSN) (Full or in any
form)

Other PII collected includes: National Provider Identifier (NPI) number; and Electronic Data Interchange Personal Identifier (EDIPN)
number pulled from the provider's Common Access Card (CAC).
If the SSN is collected, complete the following questions.
(DoD Instruction 1000.30 states that all DoD personnel shall reduce or eliminate the use of SSNs wherever possible. SSNs shall not be used in spreadsheets,
hard copy lists, electronic reports, or collected in surveys unless they meet one or more of the acceptable use criteria.)
(1) Is there a current (dated within two (2) years) DPCLTD approved SSN Justification on Memo in place?
Yes

No

If "Yes," provide the signatory and date approval. If “No,” explain why there is no SSN Justification Memo.

Approved 8/31/2017. CCQAS is not required under DoD's current SSN Reduction plan to complete a SSN Justification Memo as directed by
the signed 21 November 2012 Memorandum for Tricare Management Activity Privacy Office.

(2) Describe the approved acceptable use in accordance with DoD Instruction 1000.30 “Reduction of Social Security Number (SSN) Use within DoD”.

2. c (2) Law Enforcement, National Security, Credentialing and 2.c (5) Confirmation of Employment Eligibility. Federal statute requires that
all persons employed within the United States must provide a SSN or comparable identifier to prove that he or she is eligible to work for
or with the government of the United States.
2. c. (8) Computer Matching. CCQAS receives one data element, the National Provider Identifier, from the Defense Medical Human
Resources System- internet (DMHRSi). Health care provider information in DMHRSi currently uses SSNs as the personal identifier. Until
DMHRSi, from which CCQAS obtains data using SSNs, has been modified/upgraded to replace SSNs with DoD Electronic Data Interchange
Personal Identifiers, CCQAS will need to continue using SSNs for verification that an individual’s CCQAS records are accurately updated
with information obtained from DMHRSi as specified by the DMHRSi Justification for the Use of the Social Security Number Memorandum
for Record in the Defense Medical Human Resources System, Internet (DMHRSi); DITPR ID 130, signed by DMHRSi Project Officer,
SDD/Clinical Support Program Management Office, Defense Health Agency (DHA).
(3) Describe the mitigation efforts to reduce the use including visibility and printing of SSN in accordance with DoD Instructoin 1000.30, “Reduction of
Social Security Number (SSN) Use within DoD”.

Although the need to continue the use of SSNs with CCQAS is significant, the following steps have been taken to reduce vulnerability of
SSN within CCQAS:
1) After the deployment of CCQAS version 2.10, CCQAS and v2.14 now called CCQAS generated forms include only the last four digits of
SSN’s.
2) CCQAS uses role-based access to control visibility of SSN to a limited subset of “trusted users” such as Credentialing Officers.
3) No data is allowed to leave CCQAS via an interface or messaging system because it is protected medical quality assurance information
under 10 U.S.C 1102, Confidentiality of Medical Quality Assurance Records; Qualified Immunity for Participants.
4) CCQAS is not a “public” system accreditation and security profile, and ensures Information Assurance Vulnerability Alerts (IAVAs) are
applied in a timely manner.
5) CCQAS is centrally hosted at Defense Information Systems Agency (DISA) facilities to ensure physical access to the system is limited.

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(4) Has a plan to eliminate the use of the SSN or mitigate its use and or visibility been identified in the approved SSN Justification request?
If "Yes," provide the unique identifier and when can it be eliminated?
If "No," explain.
Yes

No

In order for a health care provider to practice at an MTF, he or she must undergo the credentialing process that entails an extensive
verification of the provider’s qualifications to perform the requested medical procedures. The SSN is the essential personal identifier to
assure that the information for an individual that is obtained from non-DoD agencies and organizations is tied to the correct MHS provider
within CCQAS. For example, the SSN must be used when confirming and verifying education with a particular institute (there are over one
hundred accredited U.S. medical schools), and/or background checks with the police departments (there are over 10,000 local police
departments in the U.S.). As required by DHA-PM 6025.13, Clinical Quality Management in the Military Health System, evidence of
qualifying educational degrees must be verified through primary sources. Organizations like the National Student Clearinghouse require
SSNs for identification. With regard to background checks with police departments, these are required in accordance with DoD Instruction
1402.5, “Criminal History Background Checks on Individuals in Child Care Services.” Therefore, continued use of the SSN within CCQAS
is critical to support the credentialing process until such a time when all non-DoD agencies and organizations that need to be contacted for
credentials verification purposes cease to use SSNs for identification purposes.
b. What is the PII confidentiality impact level2?

