65FR37792 Privacy Act of 1974; Report of Altered Systems
robop...@us.govnews.org
Posting-number: Volume 65, Issue 117, Page 37792
[Federal Register: June 16, 2000 (Volume 65, Number 117)]
[Notices]
[Page 37792-37795]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr16jn00-69]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Privacy Act of 1974; Report of Altered Systems
AGENCY: Department of Health and Human Services (HHS), Health Care
Financing Administration (HCFA).
ACTION: Notice of the modification or alteration to 20 systems of
records.
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SUMMARY: In accordance with the requirements of the Privacy Act of
1974, we are correcting information provided in 20 HCFA systems of
records specified in Appendix A. These systems are all related to
research or demonstration projects under the control of the Office of
Strategic Planning. We are deleting the published routine uses in the
system of records listed in Appendix A and replacing them with four
revised routine uses. The routine uses are being prioritized and
renumbered accordingly. We are taking the opportunity to update those
sections of the SORs that were affected by the recent reorganization.
We are also updating the language in the administrative sections to
correspond with language used in other HCFA system of records.
The primary purpose of the corrections to these systems is to
shorten the language, make the routine uses easier to read, and provide
clarity to HCFA's intention to disclose individual-specific information
related to the purposes for which the information is being collected.
EFFECTIVE DATES: HCFA filed a correction to a system report with the
Chair of the House Committee on Government Reform and Oversight, the
Chair of the Senate Committee on Governmental Affairs, and the
Administrator, Office of Information and Regulatory Affairs, Office of
Management and Budget (OMB) on June 12, 2000. To ensure that all
parties have adequate time in which to comment, the corrected systems
of records, including routine uses, will become effective 40 days from
the publication of the notice, or from the date it was submitted to OMB
and the Congress, whichever is
[[Page 37793]]
later, unless HCFA receives comments that require alterations to this
notice.
ADDRESSES: The public should address comments to: Director, Division of
Data Liaison and Distribution (DDLD), HCFA, Room N2-04-27, 7500
Security Boulevard, Baltimore, Maryland 21244-1850. Comments received
will be available for review at this location, by appointment, during
regular business hours, Monday through Friday from 9 a.m.-3 p.m.,
eastern time zone.
FOR FURTHER INFORMATION CONTACT: Sydney P. Galloway, Privacy Act
Coordinator, Systems, Technical, and Analytic Resources Group, Office
of Strategic Planning (OSP), HCFA, Mailstop C3-24-07, 7500 Security
Boulevard, Baltimore, Maryland 21244-1850. The telephone number is 410-
786-6645.
SUPPLEMENTARY INFORMATION:
I. Collection and Maintenance of Data in the System
Agency Policies, Procedures, and Restrictions on the Routine Use
We are establishing the following policies, procedures and
restrictions on routine use disclosures of information that will be
maintained in these systems. In general, routine uses of these systems
(or a subset thereof) will be approved for the minimum set of data
elements in the record needed to accomplish the purpose of the
disclosure after HCFA:
(a) Determines that the use or disclosure is consistent with the
reason that the data is being collected, e.g., conducting research
related to specific projects and demonstrations, and monitoring the
quality of care provided to patients.
(b) Determines:
(1) That the purpose for which the disclosure is to be made can
only be accomplished if the record is provided in individually
identifiable form;
(2) That the purpose for which the disclosure is to be made is of
sufficient importance to warrant the potential effect and/or risk on
the privacy of the individual that additional exposure of the record
might bring; and
(3) That there is a strong probability that the proposed use of the
data would in fact accomplish the stated purpose(s).
(c) Requires the information recipient to:
(1) Establish administrative, technical, and physical safeguards to
prevent unauthorized use of disclosure of the record; and
(2) Remove or destroy at the earliest time all patient-identifiable
information.
(d) Determines that the data are valid and reliable.
II. Proposed Routine Use Disclosures of Data in the System
The Privacy Act allows us to disclose information without an
individual's consent if the information is to be used for a purpose
that is compatible with the purpose(s) for which the information was
collected. Any such compatible use of data is known as a ``routine
use.'' The proposed routine uses in this system meet the compatibility
requirement of the Privacy Act. We are correcting the language in the
following routine use disclosures of information maintained in these
systems:
1. To an individual or organization for research, evaluation, or
epidemiological projects related to the prevention of disease or
disability, or the restoration or maintenance of health, and for
payment related projects.
The collected data will provide the research, evaluation and
epidemiological projects a broader, longitudinal, national perspective
of the data. HCFA anticipates that many researchers will have
legitimate requests to use these data in projects that could ultimately
improve the care provided to Medicare patients and the policy that
governs the care. HCFA understands the concerns about the privacy and
confidentiality of the release of data for a research use. Disclosure
of data for research and evaluation purposes may involve aggregate data
rather than individual-specific data.
