MOU RE SHARING OF VITAL RECORDS DATA WITH ADHS.PDF

MEMORANDUM OF UNDERSTANDING
MOU No. HU456045
MEMORANDUM OF UNDERSTANDING
FOR THE SHARING OF VITAL RECORDS DATA
BETWEEN
ARIZONA DEPARTMENT OF HEALTH SERVICES
AND
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH
WHEREAS, the Arizona Department of Health Services (ADHS) is a division of the State of Arizona established
to promote and protect public health and welfare through the operation of health related programs within the
state.
WHEREAS, the Maricopa County Department of Public Health is a division of county government established to
promote and protect public health and welfare through the operation of health related programs within the county.
WHEREAS, the Maricopa County Department of Public Health is a public health authority pursuant to the
requirements of the Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191) (HIPAA) and
applicable law.
WHEREAS, ADHS and the Maricopa County Department of Public Health recognize the need to set forth and
define the terms under which ADHS will provide data files to the Maricopa County Department of Public Health
containing public health records of county residents for the development of community health profiles and other
general public health surveillance activities and Public Health Practice performed by the Maricopa County
Department of Public Health.
NOW, THEREFORE, in consideration of the mutual promises and representations set forth in this Memorandum
of Understanding (MOU), the Maricopa County Department of Public Health and ADHS mutually agree as follows:
1. DEFINITIONS. Capitalized terms used herein shall have the meanings set forth in this Section 1.
1.1. "Authorized Persons" means Maricopa County Department of Public Health employees
or contractors who have a need to know or otherwise access Personally Identifying Information to
enable the Maricopa County Department of Public Health to perform its mission in conformance
with the requirements of this MOU and who are bound in writing by confidentiality obligations
sufficient to protect Personally Identifying Information in accordance with the terms and
conditions of this MOU and applicable law.
1.2. “County Data” means data included within the selection criteria of this MOU as specified in
section 2.2.1 for release only to “authorized persons” as defined under the MOU, and subject to
use and ownership as defined in section 19 of this MOU.
1.3. “Vital Records Data” means the vital records data organized and maintained by ADHS Vital
Records under A.R.S. 36-301 §34 and A.A.C. R9-19-306 and applicable law.
1.4. "Personally Identifying Information" means information provided to the Maricopa County
Department of Public Health by, or at the direction of, ADHS that: (i) identifies or can be used to
identify an individual (including, without limitation, names, signatures, addresses, telephone
numbers, e-mail addresses and other unique identifiers); or (ii) can be used to authenticate an
individual (including, without limitation, employee identification numbers, government-issued
identification numbers, passwords or PINs, financial account numbers, credit report information,
biometric or health data, answers to security questions and other personal identifiers). ADHS’
business contact information is not by itself deemed to be Personal Information.
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MEMORANDUM OF UNDERSTANDING
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1.5. “Public Health Practice” means interventions designed solely to enhance the well-being of the
specific subject population identified in this MOU, and which have reasonable expectation of
success.
1.6. “Research” means a systematic investigation, including research development, testing and
evaluation, designed to develop or contribute to generalizable knowledge. Activities which meet
this definition constitute research for purposes of this MOU, whether or not they are conducted
or supported under a program which is considered research for other purposes. For example,
some demonstration and service programs may include research activities.
1.7. "Security Breach" means: (i) any act or omission that materially compromises either the
security, confidentiality or integrity of Personally Identifying Information or the physical,
technical, administrative or organizational safeguards put in place by the Maricopa County
Department of Public Health or any Authorized Persons that relate to the protection of the
security, confidentiality or integrity of Personal Information, or (ii) receipt of a complaint in
relation to the privacy practices of the Maricopa County Department of Public Health or any
Authorized Persons or a breach or alleged breach of this MOU relating to such privacy practices.
2. PURPOSE AND SCOPE OF AGREEMENT
2.1. Purpose
Subject to availability of data and ADHS resources, ADHS agrees to provide the Maricopa
County Department of Public Health with County Data from Vital Records in a mutually
agreeable format. Currently, the Maricopa County Department of Public Health registers births,
deaths, and fetal deaths within Maricopa County and issues certified copies of vital records
through participation in the ADHS OVR Customer Service Management System (CSMS),
Electronic Birth Registration System (EBRS), and to the Electronic Death Registration System
(EDRS) and the Electronic Fetal Death Registration System (EDFRS). The Maricopa County
Department of Public Health requires access to the corresponding database tables and read-
only access to the front-end applications to ensure correct data interpretation and provide for
data quality assurance and quality improvement support. Access granted to both the database
tables and the front end applications will be for read-only mode (with no write, edit or update
ability) in order to allow the Maricopa County Department of Public Health staff to view records
on the web-based systems as well as the underlying data which will be limited to County Data
only.
