Privacy Impact Assessment (PIA) 2023

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-90191

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-6798149-611197

2a Name:

1/3/2023 8:42:36 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)?

8a Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Deputy Branch Chief

POC Name

Andrea Benin

POC Organization NCEZID/DHQP
POC Email

aqb4@cdc.gov

POC Phone

404-498-1186
New
Existing
Yes
No

Mar 10, 2023

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11 Describe the purpose of the system.

Describe the type of information the system will
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask
about the specific data elements.)
Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.
14 Does the system collect, maintain, use or share PII?

The major purpose of the National Health Safety Network
(NHSN) is to equip participating healthcare facilities to enter
data associated with healthcare safety events, such as surgical
site infections, anti-microbial 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 addresses data collection from healthcare facilities to
permit valid estimation of adverse events among patients or
residents and healthcare personnel. Similarly, it provides
facilities with risk-adjusted metrics that can be used for interfacility comparisons and local quality improvement activities.
NHSN also allows for the opportunity of collaborative research
studies with participating facilities that describe the
epidemiology of emerging health care-associated infections
(HAIs) and pathogens, assess the importance of potential risk
factors, further characterize HAI pathogens and their
mechanisms of resistance, and evaluate alternative
surveillance and prevention strategies. The NHSN Agreement
ensures compliance with legal requirements – including state
or federal laws, regulations, or other requirements – for
mandatory reporting of facility-specific adverse event,
prevention practice adherence, and other public health data.
NHSN enables healthcare facilities to report data to the Centers
for Medicare & Medicaid Services (CMS) of the U.S. Department
of Health and Human Services (DHHS) in fulfillment of CMS’s
quality measurement reporting requirements for those data.
Considering the Coronavirus Disease (COVID-19) Pandemic,
CDC created the capability for COVID-19 surveillance in NHSN,
enabling data collection reported by Long-Term Care Facilities
(LTCFs) and Outpatient Dialysis Facilities. This data is reported
through different pathways within the NHSN COVID-19
Modules for LTCFs and Outpatient Dialysis Facilities.
The type of information the NHSN system collects is described
below:
Patients: Patient identification number (may be a medical
record number), gender and date of birth. For some patients,
The National Healthcare Safety Network (NHSN) system exists
to provide state and local health departments with information
that identifies the facilities in their state that participate in
Yes
No

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15

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
Birth weight
Ethnicity and Race
Work Identification Number
Titles
Gender
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)

1,000,000 or more
Data from NHSN is used for tracking of healthcare-associated
infections, antibiotic use and resistance, and surveillance of
COVID-19.
Data from NHSN is also used as a guide for infection
prevention activities that protect patients.

20 Describe the function of the SSN.

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.

20a Cite the legal authority to use the SSN.

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

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Public Health Service Act, Section 301, "Research and
Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
Identify legal authorities governing information use which discuss authority to maintain data and provide
21
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)).
5 U.S.C. 301, 40 U.S.C. 486(c).
22

Yes

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

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.

No
Published:

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

Published:

09-90-2001: Records Used for Surveillance and
Study of Epidemics, Preventable Diseases and
Problems

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: 2023-12-31
Yes
No

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Within HHS
CMS for required COVID-19 reporting and with HHS for
COVID-19 pandemic response
Other Federal
Agency/Agencies
Federal Emergency Management Agency (FEMA),
Administration for Strategic Preparedness and Response
(ASPR), and the White House Coronavirus Task Force for
pandemic response
Identify with whom the PII is shared or disclosed and
24a
for what purpose.

State or Local
Agency/Agencies
Select Healthcare facilities in the U.S. These facilities may
track a patient using SSN. Specifically Pennsylvania 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. State, local, and territorial
health departments access PII for purposes of surveillance
and response.
Private Sector
some corporate healthcare entities and quality improvement
organizations have access to PII for purposes of surveillance
and prevention with the consent from individual facilities

