Policies and procedures to inform data-related activities were developed by the NACHC Clinical Affairs team in partnership with other NACHC teams and external partners. These policies and procedures can be applied to any activities where data of any kind is received, collected, or generated, referred to as 'informatics work' hereinafter. 

What Does Data Governance Mean to NACHC? 

NACHC defines data governance as a framework to guide the usability, integrity and security of data and to instill trust in the use of data and data-related sources across systems. At NACHC, the data governance infrastructure encompasses a decision-making body, rules (policies and procedures), decision rights (how we “decide how to decide”), accountabilities, and enforcement methods for people and information systems as they perform information-related processes.

Our data governance framework focuses on how NACHC uses processes, policies, procedures, and communication tools that ensure that data received from outside organizations and collected by NACHC is used to improve the health of individual patients and tell the health center story. 

Data Governance Decision-Making 

NACHC's data-related work is overseen by a Data Governance Council ('GC'). The GC does not provide direct informatics project oversight, but does make recommendations and decisions about project participation, implementation, and the informatics architecture used to carry out informatics projects. A description of the NACHC data and informatics architecture is available here. 

The GC meets monthly and includes nine members who represent 1) NACHC leadership, regulatory, and analytic staff, and 2) external data partners and project partners who represent a range of perspectives and collective expertise in clinical care, informatics, data science, and population health. Details of the GC membership, scope, and operations (e.g., scope, voting) are defined in a charter. 

Governance Domains and Guiding Principles

There are four domains of governance that are relevant to NACHC's informatics work: data governance, information governance, software governance, and partnership governance. While these policies and procedures are focused on data governance, some aspects of information governance, software governance, and partnership governance may be relevant.

Within those domains, NACHC adheres to eight governance principles: accountability, transparency, integrity, protection, compliance, availability, retention, and disposition as identified by the American Health Information and Management Association (AHIMA). Definitions of each are available on a related site. Relevant topics within each governance domain are addressed below. 

Section 1: Governance Approach

Roles 

NACHC conducts informatics work in partnership with data partners and project partners. 

A data partner is an organization owning and/or providing data to NACHC which can include organizations providing direct health services such as federally qualified health centers (FQHCs), primary care associations (PCA), or health center controlled networks (HCCN). FQHCs are data owners in that they own the data collected by their organization. PCAs and HCCNs do not collect clinical data but serve as a data steward for clinical data provided by their members and contribute data on behalf of their member organizations. Federal agencies such as the Health Resources and Services Administration may also be data partners, providing data to NACHC on behalf of FQHCs (example: UDS data). 

A project partner is an organization who participates in or supports informatics work by providing subject matter expertise, funding, vendor services, or other technical assistance. Vendor services may include analysis which can require direct access to project data.

Project Structure

NACHC organizes and tracks informatics work in projects. A project is established for each unique dataset that is housed by NACHC. When NACHC is performing many distinct analytic services on a given dataset, multiple projects may be established. Each project has a Confluence website which defines the project team, provides links to relevant project documentation and agreements, location of project data, and tracks project progress.  Projects have regular status meetings. Minutes and meeting materials from status meetings are made available on Confluence.  At the start of each project, a project team is identified and includes members of the the data contributor and NACHC staff and documented on the project Confluence page. Additionally, members of the project team who will have access to project data are identified at the project inception. As the project team evolves through the project lifecycle, the project team is updated on Confluence and in project-related documentation, as appropriate.

Shared Data 

There are two types of data that may be shared with NACHC.

De-identified data is data that has been “stripped of all HIPAA defined identifiers” which includes Personally Identifiable Information (PII) and Protected Health Information (PHI). 

A limited data set (LDS) is data that has been “stripped of all HIPAA identifiers, except age/dates and city/state/zip”. 

Identified data sets which include PHI identified beyond that which would qualify as a LDS and are not accepted by NACHC at this time. 

Informatics Services

NACHC's informatics services can include subject matter expertise, technical assistance, data management, and analysis services, which are defined in the table below.  Most informatics projects involve multiple informatics services. 

Work Products and Attribution

Informatics work generates the following work products: data quality results, analytic results, value sets, measure definitions, and recommendations. Work products are owned by all members of the project team and can be shared in manuscripts, abstracts, slides, and guidance documents. How and to whom work products are attributed is discussed with all project partners at the outset and as the project evolves to ensure that attribution of work projects is accurate and equitable.  