2.2 Scope
Section 2.1 notwithstanding, the Parties agree that the Maricopa County Department of Public
Health does not require, and ADHS shall not provide the Maricopa County Department of Public
Health (except upon specific request) with data files containing any of the following information
related to any individual county resident: (i) signatures, telephone numbers, e-mail addresses;
(ii) employee identification numbers, passwords or PINs, credit report information, answers to
security questions and other similar personal identifiers; (iii) individual's government-issued
identification number (including driver's license number or state-issued identified number); and
(iv) financial account number, credit card number, debit card number, credit report information,
with or without any required security code, access code, personal identification number or
password, that would permit access to an individual’s financial account or accounts.
2.2.1 Selection Criteria
ADHS will select records to give to the Maricopa County Department of Public Health if
the record meets this criterion: for residents within Maricopa County, registered within
Maricopa County, submitted by a facility within Maricopa County, or remains transported
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MEMORANDUM OF UNDERSTANDING
MOU No. HU456045
within Maricopa County for inclusion.
2.2.2. Data Requests
To request data the Maricopa County Department of Public Health must submit a
request in writing to ADHS. Following initial release of data under this MOU, the
Maricopa County Department of Public Health may request updated data and/or as
needed.
2.3 Inadvertent Disclosure
In the event that the Maricopa County Department of Public Health is inadvertently provided with
data files containing any of the information listed in subsection 2.2, the Maricopa County
Department of Public Health will notify ADHS of the disclosure and delete or destroy such data
files upon ADHS’s request.
3. NO SUPERSESSION OF PAST AGREEMENTS
This MOU is not intended to and shall not supersede or replace any currently valid MOU in place
between the Maricopa County Department of Public Health and ADHS.
4. TERM OF THE AGREEMENT
The Term of this MOU shall commence upon signature of both parties and shall continue for a period of
five (5) years, unless terminated, or canceled as otherwise provided herein.
5. CONTRACT EXTENSION
This MOU shall not exceed a total of five (5) years from the effective date of the MOU.
6. TERMINATION
6.1. This MOU remains in effect as provided in Sections 4 and 5 or until the MOU is otherwise
terminated under the following terms and conditions:
6.1.1. Termination without Cause
Both ADHS and the Maricopa County Department of Public Health may terminate this
MOU at any time with thirty (30) calendar days’ notice, in writing, specifying the
termination date. Such notices shall be given by personal delivery or by certified mail,
return receipt requested.
6.1.2. Termination for Default
The ADHS reserves the right to terminate the MOU in whole or in part due to the failure
of the Maricopa County Department of Public Health to comply with any material
obligation, term or condition of this MOU. ADHS agrees to provide the Maricopa County
Department of Public Health with written notice detailing the area of alleged lack of
compliance or non-performance and to provide the Maricopa County Department of
Public Health with thirty (30) days to correct the alleged lack of compliance or non-
performance prior to termination for default.
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MEMORANDUM OF UNDERSTANDING
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6.1.3. Cancellation for Conflict of Interest
Pursuant to A.R.S. § 38-511, ADHS may cancel this MOU within three (3) years after
MOU execution without penalty or further obligation if any person significantly involved
in initiating, negotiating, securing, drafting or creating the MOU on behalf of ADHS is, or
becomes at any time while the MOU or an extension of the MOU are in effect, an
employee of or a consultant to any other party to this MOU with respect to the subject
matter of the MOU. The cancellation shall be effective upon receipt of the written notice
of cancellation, unless the notice specifies a later time.
7. SECURITY OF CONFIDENTIAL INFORMATION
7.1. The Maricopa County Department of Public Health shall monitor the use of all Vital Records Data
disclosed by ADHS under this MOU, including but not limited to Personal Identifying Information,
and to carefully restrict the use and disclosure of such information as provided for herein.
7.2. Survival of Duty to Protect Confidential Information
It is understood and agreed by the Parties that the obligations set forth in this Section 7, shall
survive the expiration or termination of this MOU, except as expressly provided for herein.
7.3. Minimum Safeguards for PHI
7.3.1. The Maricopa County Department of Public Health shall carefully restrict use and access
of ADHS Personally Identifying Information solely to Authorized Persons and shall ensure
that the Maricopa County Department of Public Health implements the following minimum
safeguards to prevent a Security Breach in a manner consistent with the requirements of
this MOU or applicable law. The Maricopa County Department of Public Health safeguards
shall, at the minimum, require that the Maricopa County Department of Public Health and
its Authorized Persons:
7.3.2. Prohibit Personally Identifying Information supplied under the terms of this MOU from
being released or disclosed to anyone not working on the Maricopa County Department of
Public Health data collection and analysis as an Authorized Person.