Low

Moderate

High

1The definition of PHI involves evaluating conditions listed in the HIPAA. Consult with General Counsel to make this determination.
2

Guidance on determining the PII confidentiality impact level, see Section 2.5 “Categorization of PII Using NIST SP 800-122.” Use the identified PII confidentiality impact level to apply the appropriate Privacy Overlay
low, moderate, or high. This activity may be conducted as part of the categorization exercise that occurs under the Risk Management Framework (RMF). Note that categorization under the RMF is typically
conducted using the information types described in NIST Special Publication (SP) 800-60, which are not as granular as the PII data elements listed in the PIA table. Determining the PII confidentiality impact level is
most effective when done in collaboration with the Information Owner, Information System Owner, Information System Security Manager, and representatives from the security and privacy organizations, such as the
Information System Security Officer (ISSO) and Senior Component Official for Privacy (SCOP) or designees.

c. How will the PII be secured?
(1) Physical Controls. (Check all that apply)
Cipher Locks

Closed Circuit TV (CCTV)

Combination Locks

Identification Badges

Key Cards

Safes

Security Guards

If Other, enter the information in the box below

CCQAS physically resides on servers located in DISA facilities in San Antonio, Texas with off-site back-up facilities in Oklahoma City,
Oklahoma. Physical controls are consistent across all facilities in which the system data is used and maintained.

(2) Administrative Controls. (Check all that apply)
Backups Secured Off-site
Encryption of Backups
Methods to Ensure Only Authorized Personnel Access to PII
Periodic Security Audits
Regular Monitoring of Users' Security Practices
If Other, enter the information in the box below

Because CCQAS is maintained in a secure DISA environment, all controls and fail-safe measures are governed by DISA policies and
procedures. DISA performs daily incremental and weekly full backups. The following backup retentions apply: daily incremental backups
kept for two weeks, weekly full backups kept for five weeks. Daily incremental backups are intended for local recovery use and will not be
stored off-site. Weekly full backups are intended for remote disaster recovery use and will be maintained off-site for the duration of the
retention period. Failed backup processing will be reported on a daily basis to the applicable System Administrator for resolution and
restarted as required.
CCQAS maintains audit logs of the use of each authorized user for every module used or opened. The audit log maintains the record of
access and the dates that the user was in the module, by functional area so that if there were a breach of data, it would be visible to system
administrators. Incremental file backup and archived file storage is provided by the DISA facility site in Oklahoma City, OK.
The system maintains a user's manual that will be updated along with each new release. As part of the guidelines for employment within the
Defense Health Agency, users must comply with HIPAA regulations and as such, take annual training.
(3) Technical Controls. (Check all that apply)
Biometrics

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Common Access Card (CAC)
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DoD Public Key Infrastructure Certificates
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Encryption of Data at Rest

Encryption of Data in Transit

External Certificate Authority Certificates

Firewall

Intrusion Detection System (IDS)

Least Privilege Access

Role-Based Access Controls

Used Only for Privileged (Elevated Roles)

User Identification and Password

Virtual Private Network (VPN)

If Other, enter the information in the box below

All users must have either a Common Access Card (CAC) or Personal Identification Verification (PIV) card to access CCQAS. These
access cards are often combined with a Military Identification (ID), Department of Defense ID, or other Federal or state agency ID that is
required for access to the facility and/or position.
Data in transit that is transmitted/received between the application servers and the end user is encrypted with SSL/TLS over HTTPS. Data in
transit between DMHRSi and CCQAS is inside the DISA facility and is not encrypted.
Although CCQAS hosts a web site at https://ccqas.csd.disa.mil, it is not publicly accessible and is protected within the DISA DMZ and by
access control restrictions.
d. What additional measures/safeguards have been put in place to address privacy risks for this information system or electronic collection?

CCQAS is susceptible to the same privacy risks, inherent in any system collecting, using, and sharing PII/PHI. If this system is not properly
protected, then the PII/PHI contained therein could be accessed by unauthorized individuals through various methods, such as data
interception, unauthorized access, internal threats, and external threats.
System planning for CCQAS has included threat analysis and vulnerability assessments to support operational telecommunications
requirements, and to establish resource allocation priorities and satisfy requirements for countermeasures. Authentication methods are used
to defend against imitative communications deception and to authenticate stations, transmissions and communicators.
All PII data has been evaluated with regard to the implications of it being lost, stolen, or disclosed. All data in CCQAS is protected from
disclosure by 10 U.S.C. 1102 and is physically protected by strong security safeguards in place at DISA.
The data is considered Moderate Impact and is not released to the public. Moderate Impact PII information can be retrieved from CCQAS
via standard and ad hoc reports and saved on mobile computing devices and removable electronic media, but users are cautioned against
doing so during CCQAS training, in user manuals, and via other communications. If such data needs to be retrieved for reporting purposes,
users know to keep the data protected by using encryption, passwords, and other safeguard practices.
All software development activities for the CCQAS system occur in a closed, secure environment. All personnel who develop, operate, and
maintain the system require a Public Trust or Secret Clearance, depending on the activity being performed. Access to the system’s software
and hardware is controlled based on an individual’s need to know and job responsibilities.
The data in CCQAS is tightly controlled and strict oversight is in place to assure its integrity, accuracy, currency, and relevance. The Office
of the Surgeon General-level personnel oversee what their respective MTF personnel are entering into the system and work with them on a
daily basis to ensure that the data is accurate and of high quality. One of the major methods of ensuring the quality of the data is that certain
types of information in a provider's credentials record must be primary source verified, meaning that a medical diploma or license will be
verified with the issuing university or licensing board. This fact-checking must be done before a provider can report for duty at another
facility.
Further, CCQAS follows 10 U.S.C. 1102 which requires Confidentiality of records and prohibits records disclosure and testimony.

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