SOW Symplr Credentialing Management.doc

STATEMENT FOR SCOPE OF WORK

Symplr Credentialing Management REQUESTING SERVICE: Credentialing & Privileging Program – Veterans Affairs Sierra Pacific Network (VISN 21)

OBJECTIVE:

To provide a Base plus 4 option year contract to provide Software License and support for the continued use of the Medical Staff Office PrivPlus Credentialing Software now under the name Symplr, sProvider Credentialing Software. Symplr provides all required credentialing documentation, templates, tracking and reporting that the Dept of Veterans Affairs VetPro fails to provide.

BACKGROUND:

PrivPlus is a database software used nationally by Credentialing & Privileging to offset various data metrics currently unavailable in VetPro. These include but not limited to tracking of departmental specialties, who’s board certified vs who is not, licensure, certification, DEA, registration tracking reports, ability to track privileges held by providers, create verification of privileges held and affiliation letters of providers past and present. Symplr is currently the owner of the software and as of December 31, 2022, will no longer be supporting the software with updates and help desk support. In the past the licensing agreement was purchased yearly by the facilities and then a national contract was procured, however, due to PrivPlus being end of life, a national contract will no longer be funded as of December 31, 2024. VA Palo Alto has been selected as the site to initiate a VISN 21 Contract to implement the Symplr sProvider system as the PRIVPlus system is end of life, requiring VISN 21 to purchase the upgrade to Symplr system in order to continue the use of all archived PRIVPlus data and reporting functions. Credentialing and Privileging Offices have been using PRIVPlus for Credentialing and privileging documentation and tracking since January 1, 1996. PRIVPlus has archived data for all Licensed Independent Practitioners that had previously held privileges and appointments. This archived data is invaluable as the Credentialing and Privileging Offices use this archived data to provide appointment and privileging verifications on past employees and provide Risk Management with appointment dates for past employees for claims verification requests. Currently the PRIVPlus system provides productivity reports, FPPE/OPPE and Privileging modules. VA VetPro system is incapable of currently providing.

SCOPE:

1. Annual Software Licenses (unlimited users) will be immediately available upon Symplr acceptance of this order.

2. Symplr Data Conversion from PrivPlus to sProvider Symplr of all archived Licensed Independent Practitioner (LIP) and current LIP credentialing files.

3. Symplr Data Conversion of all VetPro Data for LIP and Non-LIP credentialing files.

4. Symplr will provide training for each site at the completion of installation.

5. Symplr personnel will be available for full support throughout the implementation / upgrade from PrivPlus to Symplr and extend for one year.

6. Continued license and support of the Current PrivPlus software to continue through the upgrade to Symplr, sProvider.

7. The system to be covered and supported are at the following locations at various VISN 21 facilities. The specific locations for each site and estimated number of providers are noted next to each location.

Central California Health Care System (570)

1137 Providers

2615 E Clinton Avenue

Fresno, CA 93703 Northern California Health Care System (612)

3176 Providers 150 Muir Road

Martinez CA 94553

Palo Alto Health Care System (640)

3831 Providers 3801 Miranda Avenue

Palo Alto, CA 94304

San Francisco Health Care System (662)

2680 Providers 4150 Clement Street

San Francisco CA 94121 VA Pacific Islands Health Care System (459)

990 Providers 459 Patterson Road

Honolulu, HI 96819-1522

VA Southern Nevada Health Care System (593)

2127 Providers 6900 North Pecos Road

North Las Vegas NV 89086 Sierra Nevada Health Care System (654)

1151 Providers 975 Kirman Ave

Reno NV 89502

PERFORMANCE REQUIREMENTS:

1. PERIOD OF PERFORMANCE:

· Base year Period of performance:

05/1/2024-04/30/2025

· Option 1 Period of performance:

05/1/2024-04/30/2026

· Option 1 Period of performance:

05/1/2025-04/30/2027

· Option 1 Period of performance:

05/1/2026-04/30/2028

2. CONFORMANCE STANDARDS: Contractor shall provide installation service and ensure that the software functions in accordance with the software manufacturer’s technical performance specifications. Contractor shall conform to all regulations to include but not be limited to federal, state, and local governing any chemicals, equipment or work which may be used or performed in the work under this contract

3. DELIVERABLES: The following list itemizes the deliverables that are expected to be provided through this procurement:

a. Software delivery, installation, and training will be complete within thirty (30) days of symplr acceptance of the order.

b. Licensed software, downloads from the internet will be available immediately upon symplr acceptance of the order.

c. Vendor will provide all software updates upon release at no additional cost to the Government throughout the life of this contract.