7.3.3. Ensure that any Authorized Persons, including any agent, or subcontractor to the
Maricopa County Department of Public Health, to whom the Maricopa County Department
of Public Health provides confidential medical information, or Personally Identifying
Information under this MOU, agrees to the same restrictions and conditions that apply
through this MOU to the Maricopa County Department of Public Health with respect to
such information.
7.3.4. Secure all printouts containing individual identifiers or confidential data in a locked vault,
file cabinet or other method reasonably necessary to protect the confidential information.
7.3.5. Store all Vital Records Data shared pursuant to this MOU only on secured servers or
encrypted devices within the Maricopa County Department of Public Health, which, at the
termination of this MOU, shall be securely deleted upon the conclusion of this MOU
consistent with the requirements of this MOU and applicable law.
7.3.6. Provide ADHS with a description of the security measures that are in place to maintain the
confidentiality of the data being received under this MOU. The Maricopa County
Department of Public Health will consider the items described in the document titled
"Security Considerations for Applicants" prepared by the ADHS HSRB (See
http://www.azdhs.gov/ops/oacr/documents/HSRB_SecurityChecklist.pdf).
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MEMORANDUM OF UNDERSTANDING
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7.3.7. Provide ADHS, upon request, with a current list of Authorized Persons, and evidence
that all Authorized Persons who have access to the Vital Records Data shared under this
MOU have participated in any required training and signed any documents that are
necessary to keep both the Maricopa County Department of Public Health and ADHS in
compliance with HIPAA, including but not limited to, Business Associate Agreement, user
confidentiality affirmation statement, HIPAA training certification or other HIPAA related
compliance documents, if applicable.
7.3.8. Provide or continue to provide the ADHS with a copy of the Maricopa County Department
of Public Health's procedure for the notification of ADHS of any Security Breach, which
shall include a requirement that any user of the Vital Records Data shared under this MOU
shall immediately notify a designated individual at the Maricopa County Department of
Public Health of any known or reasonably suspected Security Breach.
7.3.9. Maintain a log of all encrypted devices and identification numbers of those devices that
are authorized to transmit, receive or store the Vital Records Data shared under this MOU,
until the data is destroyed. The ADHS may request a copy of the log at any time during the
term of the MOU or until the data is destroyed.
7.3.10. Make clear to all Authorized Persons and other the Maricopa County Department of Public
Health employees with a need to know that the Maricopa County Department of Public
Health is prohibited from storing Vital Records Data on non-encrypted flash drives, CDs,
external drives, smart phones or other non- networked hard drives.
7.3.11. Provide ADHS prompt proof of the complete destruction of the original data and any
copies or subsidiary data sets containing Personally Identifying Information that are
developed from the original data upon the conclusion of this MOU or at such time that
such destruction is required by applicable law.
7.3.12. Take all reasonable steps to ensure that Authorized Persons who have access to the Vital
Records Data shared under this MOU shall maintain the same in strict confidence after the
termination of this MOU; provided that the Maricopa County Department of Public Health’s
obligations hereunder shall not apply to information that:
7.3.13. Was already known to the receiving party prior to the time of first disclosure, as
demonstrated by contemporaneous, written documentation; or
7.3.13.1. Is received without any obligation of confidentiality from a third party
having a legal right to disclose the same; or
7.3.13.2. Is independently developed by the receiving party by individuals without
access to such information, as demonstrated by contemporaneous,
written documentation; or
7.3.13.3. Is required to be disclosed by the receiving party pursuant to a legally
enforceable order, subpoena, or other regulation (ORDER), provided,
however, that the receiving party promptly notifies the disclosing party In
advance of such disclosure and discloses only that information necessary
to comply with said ORDER.
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MEMORANDUM OF UNDERSTANDING
MOU No. HU456045
7.4. Security Breach
In the event of a Security Breach, pursuant to A.R.S. § 44-7501, the Maricopa County
Department of Public Health and ADHS agree to collaborate with each other on the
investigation, mitigation, remediation and, if necessary, breach notification of citizens. Pursuant
to A.R.S. § 41-3507, the Maricopa County Department of Public Health and ADHS shall notify
the Arizona Strategic Enterprise Technology (ASET) Statewide Information Security and Privacy
Office (SISPO) immediately upon becoming aware or receiving notice of a Security Breach.
8. NON-DISCRIMINATION
The Parties shall comply with Executive Order 75-5 as modified by Executive Order 2009-09, which
mandates that all persons, regardless of race, color, religion, sex, age, national origin or political
affiliation, shall have equal access to employment opportunities, and all other applicable State and
Federal employment laws, rules, and regulations, including the Americans with Disabilities Act. The
Parties shall take affirmative action to ensure that applicants for employment and employees are not
discriminated against due to race, creed, color, religion, sex, national origin or disability.
