NTP STAT Portal and PACS Data Management System-ISSO-PO Reviewed - 3 Year.docx

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B537--Service/Support and Renewal of Licensing for NTP STAT Portal and Analytics System
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36C26126Q0004
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This document is a Product Description for the Department of Veterans Affairs (VA) National Teleradiology Program (NTP) detailing requirements for a web-based STAT Portal and Picture Archive and Communication System (PACS) data management system. The system, branded "Foundations" from Health Level Incorporated, must support 3 million annual studies with an initial study volume license of 1,500,000 annual cases and a 10% buffer. Key system requirements include bi-directional HL7 interface with NTP's PACS, integration of disparate data sources, web-based reporting, unlimited user accounts with role-based permissions, and comprehensive analytics capabilities for radiology workflow, business intelligence, performance management, and billing functions.

The contract includes a base year and three option years, with study volume incrementally increasing each year (Option Year 1: 1,600,000 studies, Option Year 2: 1,700,000 studies). Technical support will be provided 6 am to 6 pm Pacific time with emergency response within 30 minutes, 24/7. The system must be hosted on VA-provided hardware at the Sacramento Data Center, comply with VA security clauses, and ensure 99.9% uptime. The contract will include modules for capacity management, customer invoicing, patient care communication, and post-procedure data analytics. Vendor must have approved VA remote access credentials and comply with extensive security and privacy requirements, including annual security training and strict data protection protocols.

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PRODUCT DESCRIPTION

DEPARTMENT OF VETERANS AFFAIRS

VHA National Teleradiology Program

Brand Name: Foundations STAT Portal and PACS Data Management System

1.0 PRODUCT REQUIREMENTS

Department of Veterans Affairs (VA) National Teleradiology Program (NTP) has a requirement for web-based STAT Portal and Picture Archive and Communication System (PACS) data management system which will integrate with the NTP PACS. The system must have the design capability to support 3 million annual studies and shall have an initial study volume license in the base year of 1,500,000 annual cases (volume is based on Study Instance Unique Identifier (SIUID) of NTP issued final report) with a 10% buffer.

Vendor shall provide all software, service, support and custom configuration for the system and all associated modules as outlined below. In addition to the STAT Portal functionality, the system shall provide core clinical analytics functionality for NTP operations. The Brand Name system is "Foundations" from Health Level Incorporated and is to be hosted on VA provided hardware at the Sacramento Data Center. Vendor must have approved VA remote access credentials to perform ongoing support, maintenance, management, and upgrades for the system. Vendor shall comply with all applicable VA security clauses. Technical support shall be provided 6 am to 6 pm pacific and emergency response within 30 minutes, 24x7. Scheduled support to include maintenance bug fixes, feature updates and upgrades to existing modules with a 99.9% uptime guarantee.

System shall include a bi-directional HL7 interface with NTP’s PACS, an Application Program Interface (API) to the NTP PACS and an Open Database Connection (ODBC) with the NTP PACS. System shall support VA’s Electronic Medical Records and the disparate formats for Radiology accession numbers and Common Procedure Terminology (CPT) codes and Logical Observation Identifiers Names and Codes (LOINC).

Salient Characteristics:

· The system must be a Radiology PACS appliance to assist with STAT and Critical priority case acceptance by NTP and include clinical study management and workflow analysis.

· Have a validated bi-directional HL7 interface and ODBC connection to NTP's PACS.

· Provide radiology workflow, business intelligence and analytics capabilities to assist with workload tracking, capacity planning, performance management, quality assurance and billing functions.

· Integrate disparate data sources from NTP's PACS and staffing module from qGenda.

· Have web-based reporting with fully user customizable reports that can be created from scratch or modified based on an extensive preconfigured report set to be developed by the vendor.

· Provide integration of disparate data sources into a common database to enable PACS analytics and reporting for NTP's operational use. Source data formats include: HL7, DICOM, EDI, CSV, and XLS.