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Information and the NHSN Data Use Agreement document can
be found at http://www.cdc.gov/hai/surveillance/DUAannouncment.html. Each state or local jurisdiction 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.
Health Departments (HD) with NHSN DUAs:
Chicago Department of Public Health
Harris County Health Department
Houston Health Department
Los Angeles County Department of Public Health
Maricopa County Department of Public Health (Phoenix, AZ)
New York City DOH & Mental Hygiene
Southern Nevada Health District
San Diego (County of San Diego Health & Human Services
Describe any agreements in place that authorizes the Agency)
Orange County Health Department
information sharing or disclosure (e.g. Computer
Arizona Department of Health Services
24b Matching Agreement, Memorandum of
Florida Department of Health
Understanding (MOU), or Information Sharing
Idaho Department of Health and Welfare
Agreement (ISA)).
Indiana State Department of Health
Kansas Department of Health and Environment
Kentucky Department of Public Health
Louisiana Department of Health, Infectious Disease
Epidemiology Section
Minnesota Department of Health ("MDH")
Montana Department of Public Health and Human Services
Nevada Division of Public and Behavioral Health
New York State Department of Health
North Dakota Department of Health
Ohio Department of Health
South Dakota Department of Health
Texas Department of State Health Services(TXDSHS)
Vermont Department of Health
Washington State Dept of Health
(Territory) Guam Department of Public Health and Social
Services
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.

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. When facilities agree to
the NHSN Agreement to Participate and Consent upon
enrollment in NHSN, they are made aware of the purposes of
NHSN and how the data reported to NHSN may and may not
be used, including PII.
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 public
health surveillance.

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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.
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.

Identify who will have access to the PII in the system
31
and the reason why they require access.

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.
Users

Users will have access to the PII in the
system for Epidemiologic Analysis.

Administrators

Administrators will have access to the
PII in the system for data management
purposes.

Developers

Developers will have access to the PII
in the system for NHSN Development
and Maintenance.

Contractors

Others

Direct Contractors with Personal
Identity Verification (PIV) cards need
access to perform Epidemiologic
Analysis.
Epidemiologic Analysis by approved
CDC staff and guest researchers.

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

Yes
No

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Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

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.
NHSN record schedule adhere to N1-442-09-001, item 1
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.

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General Comments

Q10: In response the COVID-19 pandemic, the National Healthcare Safety Network (NHSN) augmented the
existing NHSN system to monitor and analyze the capacity of the domestic healthcare system so that
federal, state, and local officials can adjust their response efforts. This augmentation encompassed the
distinct COVID-19 reporting modules including a hospital capacity and patient impact COVID-19 module
for hospitals, a long-term care facility (LTCF) COVID-19 module, an outpatient dialysis module, and
collection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) point-of-care antigen test
data from long-term care facilities. On May 8, 2020, the Centers for Medicare and Medicaid Services (CMS)
published an Interim Final Rule with Comment Period to mandate that all approximately 15,600 CMScertified nursing homes report standard COVID-19 data to NHSN through the LTCF COVID-19 module. As
part of this rule, CMS publicly reports facility-level nursing home data. Facilities began to submit data to
this module on May 17, 2020 and must submit data through NHSN at least once every seven days. It
should be noted that reporting into the hospital capacity and patient impact COVID-19 module began in
March of 2020 and ended on July 15, 2020. Reporting into the dialysis module began in November of
2020. SARS-CoV-2 point-of-care antigen test data from long-term care facilities is reported to NHSN and
then transmitted via HL7 Clinical Documentation Architecture to the Association of Public Health
Laboratories’ Informatics Messaging Services (AIMS) platform. The data is then provided to State Health
Departments and HHS.
In addition to NHSN’s response to the pandemic, NHSN’s new Neonatal Component is expected to launch
during the winter of 2020/2021. This component will focus on premature neonates and the healthcareassociated events that occur as a result of their prematurity. This component will be released with one
module, which includes Late Onset-Sepsis and Meningitis, which are common complications of extreme
prematurity. There is no manual entry available to users for the new neonatal component. Both
numerator and denominator data will be imported into the Clinical Document Architecture (CDA) via
electronic data transfer. This will allow users to obtain data submitted via CDA and focus on prevention
activities within their respective hospitals or facilities. All data collected in these modules and in the POC
initiative fall under the personally identifiable information (PII) previously specified in the hospital
acquired infection (HAI) data collected by NHSN.

OPDIV Senior Official
for Privacy Signature

signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2023.01.19 11:46:41
-S
-05'00'

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