9. RECORDS AND RIGHT OF INSPECTION
Under A.R.S. § 35-214 and § 35-215, the Maricopa County Department of Public Health shall retain all
data and other records (“records”) relating to the MOU for a period of five (5) years after the completion
of the MOU. All records shall be subject to inspection and audit by ADHS at reasonable times. The
Maricopa County Department of Public Health shall provide ADHS the right of access to the Maricopa
County Department of Public Health and those servers or drives used for the storage of Personally
Identifying Information, at all reasonable times, in order to monitor and evaluate performance,
compliance, and/or quality assurance under this MOU.
10. ARBITRATION
The parties to this MOU agree to resolve all disputes arising out of or relating to this MOU, after
exhausting applicable administrative review, through arbitration to the extent required by A.R.S. §12-
1518
11. AMENDMENT OR MODIFICATIONS
No amendment or modifications to this MOU, including any amendment or modification of this Section,
shall be effective unless the same is in writing signed by the Parties.
12. ARIZONA LAW
The law of Arizona applies to this MOU including, where applicable, the Uniform Commercial Code as
adopted by the State of Arizona.
13. RELATIONSHIP OF PARTIES
The Maricopa County Department of Public Health warrants that it is acting as an independent entity
under this MOU. Neither party to this MOU shall be deemed to be the employee or agent of the other
party to the MOU.
14. SEVERABILITY
The Provisions of this MOU are severable. Any term or condition deemed illegal or invalid shall not
affect any other term or condition of the MOU.
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MEMORANDUM OF UNDERSTANDING
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15. NO PAROLE EVIDENCE
This MOU is intended by the parties to be a final and complete expression of their agreement. No
course of prior dealings between the parties and no usage of the trade shall supplement or explain any
terms used in this document.
16. NO WAIVER
Either Party’s failure to insist on strict performance of any term or condition of the MOU shall not be
deemed a waiver of that term or condition even if the party accepting or acquiescing in the
nonconforming performance knows of the nature of the performance and fails to object to it.
17. HEADINGS
Headings are for organizational purposes only and shall not be interpreted as having legal significance
or meaning.
18. ADVERTISING AND PROMOTION OF CONTRACT
The Maricopa County Department of Public Health shall not advertise, publish, or re-release any
information for commercial benefit concerning this MOU without the prior written approval of an ADHS
Procurement Officer and the ADHS Human Subject Review Board (HSRB).
19. DATA USE AND OWNERSHIP
19.1. The Maricopa County Department of Public Health will use the Vital Records Data exclusively for
(i) community health profiles; (ii) health surveillance activities; (iii) public health interventions
designed solely to enhance the well-being of county residents.
19.2. The Maricopa County Department of Public Health must request approval from ADHS HSRB to
use data for the development of research studies as defined in this MOU. If it is unclear to the
Maricopa County Department of Public Health whether the data use is research or public health
practice or both, then the Maricopa County Department of Public Health must request clarification
from ADHS HSRB.
19.3. Maricopa County Department of Public Health activities using the ADHS data that generate
external papers or publications for dissemination outside of the Maricopa County Department of
Public Health must have specific written review and clearance from the data owner at ADHS
before release. The Maricopa County Department of Public Health shall allow 30 calendar days for
ADHS review.
19.4. ADHS shall be cited as the source of the data in all tables, reports, presentations, and scientific
papers, and the Maricopa County Department of Public Health or its corresponding authors shall
be cited as the source of interpretations, calculations, and/or manipulations of the data.
19.5. ADHS retains exclusive ownership of the data shared with The Maricopa County Department of
Public Health under this MOU. Any release, or modified re-release, of data shared under this MOU
requires prior ADHS approval.
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MEMORANDUM OF UNDERSTANDING
MOU No. HU456045
20. NOTICES, CORRESPONDENCE AND REPORTS
20.1. Notices, correspondence and reports from Maricopa County Department of Public Health to ADHS
shall be sent to:
ARIZONA DEPARTMENT OF HEALTH SERVICES
Hospital Data Manager, Bureau of Public Health Statistics
150 N. 18th Avenue, Suite 550
Phoenix, AZ 85007
Phone: (602)542-8064
20.2. Notices, correspondence, and reports from ADHS to Maricopa County Department of Public
Health shall be sent to:
Maricopa County Department of Public Health
Attn: Kaila (Gail) Johnson
Grants/Contracts Administrator
4041 N. Central Avenue, Suite 1400
Phoenix, Arizona 85012-3314
Phone: (602) 372-0674
Fax: (602) 506-6885
KailaJohnson@mail.maricopa.gov
21. SIGNATURES/APPROVALS:
For: Maricopa County Department For: Arizona Department of Health Services:
of Public Health
________________________________ ____________________________________
Steve Chucri Authorized Signature
Board Chairman
________________________________ ____________________________________
Date Print Name & Title
____________________________________
Date
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