· Software must be compatible with VA provided virtual servers running Windows 2019 or later, SQL 2019 or later with standard VA server policies, Microsoft updates and anti-virus scanning.

· Provide unlimited user accounts with role-based user permissions (NTP customer, NTP Radiologist, Business Office, Administrator, Rad Tech and Rad AO) and a hierarchal access structure.

· The system design must be predicated on a flexible, easy-to-use and highly customizable user interface.

Data must be exportable in multiple formats readable via VA desktop applications.

· Billing reports must tabulate study volume by site with assignable costs by modality, criticality, and CPT code. System must be able to calculate billable charges with tiered billing based on NTP determined breakdown. Billing report must be able to segregate for rural and non-rural sites and account for printset and bilateral billing adjustments.

· Performance management module must track Radiologist productivity based on study volume, RVUs, NTP defined productivity measure and billable rate.

· Vendor must provide remote support and after-hours software patches, updates and upgrades.

· Access will be through VA's approved remote access client and vendor personnel will be required to annually complete VA's security and privacy training. No VA data shall be exported off site and all data, reports, and analytics outputs remain property of VA.

· Data listed below is the baseline data that will be incorporated into the system and the system must provide the capability to add additional data inputs without added cost.

· Provide easy organization of data and insights with worklists, along with advanced visualization capabilities such as charting, grouping, scatter charts, heatmaps and timeline graphics.

· Ability to drill into worklists and patient objects with ease and data governance and security.

· Ability to issue notifications and alerts based on certain user definable events and triggers, including daily, weekly, and monthly notifications of routinely necessary summaries and data sets.

· Contractor will address bug fixes and updates on a recurring basis, not to exceed once a quarter.

· Status reviews of system functionality will be completed once a quarter and any outstanding issues will be relay to the Contractor for resolution.

· Example PACS Data Imported: Server Received Time, Report Delivered Time, Exam Status, Originating Source, Order #., Accession #, Modality, Study Time, Study Desc, CPT Code, Body Part, Priority, Reason for Study, # Images, Ref Phys, Reading Phys, Remarks, Follow Up Code, SIUID, Notes, Billable Rate.

· Example Peer Review & Callback Data Imported: Accession #, Date-Time Created, Contact Source, Contact Name, Time Zone, Server Time, Created By, Comments, Alert Code, Callback Time Elapsed, Physician Scheduling Program Data Imported: Reading Phys, Day of Week, Tour of Duty.

CLIN 0001 Part# FPLAT: Base System Configuration: Contractor shall provide service/support and custom configuration/optimization for the existing NTP Radiology PACS STAT Portal and clinical analytics system and all associated modules outlined in subsequent line items for a 1 year term with 3 option years. System to include functionality to support new procedure per year (billable exam count); Unlimited Users, Unlimited Workspaces, Visual Units, Key Performance Indicators (KPIs) with user managed thresholds, Rubrics, Notifications, Performance Management Module, Real-Time Data Analytics Model and Smart Connectors.

CLIN 0002 Part#: CPMM: Capacity Management Module for staff calendar reconciliation from MD calendar manager data source, forecasting models and required resource prediction, includes the workload manager and vacation manager/forms and worklist. Based on pre-established study volume and RVU targets along with average productivity of NTP staff per shift. System must provide an interactive tool that calculates staffing required to support volume increases based on number of studies, priority of studies, modality and time of acquisition.

CLIN 0003 Part#: FNDAP1: Customer Invoices, MD Fee Payments, Customer and MD Access, Price and Revenue Management solution.

CLIN 0004 Part#: HLCCM1: STAT Portal - Patient Care STAT cases and radiology patient handoff between VAMC and VA NTP with closed loop communication.

CLIN 0005 Part#: FPOST: Radiology Post Procedure data analytics subject matters includes case data, turnaround time, rvu, diagnostic codes, callbacks, diagnostic report text display and search and other subject matter relevant to radiology post procedure data analytics.

CLIN 0006 Part#: HLSVCF: Customization and Professional Services, engineering time and materials.