2. To agency contractors, or consultants who have been engaged by
the agency to assist in the performance of a service related to this
system of records and who need to have access to the records in order
to perform the activity.
We contemplate disclosing information under this routine use only
in situations in which HCFA may enter into a contractual or similar
agreement with a third party to assist in accomplishing HCFA function
relating to purposes for these systems of records.
HCFA occasionally contracts out certain of its functions when doing
so would contribute to effective and efficient operations. HCFA must be
able to give a contractor or consultant whatever information is
necessary for the contractor or consultant to fulfill its duties. In
these situations, safeguards are provided in the contract prohibiting
the contractor or consultant from using or disclosing the information
for any purpose other than that described in the contract and requires
the contractor or consultant to return or destroy all information at
the completion of the contract.
3. To a member of congress or to a congressional staff member in
response to an inquiry of the congressional office made at the written
request of the constituent about whom the record is maintained.
Beneficiaries sometimes request the help of a member of congress in
resolving an issue relating to a matter before HCFA. The member of
congress then writes HCFA, and HCFA must be able to give sufficient
information to be responsive to the inquiry.
4. To the Department of Justice (DOJ), court or adjudicatory body
when:
(a) The agency or any component thereof, or
(b) Any employee of the agency in his or her official capacity, or
(c) Any employee of the agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
(d) The United States Government
is a party to litigation or has an interest in such litigation, and by
careful review, HCFA determines that the records are both relevant and
necessary to the litigation and that the use of such records by the
DOJ, court or adjudicatory body is compatible with the purpose for
which the agency collected the records.
Whenever HCFA is involved in litigation, or occasionally when
another party is involved in litigation and HCFA's policies or
operations could be affected by the outcome of the litigation, HCFA
would be able to disclose information to the DOJ, court or adjudicatory
body involved. A determination would be made in each instance that,
under the circumstances involved, the purposes served by the use of the
information in the particular litigation is compatible with a purpose
for which HCFA collects the information.
III. Safeguards
The systems will conform with applicable law and policy governing
the privacy and security of federal automated information systems.
These include but are not limited to: the Privacy Act of 1974, Computer
Security Act of 1987, the Paperwork Reduction Act (PRA) of 1995, the
Clinger-Cohen Act of 1996, and OMB Circular A-130, Appendix III,
``Security of Federal Automated Information Resources.'' HCFA has
prepared a comprehensive system security plan as required by the Office
of Management and Budget (OMB) Circular A-130, Appendix III. This plan
conforms fully to guidance issued by the National Institute for
Standards and Technology (NIST) in NIST Special Publication 800-18,
[[Page 37794]]
``Guide for Developing Security Plans for Information Technology
Systems.'' Paragraphs A-C of this section highlight some of the
specific methods that HCFA is using to ensure the security of this
system and the information within it.
A. Authorized users: Personnel having access to the system have
been trained in Privacy Act and systems security requirements.
Employees who maintain records in the system are instructed not to
release any data until the intended recipient agrees to implement
appropriate administrative, technical, procedural, and physical
safeguards sufficient to protect the confidentiality of the data and to
prevent unauthorized access to the data. In addition, HCFA is
monitoring the authorized users to ensure against excessive or
unauthorized use. Records are used in a designated work area or work
station and the system location is attended at all times during working
hours.
To assure security of the data, the proper level of class user is
assigned for each individual user as determined at the agency level.
This prevents unauthorized users from accessing and modifying critical
data. The system database configuration includes five classes of
database users:
<bullet> Database Administrator class owns the database objects,
e.g., tables, triggers, indexes, stored procedures, packages, and has
database administration privileges to these objects;
<bullet> Quality Control Administrator class has read and write
access to key fields in the database;
<bullet> Quality Indicator (QI) Report Generator class has read-
only access to all fields and tables;
<bullet> Policy Research class has query access to tables, but are
not allowed to access confidential patient identification information;
and
<bullet> Submitter class has read and write access to database
objects, but no database administration privileges.
B. Physical Safeguards: All server sites have implemented the
following minimum requirements to assist in reducing the exposure of
computer equipment and thus achieve an optimum level of protection and
security for the each system:
Access to all servers is controlled, with access limited to only
those support personnel with a demonstrated need for access. Servers
are to be kept in a locked room accessible only by specified management
and system support personnel. Each server requires a specific log-on
process. All entrance doors are identified and marked. A log is kept of
all personnel who were issued a security card, key and/or combination
which grants access to the room housing the server, and all visitors
are escorted while in this room. All servers are housed in an area
where appropriate environmental security controls are implemented,
which include measures implemented to mitigate damage to Automated
Information System (AIS) resources caused by fire, electricity, water
and inadequate climate controls.