Identification of Health Centers in Work Products

TBD

Section 2: Contracts and Regulatory

Data Use Agreements (DUAs)

Because a LDS is still PHI, the HIPAA Privacy Regulations contemplate that the privacy of individuals will be protected by requiring covered entities (e.g.,health centers) to enter into DUAs with recipients of the LDS (NACHC). The data use agreement must meet standards specified in the Privacy Regulations. The purpose of a DUA, as required by HIPAA, is to:

• establish the permitted uses and disclosures of the limited data set;
• identify who may use or receive the information;
• prohibit the recipient from using or further disclosing the information, except as permitted by the agreement or as permitted by law;
• require the recipient to use appropriate safeguards to prevent a use or disclosure that is not permitted by the agreement;
• require the recipient to report to the covered entity any unauthorized use or disclosure of which it becomes aware;
• require the recipient to ensure that any agents (including a subcontractor) to whom it provides the information will agree to the same restrictions as provided in the agreement; and
• prohibit the recipient from identifying the information or contacting the individuals.

Because DUA's require a high level of specificity, each DUA is project-specific. DUAs can be two party, meaning between NACHC and a data contributor, or multi-party, meaning between NACHC and multiple data contributors. Additionally, DUA's can include a reciprocity clause so that the DUA functions in both directions, a data partner sharing data with NACHC and NACHC sharing data with a data partner.

NACHC has a DUA template that has been vetted and approved by NACHC legal council. Alternatively, data partners are welcome to request the use of their institutional DUA template that can be customized for the project by NACHC staff. A process to initiate a DUA is documented below.

De-identified data does not require a data use agreement (DUA); however some data partners may require a DUA just to cover their transmission of the data to another entity. PII is a subset of PHI and the list of 18 data elements that are considered PHI are documented in the HIPAA Safe Harbor definition. To be considered de-identified, all 18 identifiers must be removed. Some data partners participate in date-shifting of encounter dates.  

- a LDS DUA is required when HIPAA authorization for the data sharing has not been obtained from the participants. If participants have signed a HIPAA authorization that allows for the data sharing, a DUA referencing a LDS is not necessary. It is rare that HIPAA authorization has been collected from patients for a NACHC project as most projects are secondary data analysis.

DUA Responsibilities 

When NACHC is the provider of the data:

NACHC has drafted a DUA for use by those who wish to disclose a LDS to recipients.  This template may be accessed from the NACHC contracts office. When NACHC is providing a LDS, if any material change is to be made to the NACHC template, or if another party’s version of a DUA is to be used, the NACHC legal council must review and approve the terms of the agreement. 

When NACHC is the recipient of the data:

If NACHC is the recipient of a LDS of PHI from a non-NACHC source, the NACHC project lead with either use the NACHC template or be asked to sign the other party’s Data Use Agreement.  When using another party's DUA, the NACHC project lead is responsible for reviewing the Data Use Agreement and determining if it complies in material terms with the NACHC DUA template.  If the other party’s DUA differs materially from the NACHC DUA template, or if there is any uncertainty, the NACHC legal council must be consulted.

Process to Initiate a Data Use Agreement (DUA)

Not all projects require a DUA but each project where data is being shared should consider the need for a data use agreement upon project initiation. The following process is recommended. 

1. 1. NACHC project lead completes the NACHC DUA Checklist to determine if a DUA is needed. This should occur as part of the project's initiation.
   2. The checklist is reviewed with data partner at an early project meeting to confirm the need for a DUA and level of identification of a dataset
   3. Once completed, the DUA checklist is stored in the project Confluence page. 
   4. If the DUA checklist identified a need for a DUA, the checklist is shared with the NACHC contract officer to begin the creation of a project-specific DUA.

Section 3: Requests

Section 4: Other Governance Topics 

Institutional Review Board (IRB)

NACHC adheres to the Office for Human Research Protections regulations (45 CFR part 46) of human subjects research. NACHC informatics work is primarily quality improvement (QI) in nature which OHRP provides specific IRB guidelines. In general, OHRP states that QI is not human subjects research. Research is defined as systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.  When QI projects do not align with this research definitions, HHS regulations for the protection of human subjects do not apply and there is no requirement under these regulations for such activities to undergo review by an IRB, or for these activities to be conducted with provider or patient informed consent.

However, NACHC does conduct research and some quality improvement projects with research elements, which requires IRB review. NACHC has a relationship multiple IRBs but recommends the use of the IRB at AT Still University with whom NACHC has an established relationship. A detailed manual is available to provide guidance for an IRB submission. NACHC also supports data partners or project partners use of an affiliated IRB. When IRB is needed, NACHC appoints an institutional primary investigator. Individuals who can be NACHC PI's maintain the appropriate CITI certifications and have an established PI number with AT Still's IRB.