Service/Support Response Requirements

Once notice and reasonable documentation of a defect has been provided by NTP to the Contractor, Contractor will send a response by Issue Tracker and/or email to one of NTP’s authorized support contacts in accordance with the response times set forth below. Contractor will provide NTP with a resolution, a workaround or a corrective action plan to resolve the issue within the timeframes listed below.

Severity Level Category
Response Time
Resolution Time
STAT
30 Minutes
12 hours
High
2 days
14 Calendar Days
Medium
5 Calendar Days
Data issues within 30 days

Product issues scheduled for future update

Low
15 Calendar Days
Data issues within 60 days

Product issues for a Future Update

Severity Levels
Description
STAT
A defect which has a fatal commercial impact on the Customer’s business or the businesses of Customer’s Authorized Users which either makes the Software Service inoperable or prevents any access to the Company Products by Customer or its agents, for which there is no workaround.
High
A defect for which there is no immediate workaround, and which has a significant commercial impact on the Customer’s business or the businesses of Customer’s Authorized Users but one for which the Software Service is operable and accessible in whole or in part for use by the Customer and Customer’s Authorized Users.
Medium
A defect which has a limited commercial impact on the Customer’s business or the businesses of Customer’s Authorized Users which does not make critical areas of functionality of the Software Service inaccessible or inoperable or prevent the provision of the Software Service to the Customer’s Authorized Users.
Low
A defect which has a minimal commercial impact on the Customer’s business or the businesses of Customer’s Authorized Users which either makes one or more critical areas of functionality of the Software Service inaccessible or inoperable or prevents the provision of the Software Service to the Customer’s Authorized Users.

OPTION YEAR 1

CLINS 1001-1006 - Study volume increase to 1,600,000 annual studies with a 10% buffer.

OPTION YEAR 2

CLINS 2001-2006 with study volume increase to 1,700,000 annual studies with a 10% buffer.

6500.6 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. VA INFORMATION CUSTODIAL LANGUAGE

a. The Government shall receive unlimited rights to data/intellectual property first produced and delivered in the performance of this contract or order (hereinafter “contract”) unless expressly stated otherwise in this contract. This includes all rights to source code and all documentation created in support thereof. The primary clause used to define Government and Contractor data rights is FAR 52.227-14 Rights in Data – General. The primary clause used to define computer software license (not data/intellectual property first produced under this contractor or order) is FAR 52.227-19, Commercial Computer Software License.

b. Information made available to the contractor by VA for the performance or administration of this contract will be used only for the purposes specified in the service agreement, SOW, PWS, PD, and/or contract. The contractor shall not use VA information in any other manner without prior written approval from a VA Contracting Officer (CO). The primary clause used to define Government and Contractor data rights is FAR 52.227-14 Rights in Data – General.

c. VA information will not be co-mingled with any other data on the contractor’s information systems or media storage systems. The contractor shall ensure compliance with Federal and VA requirements related to data protection, data encryption, physical data segregation, logical data segregation, classification requirements and media sanitization.

d. VA reserves the right to conduct scheduled or unscheduled audits, assessments, or investigations of contractor Information Technology (IT) resources to ensure information security is compliant with Federal and VA requirements. The contractor shall provide all necessary access to records (including electronic and documentary materials related to the contracts and subcontracts) and support (including access to contractor and subcontractor staff associated with the contract) to VA, VA's Office Inspector General (OIG), and/or Government Accountability Office (GAO) staff during periodic control assessments, audits, or investigations.

e. The contractor may only use VA information within the terms of the contract and applicable Federal law, regulations, and VA policies. If new Federal information security laws, regulations or VA policies become applicable after execution of the contract, the parties agree to negotiate contract modification and adjustment necessary to implement the new laws, regulations, and/or policies.

f. The contractor shall not make copies of VA information except as specifically authorized and necessary to perform the terms of the contract. If copies are made for restoration purposes, after the restoration is complete, the copies shall be destroyed in accordance with VA Directive 6500, VA Cybersecurity Program and VA Information Security Knowledge Service.