Protection applied to the workstations, servers and databases
include:
<bullet> User Log-ons--Authentication is performed by the Primary
Domain Controller/Backup Domain Controller of the log-on domain.
<bullet> Workstation Names--Workstation naming conventions may be
defined and implemented at the agency level.
<bullet> Hours of Operation--May be restricted by Windows NT. When
activated all applicable processes will automatically shut down at a
specific time and not be permitted to resume until the predetermined
time. The appropriate hours of operation are determined and implemented
at the agency level.
<bullet> Inactivity Log-out--Access to the NT workstation is
automatically logged out after a specified period of inactivity.
<bullet> Warnings--Legal notices and security warnings display on
all servers and workstations.
<bullet> Remote Access Services (RAS)--Windows NT RAS security
handles resource access control. Access to NT resources is controlled
for remote users in the same manner as local users, by utilizing
Windows NT file and sharing permissions. Dial-in access can be granted
or restricted on a user-by-user basis through the Windows NT RAS
administration tool.
There are several levels of security found in each system. Windows
NT provides much of the overall system security. The Windows NT
security model is designed to meet the C2-level criteria as defined by
the U.S. Department of Defense's Trusted Computer System Evaluation
Criteria document (DoD 5200.28-STD, December 1985). Netscape Enterprise
Server is the security mechanism for all transmission connections to
the system. As a result, Netscape controls all information access
requests. Anti-virus software is applied at both the workstation and NT
server levels.
Access to different areas on the Windows NT server are maintained
through the use of file, directory and share level permissions. These
different levels of access control provide security that is managed at
the user and group level within the NT domain. The file and directory
level access controls rely on the presence of an NT File System (NTFS)
hard drive partition. This provides the most robust security and is
tied directly to the file system. Windows NT security is applied at
both the workstation and NT server levels.
C. Procedural Safeguards: All automated systems must comply with
federal laws, guidance, and policies for information systems security
as stated previously in this section. Each automated information system
should ensure a level of security commensurate with the level of
sensitivity of the data, risk, and magnitude of the harm that may
result from the loss, misuse, disclosure, or modification of the
information contained in the system.
IV. Effect of the Modified System of Records on Individual Rights
HCFA proposes to establish each system in accordance with the
principles and requirements of the Privacy Act and will collect, use,
and disseminate information only as prescribed therein. Data in each
system will be subject to the authorized releases in accordance with
the routine uses identified in each systems of records.
HCFA will monitor the collection and reporting of all data. All
information on beneficiaries is completed by the contractor and
submitted to HCFA through standard systems located at the contractor
sites. HCFA will utilize a variety of onsite and offsite edits and
audits to increase the accuracy of all data.
HCFA will take precautionary measures (see item III. above) to
minimize the risks of unauthorized access to the records and the
potential harm to individual privacy or other personal or property
rights including not collecting patient identifiable data for non-
Medicare and non-Medicaid patients. HCFA will collect only that
information necessary to perform the system's functions. In addition,
HCFA will make disclosure of identifiable data from the modified system
only with consent of the subject individual, or his/her legal
representative, or in accordance with an applicable exception provision
of the Privacy Act.
HCFA, therefore, does not anticipate an unfavorable effect on
individual privacy as a result of the disclosure of information
relating to individuals.
Dated: June 12, 2000.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
The corrections to the systems of records listed in Appendix A are
as follows:
* * * * *
[[Page 37795]]
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive Data.
SYSTEM LOCATION:
HCFA Data Center, 7500 Security Boulevard, North Building, First
Floor, Baltimore, Maryland 21244-1850.
* * * * *
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OF USERS AND THE PURPOSES OF SUCH USES:
The Privacy Act allows us to disclose information without an
individual's consent if the information is to be used for a purpose
that is compatible with the purpose(s) for which the information was
collected. Any such compatible use of data is known as a ``routine
use.'' Disclosure may be made:
1. To an individual or organization for research, evaluation, or
epidemiological projects related to the prevention of disease or
disability, or the restoration or maintenance of health, and for
payment related projects.
2. To agency contractors, or consultants who have been engaged by
the agency to assist in the performance of a service related to this
system of records and who need to have access to the records in order
to perform the activity.
3. To a member of Congress or to a Congressional staff member in
response to an inquiry of the Congressional Office made at the written
request of the constituent about whom the record is maintained.
4. To the Department of Justice (DOJ), court or adjudicatory body
when:
(a) The agency or any component thereof, or
(b) Any employee of the agency in his or her official capacity, or
(c) Any employee of the agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
(d) The United States Government is a party to litigation or has an
interest in such litigation, and by careful review, HCFA determines
that the records are both relevant and necessary to the litigation and
that the use of such records by the DOJ, court or adjudicatory body is
compatible with the purpose for which the agency collected the records.