4. INFORMATION SECURITY CONSIDERATIONS:

a. All VA sensitive information shall be protected at all the times in accordance with VA Local site. Vendor is responsible for reporting any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information to the VA POC.

d. VA POC is: Shawna Hults, Shawna.Hults@va.gov

e. Identification: All contractor personnel (without exception) must report to the Police Office to check in. No employee of the contractor shall enter the project site without a valid identification badge issued by the VA. In order to obtain a short-term identification badge, contractor personnel shall present to the VA POC or VA Site PIV Coordinator a valid (non-expired) photo identification issued by a US federal, state or local government agency. This check- in is mandatory, to sign in and receive a contractor identification badge before any onsite installation, training or support work is performed.

f. Escort: Contractor personnel will be escorted by VA Staff for the duration of any installation, training or support performed and return to the same location to sign out and turn-in said badge.

g. The identified Sole Source Vendor: shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in standard acquisition guidelines. Per the VA handbook 6500.6, no VA sensitive information will be transferred, shared, or stored with said vendor. As such, no additional mechanisms will be needed to ensure the protection of information.

5. RECORDS MANAGEMENT: The following standard items relate to records generated in executing the contract and should be included in a typical Electronic Information Systems (EIS) procurement contract:

a. Citations to pertinent laws, codes and regulations such as 44 U.S.C chapters 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.

b. Contractor shall treat all deliverables under the contract as the property of the U.S. Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

c. Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.

d. Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act.

e. Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

f. The VA owns the rights to all data/records produced as part of this contract.

g. The VA owns the rights to all electronic information produced not limited to electronic data, electronic information systems, electronic databases, etc.

6. PAYMENT: Invoices will be paid upon the completion and acceptance of the procured service. Invoices shall include at a minimum, the following information: Contract Number, Purchase Order/Task Order Number, Contractor Name, and Item(s) or services provided. All invoices shall be submitted through the Invoice Payment Processing System (IPPS) Online Invoicing for the Department of Veterans Affairs Financial Services Center.

7. ADDITIONAL CHARGES: There shall be no additional charge for time spent troubleshooting any site (during, or after the normal hours of coverage).

Security Clauses Appendix B

The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.

Appendix C

1. GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

a. A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

b. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

c. Custom software development and outsourced operations must be located in the U.S.to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

d. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

3. VA INFORMATION CUSTODIAL LANGUAGE

a. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

b. VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct on-site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

c. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

d. The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

e. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

g. If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

a. Information systems that are designed or developed for or on behalf of VA at non-VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information and system security categorization level designations in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA Information Security Program). During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the COTR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact Assessment.

b. The contractor/subcontractor shall certify to the COTR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet Explorer 7 configured to operate on Windows XP and Vista (in Protected Mode on Vista) and future versions, as required.

c. The standard installation, operation, maintenance, updating, and patching of software shall not alter the configuration settings from the VA approved and FDCC configuration. Information technology staff must also use the Windows Installer Service for installation to the default “program files” directory and silently install and uninstall.

d. Applications designed for normal end users shall run in the standard user context without elevated system administration privileges.

e. The contractor/subcontractor agrees to:

(1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies:

(a) The Systems of Records (SOR); and (b) The design, development, or operation work that the contractor/subcontractor is to perform;

(2) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the redesign, development, or operation of a SOR on individuals that is subject to the Privacy Act; and

(3) Include this Privacy Act clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a SOR.

f. The vendor shall notify VA within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the Systems (including the confidentiality or integrity of its data and operations, or the availability of the system). Such issues shall be remediated as quickly as is practical, but in no event longer than ____ days.

5. SECURITY INCIDENT INVESTIGATION

a. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

b. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

c. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

d. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

6. LIQUIDATED DAMAGES FOR DATA BREACH

a. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

b. The contractor/subcontractor shall provide notice to VA of a “security incident” as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

c. Each risk analysis shall address all relevant information concerning the data breach, including the following:

(1) Nature of the event (loss, theft, unauthorized access);

(2) Description of the event, including:

(a) date of occurrence;

(b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code;

(3) Number of individuals affected or potentially affected;

(4) Names of individuals or groups affected or potentially affected;

(5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;

(6) Amount of time the data has been out of VA control;

(7) The likelihood that the sensitive personal information will or has been compromised

(made accessible to and usable by unauthorized persons);

(8) Known misuses of data containing sensitive personal information, if any;

(9) Assessment of the potential harm to the affected individuals;

(10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy

Incidents, as appropriate; and

(11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.

d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $37.50 per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

(1) Notification;

(2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;

(3) Data breach analysis;

(4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;

(5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and

(6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.

7. TRAINING

a. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

(1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems;

(2) Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training;

(3) Successfully complete the appropriate VA privacy training and annually complete required privacy training; and

(4) Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document – e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.]

b. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

c. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.