g. If a Veterans Health Administration (VHA) contract is terminated for default or cause with a business associate, the related local Business Associate Agreement (BAA) shall also be terminated and actions taken in accordance with VHA Directive 1605.05, Business Associate Agreements. If there is an executed national BAA associated with the contract, VA will determine what actions are appropriate and notify the contactor.

h. The contractor shall store and transmit VA sensitive information in an encrypted form, using VA-approved encryption tools which are, at a minimum, Federal Information Processing Standards (FIPS) 140-2, Security Requirements for Cryptographic Modules (or its successor) validated and in conformance with VA Information Security Knowledge Service requirements. The contractor shall transmit VA sensitive information using VA approved Transport Layer Security (TLS) configured with FIPS based cipher suites in conformance with National Institute of Standards and Technology (NIST) 800-52, Guidelines for the Selection, Configuration and Use of Transport Layer Security (TLS) Implementations.

i. The contractor’s firewall and web services security controls, as applicable, shall meet or exceed VA’s minimum requirements.

j. Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor may use and disclose VA information only in two situations: (i) in response to a qualifying order of a court of competent jurisdiction after notification to VA CO (ii) with written approval from the VA CO. The contractor shall refer all requests for, demands for production of or inquiries about, VA information and information systems to the VA CO for response.

k. Notwithstanding the provision above, the contractor shall not release VA records protected by Title 38 U.S.C. § 5705, Confidentiality of medical quality-assurance records and/or Title 38 U.S.C. § 7332, Confidentiality of certain medical records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse or infection with Human Immunodeficiency Virus (HIV). If the contractor is in receipt of a court order or other requests for the above-mentioned information, the contractor shall immediately refer such court order or other requests to the VA CO for response.

l. Information made available to the contractor by VA for the performance or administration of this contract or information developed by the contractor in performance or administration of the contract will be protected and secured in accordance with VA Directive 6500 and Identity and Access Management (IAM) Security processes specified in the VA Information Security Knowledge Service.

m. Any data destruction done on behalf of VA by a contractor shall be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management, VA Handbook 6300.1, Records Management Procedures, and applicable VA Records Control Schedules.

n. The contractor shall provide its plan for destruction of all VA data in its possession according to VA Directive 6500 and NIST 800-88, Guidelines for Media Sanitization prior to termination or completion of this contract. If directed by the COR/CO, the contractor shall return all Federal Records to VA for disposition.

o. Any media, such as paper, magnetic tape, magnetic disks, solid state devices or optical discs that is used to store, process, or access VA information that cannot be destroyed shall be returned to VA.The contractor shall hold the appropriate material until otherwise directed by the Contracting Officer’s Representative (COR) or CO. Items shall be returned securely via VA-approved methods. VA sensitive information must be transmitted utilizing VA-approved encryption tools which are validated under FIPS 140-2 (or its successor) and NIST 800-52. If mailed, the contractor shall send via a trackable method (USPS, UPS, FedEx, etc.) and immediately provide the COR/CO with the tracking information. Self-certification by the contractor that the data destruction requirements above have been met shall be sent to the COR/CO within 30 business days of termination of the contract.

p. All electronic storage media (hard drives, optical disks, CDs, back-up tapes, etc.) used to store, process or access VA information will not be returned to the contractor at the end of lease, loan, or trade-in. Exceptions to this paragraph will only be granted with the written approval of the VA CO.

1. 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).