* * * * *
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
* * * * *
SAFEGUARDS:
HCFA has safeguards for authorized users and monitors such users to
ensure against excessive or unauthorized use. Personnel having access
to the system have been trained in the Privacy Act and systems security
requirements. Employees who maintain records in the system are
instructed not to release any data until the intended recipient agrees
to implement appropriate administrative, technical, procedural, and
physical safeguards sufficient to protect the confidentiality of the
data and to prevent unauthorized access to the data.
In addition, HCFA has physical safeguards in place to reduce the
exposure of computer equipment and thus achieve an optimum level of
protection and security for the HCFA system. For computerized records,
safeguards have been established in accordance with Department of
Health and Human Services (HHS) standards and National Institute of
Standards and Technology guidelines, e.g., security codes will be used,
limiting access to authorized personnel. System securities are
established in accordance with HHS, Information Resource Management
(IRM) Circular #10, Automated Information Systems Security Program,
HCFA Automated Information Systems (AIS) Guide, Systems Securities
Policies, and OMB Circular No. A-130 (revised), Appendix III.
* * * * *
SYSTEM MANAGER(S) AND ADDRESS:
Director, Office of Strategic Planning, HCFA, Room C3-20-11, 7500
Security Boulevard, Baltimore, Maryland, 21244-1850. The telephone
number is 410-786-6501.
NOTIFICATION PROCEDURE:
For purpose of access, the subject individual should write to the
system manager who will require the system name, health insurance claim
number, address, age, and sex, and for verification purposes, the
subject individual's name (woman's maiden name, if applicable) and
social security number (SSN). Furnishing the SSN is voluntary, but it
may make searching for a record easier and prevent delay.
RECORD ACCESS PROCEDURE:
For purpose of access, use the same procedures outlined in
Notification Procedures above. Requestors should also reasonably
specify the record contents being sought. (These procedures are in
accordance with Department regulation 45 CFR 5b.5(a)(2)).
CONTESTING RECORD PROCEDURES:
The subject individual should contact the system manager named
above, and reasonably identify the record and specify the information
to be contested. State the corrective action sought and the reasons for
the correction with supporting justification. (These procedures are in
accordance with Department regulation 45 CFR 5b.7).
* * * * *
Appendix A
09-70-0022 Municipal Health Services Program, HHS/HCFA/OSP
09-70-0030 National Long-Term Care Study Follow up, HHS/HCFA/OSP
09-70-0033 Person-Level Medicaid Data System, HHS/HCFA/OSP
09-70-0036 Evaluation of Competitive Bidding for Durable Medical
Equipment Demonstrations, HHS/HCFA/OSP
09-70-0039 Evaluation of the Medicare Alzheimer's Disease
Demonstration, HHS/HCFA/OSP
09-70-0040 Health Care Financing Administration Medicare Heart
Transplant Data File, HHS/HCFA/OSP
09-70-0042 Medicare Cancer Registry Record System, HHS/HCFA/OSP
09-70-0045 Evaluation of the Arizona Health Care Cost Containment
and Long Term Care Systems Demonstration, HHS/HCFA/OSP
09-70-0046 Home Health Quality Indicator System (HHQUIS), HHS/HCFA/
OSP
09-70-0048 Monitoring of the Home Health Agency Prospective Payment
Demonstration, HHS/HCFA/OSP
09-70-0049 Evaluation of the Home Health Agency (HHA) Prospective
Payment Demonstration, HHS/HCFA/OSP
09-70-0050 The Medicare/Medicaid Multi-State Case Mix and Quality
Data Base for Nursing Home Residents, HHS/HCFA/OSP
09-70-0051 Quality Assurance for the Home Health Agency (HHA)
Prospective Payment Demonstration, HHS/HCFA/OSP
09-70-0052 Post-Hospitalization Outcomes Studies, HHS/HCFA/OSP
09-70-0053 The Medicare Beneficiary Health Status Registry Pilot,
HHS/HCFA/OSP
09-70-0057 Evaluation of the Medicaid Extension of Eligibility to
Certain Low Income Families Not Otherwise qualified to receive
Medicaid Benefits Demonstration, HHS/HCFA/OSP
09-70-0058 Evaluation of the Medicare SELECT Program, HHS/HCFA/OSP
09-70-0059 The Medicaid Necessity, Appropriateness, and Outcomes of
Care Study, HHS/HCFA/OSP
09-70-0063 Evaluation of the Medicaid Demonstration for Improving
Access to Care for Substance Abusing Pregnant Women, HHS/HCFA/OSP
09-70-0066 Evaluation of, and External Quality Assurance for, the
Community Nursing Organization (CNO) Demonstration, HHS/HCFA/OSP
[FR Doc. 00-15231 Filed 6-15-00; 8:45 am]
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