2. For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COTR.

3. 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 and subcontractors only to the extent necessary to perform the services specified in the solicitation or contract. This includes indirect entities, both affiliate of contractor/subcontractor and agent of contractor/subcontractor.

b. Contractors and subcontractors shall sign the VA Information Security Rule of Behavior (ROB) before access is provided to VA information and information systems (see Section 4, Training, below). The ROB contains the minimum user compliance requirements and does not supersede any policies of VA facilities or other agency components which provide higher levels of protection to VA’s information or information systems. Users who require privileged access shall complete the VA elevated privilege access request processes before privileged access is granted.

c. All contractors and subcontractors working with VA information are subject to the same security investigative and clearance 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 shall be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office of Human Resources and Administration/Operations, Security and Preparedness (HRA/OSP) is responsible for these policies and procedures. Contract personnel who require access to classified information or information systems shall have an appropriate security clearance. Verification of a Security Clearance shall be processed through the Special Security Officer located in HRA/OSP. Contractors shall conform to all requirements stated in the National Industrial Security Program Operating Manual (NISPOM).

d. All contractors and subcontractors shall comply with conditions specified in VAAR 852.204-71(d); Contractor operations required to be in United States. All contractors and subcontractors working with VA information must be permanently located within a jurisdiction subject to the law of the United States or its Territories to the maximum extent feasible. If services are proposed to be performed abroad the contractor must state where all non-U.S. services are provided. The contractor shall deliver to VA a detailed plan specifically addressing communications, personnel control, data protection and potential legal issues. The plan shall be approved by the COR/CO in writing prior to access being granted.

e. The contractor shall notify the COR/CO in writing immediately (no later than 24 hours) after personnel separation or occurrence of other causes. Causes may include the following:

(1) Contractor/subcontractor personnel no longer has a need for access to VA information or VA information systems.

(2) Contractor/subcontractor personnel are terminated, suspended, or otherwise has their work on a VA project discontinued for any reason.

(3) Contractor believes their own personnel or subcontractor personnel may pose a threat to their company’s working environment or to any company-owned property. This includes contractor-owned assets, buildings, confidential data, customers, employees, networks, systems, trade secrets and/or VA data.

(4) Any previously undisclosed changes to contractor/subcontractor background history are brought to light, including but not limited to changes to background investigation or employee record.

(5) Contractor/subcontractor personnel have their authorization to work in the United States revoked.

(6) Agreement by which contractor provides products and services to VA has either been fulfilled or terminated, such that VA can cut off electronic and/or physical access for contractor personnel.

f. In such cases of contract fulfillment, termination, or other causes; the contractor shall take the necessary measures to immediately revoke access to VA network, property, information, and information systems (logical and physical) by contractor/subcontractor personnel. These measures include (but are not limited to): removing and then securing Personal Identity Verification (PIV) badges and PIV – Interoperable (PIV-I) access badges, VA-issued photo badges, credentials for VA facilities and devices, VA-issued laptops, and authentication tokens. Contractors shall notify the appropriate VA COR/CO immediately to initiate access removal.

g. Contractors/subcontractors who no longer require VA accesses will return VA-issued property to VA. This property includes (but is not limited to): documents, electronic equipment, keys, and parking passes. PIV and PIV-I access badges shall be returned to the nearest VA PIV Badge Issuance Office. Once they have had access to VA information, information systems, networks and VA property in their possessions removed, contractors shall notify the appropriate VA COR/CO.

4. TRAINING

a. All contractors and subcontractors requiring access to VA information and VA information systems shall successfully complete the following before being granted access to VA information and its systems:

(1) VA Privacy and Information Security Awareness and Rules of Behavior course (Talent Management System (TMS) #10176) initially and annually thereafter.

(2) Sign and acknowledge (electronically through TMS #10176) understanding of and responsibilities for compliance with the Organizational Rules of Behavior, relating to access to VA information and information systems initially and annually thereafter; and

(3) Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system or information access [to be defined by the VA program official and provided to the VA CO for inclusion in the solicitation document – i.e., any role-based information security training].

b. The contractor shall provide to the COR/CO a copy of the training certificates and certification of signing the Organizational Rules of Behavior for each applicable employee within five days of the initiation of the contract and annually thereafter, as required.

c. Failure to complete the mandatory annual training 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 required training is complete.

5. SECURITY INCIDENT INVESTIGATION

a. The contractor, subcontractor, their employees, or business associates shall immediately (within one hour) report suspected security / privacy incidents to the VA OIT’s Enterprise Service Desk (ESD) by calling (855) 673-4357 (TTY: 711). The ESD is OIT’s 24/7/365 single point of contact for IT-related issues. After reporting to the ESD, the contractor, subcontractor, their employees, or business associates shall, within one hour, provide the COR/CO the incident number received from the ESD.

b. To the extent known by the contractor/subcontractor, the contractor/ subcontractor's notice to VA shall identify the information involved and the circumstances surrounding the incident, including the following:

(1) The date and time (or approximation of) the Security Incident occurred.

(2) The names of individuals involved (when applicable).

(3) The physical and logical (if applicable) location of the incident.

(4) Why the Security Incident took place (i.e., catalyst for the failure).

(5) The amount of data belonging to VA believed to have been compromised.

(6) The remediation measures the contractor is taking to ensure no future incidents of a similar nature.

c. After the contractor has provided the initial detailed incident summary to VA, they will continue to provide written updates on any new and relevant circumstances or facts they discover. The contractor, subcontractor, and their employes shall fully cooperate with VA or third-party entity performing an independent risk analysis on behalf of VA. Failure to cooperate may be deemed a material breach and grounds for contract termination.

d. VA IT contractors shall follow VA Handbook 6500, Risk Management Framework for VA Information Systems VA Information Security Program, and VA Information Security Knowledge Service guidance for implementing an Incident Response Plan or integrating with an existing VA implementation.

e. 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 the VA Office of 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.

f. The contractor shall comply with VA Handbook 6500.2, Management of Breaches Involving Sensitive Personal Information, which establishes the breach management policies and assigns responsibilities for the oversight, management and reporting procedures associated with managing of breaches.

g. With respect to unsecured Protected Health Information (PHI), the contractor is deemed to have discovered a data breach when the contractor knew or should have known of breach of such information. When a business associate is part of VHA contract, notification to the covered entity (VHA) shall be made in accordance with the executed BAA.

h. If the contractor or any of its agents fails to protect VA sensitive personal information or otherwise engages in conduct which results in a data breach involving any VA sensitive personal information the contractor/subcontractor processes or maintains under the contract; the contractor shall pay liquidated damages to the VA as set forth in clause 852.211-76, Liquidated Damages—Reimbursement for Data Breach Costs.

6. INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE OR USE.

a. The contractor shall comply with all Federal laws, regulations, and VA policies for Information systems (cloud and non-cloud) that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities. Security controls for collecting, processing, transmitting, and storing of VA sensitive information, must be in place. The controls will be tested by VA or a VA sanctioned 3PAO and approved by VA prior to hosting, operation, maintenance or use of the information system or systems by or on behalf of VA. This includes conducting compliance risk assessments, security architecture analysis, routine vulnerability scanning, system patching, change management procedures and the completion of an acceptable contingency plan for each system. The contractor’s security control procedures shall be the same as procedures used to secure VA-operated information systems.

b. Outsourcing (contractor facility, equipment, or staff) of systems or network operations, telecommunications services or other managed services require Assessment and Authorization (A&A) of the contractor’s systems in accordance with VA Handbook 6500 as specified in VA Information Security Knowledge Service. Major changes to the A&A package may require reviewing and updating all the documentation associated with the change. The contractor’s cloud computing systems shall comply with FedRAMP and VA Directive 6517 requirements.

c. The contractor shall return all electronic storage media (hard drives, optical disks, CDs, back-up tapes, etc.) on non-VA leased or non-VA owned IT equipment used to store, process or access VA information to VA in accordance with A&A package requirements. This applies when the contract is terminated or completed and prior to disposal of media. The contractor shall provide its plan for destruction of all VA data in its possession according to VA Information Security Knowledge Service requirements and NIST 800-88. The contractor shall send a self-certification that the data destruction requirements above have been met to the COR/CO within 30 business days of termination of the contract.

d. All external internet connections to VA network involving VA information must be in accordance with VA Trusted Internet Connection (TIC) Reference Architecture and VA Directive and Handbook 6513, Secure External Connections and reviewed and approved by VA prior to implementation. Government-owned contractor-operated systems, third party or business partner networks require a Memorandum of Understanding (MOU) and Interconnection Security Agreements (ISA).

e. Contractor procedures shall be subject to periodic, announced, or unannounced assessments by VA officials, the OIG or a 3PAO. The physical security aspects associated with contractor activities are also subject to such assessments. The contractor shall report, in writing, any deficiencies noted during the above assessment to the VA COR/CO. The contractor shall use VA’s defined processes to document planned remedial actions that address identified deficiencies in information security policies, procedures, and practices. The contractor shall correct security deficiencies within the timeframes specified in the VA Information Security Knowledge Service.

f. All major information system changes which occur in the production environment shall be reviewed by the VA to determine the impact on privacy and security of the system. Based on the review results, updates to the Authority to Operate (ATO) documentation and parameters may be required to remain in compliance with VA Handbook 6500 and VA Information Security Knowledge Service requirements.

g. The contractor shall conduct an annual privacy and security self-assessment on all information systems and outsourced services as required. Copies of the assessment shall be provided to the COR/CO. The VA/Government reserves the right to conduct assessment using government personnel or a third-party if deemed necessary. The contractor shall correct or mitigate any weaknesses discovered during the assessment.

h. VA prohibits the installation and use of personally owned or contractor-owned equipment or software on VA information systems. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW, PWS, PD or contract. All security controls required for government furnished equipment must be utilized in VA approved Other Equipment (OE). Configuration changes to the contractor OE, must be funded by the owner of the equipment. All remote systems must use a VA-approved antivirus software and a personal (host-based or enclave based) firewall with a VA-approved configuration. The contractor shall ensure software on OE is kept current with all critical updates and patches. Owners of approved OE are responsible for providing and maintaining the anti-virus software and the firewall on the non-VA owned OE. Approved contractor OE will be subject to technical inspection at any time.

i. The contractor shall notify the COR/CO within one hour of disclosure or successful exploits of any vulnerability which can compromise the confidentiality, integrity, or availability of the information systems. The system or effected component(s) need(s) to be isolated from the network. A forensic analysis needs to be conducted jointly with VA. Such issues will be remediated as quickly as practicable, but in no event longer than the timeframe specified by VA Information Security Knowledge Service. If sensitive personal information is compromised reference VA Handbook 6500.2 and Section 5, Security Incident Investigation.

j. For cases wherein the contractor discovers material defects or vulnerabilities impacting products and services they provide to VA, the contractor shall develop and implement policies and procedures for disclosure to VA, as well as remediation. The contractor shall, within 30 business days of discovery, document a summary of these vulnerabilities or defects. The documentation will include a description of the potential impact of each vulnerability and material defect, compensating security controls, mitigations, recommended corrective actions, root cause analysis and/or workarounds (i.e., monitoring). Should there exist any backdoors in the products or services they provide to VA (referring to methods for bypassing computer authentication), the contractor shall provide the VA CO/CO written assurance they have permanently remediated these backdoors.

k. All other vulnerabilities, including those discovered through routine scans or other assessments, will be remediated based on risk, in accordance with the remediation timelines specified by the VA Information Security Knowledge Service and/or the applicable timeframe mandated by Cybersecurity & Infrastructure Security Agency (CISA) Binding Operational Directive (BOD) 22-01 and BOD 19-02 for Internet-accessible systems. Exceptions to this paragraph will only be granted with the approval of the COR/CO.

Based upon a review of the PWS/SOW as presented, the contractor will have access to VA sensitive information to fulfill the terms of the contract. That sensitive information will include PII/PHI. However, this situation falls under an exception to the BAA rule, covered entity. A BAA will not be required. Please contact the Privacy Officer at V21PALPrivacyoffice@va.gov.

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