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VA Technical Reference Model v 24.11

Nuance Clintegrity

General Information

Technologies must be operated and maintained in accordance with Federal and Department security and privacy policies and guidelines. More information on the proper use of the TRM can be found on the TRM Proper Use Tab/Section.

Website:	Go to site
Description:	Nuance Clintegrity is an application that provides a number of modules that interface with Veterans Health Information Systems and Technology Architecture (VistA). This Clinical Decision Support (CDS) application is used in order to manage health information, capture and document information at the point-of-care, and facilitate automated chart review. The Clintegrity product and associated modules are installed on the same VA server, enabling clients to access the system using a web-based interface. This technology stores sensitive data in a Microsoft Structured Query Language (SQL) Server database and supports Transparent Data Encryption (TDE). Please note that there is no specific product page for this technology and thus the vendor webpage is used in its place.
Technology/Standard Usage Requirements:	Users must ensure their use of this technology/standard is consistent with VA policies and standards, including, but not limited to, VA Handbooks 6102 and 6500; VA Directives 6004, 6513, and 6517; and National Institute of Standards and Technology (NIST) standards, including Federal Information Processing Standards (FIPS). Users must ensure sensitive data is properly protected in compliance with all VA regulations. Prior to use of this technology, users should check with their supervisor, Information Security Officer (ISO), Facility Chief Information Officer (CIO), or local Office of Information and Technology (OI&T) representative to ensure that all actions are consistent with current VA policies and procedures prior to implementation.
Section 508 Information:	This technology has not been assessed by the Section 508 Office. The Implementer of this technology has the responsibility to ensure the version deployed is 508-compliant. Section 508 compliance may be reviewed by the Section 508 Office and appropriate remedial action required if necessary. For additional information or assistance regarding Section 508, please contact the Section 508 Office at Section508@va.gov
Decision:	View Decisions

Decision Source:	TRM Mgmt Group
Decision Process:	One-VA TRM v24.4
Decision Date:	04/22/2024 at 17:37:29 UTC
Aliases:	Nuance Clintegrity 360
Introduced By:	TRM Request
Vendor Name:	Nuance

Vendor Release Information

The Vendor Release table provides the known releases for the TRM Technology, obtained from the vendor (or from the release source).

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Version	Release Date	Vendor End of Life Date	Vendor Desupport Date
17.x
18.x
19.x
20.x
21.x
22.x
23.x
24.x

Current Decision Matrix (04/17/2024)

Users must ensure their use of this technology/standard is consistent with VA policies and standards, including, but not limited to, VA Handbooks 6102 and 6500; VA Directives 6004, 6513, and 6517; and National Institute of Standards and Technology (NIST) standards, including Federal Information Processing Standards (FIPS). Users must ensure sensitive data is properly protected in compliance with all VA regulations. Prior to use of this technology, users should check with their supervisor, Information Security Officer (ISO), Facility Chief Information Officer (CIO), or local Office of Information and Technology (OI&T) representative to ensure that all actions are consistent with current VA policies and procedures prior to implementation.

The VA Decision Matrix displays the current and future VAIT position regarding different releases of a TRM entry. These decisions are based upon the best information available as of the most current date. The consumer of this information has the responsibility to consult the organizations responsible for the desktop, testing, and/or production environments to ensure that the target version of the technology will be supported.

Legend:

White	Authorized: The technology/standard has been authorized for use.
Yellow	Authorized w/ Constraints: The technology/standard can be used within the specified constraints located below the decision matrix in the footnote[1] and on the General tab.
Gray	Authorized w/ Constraints (POA&M): This technology or standard can be used only if a POA&M review is conducted and signed by the Authorizing Official Designated Representative (AODR) as designated by the Authorizing Official (AO) or designee and based upon a recommendation from the POA&M Compliance Enforcement, has been granted to the project team or organization that wishes to use the technology.
Orange	Authorized w/ Constraints (DIVEST): VA has decided to divest itself on the use of the technology/standard. As a result, all projects currently utilizing the technology/standard must plan to eliminate their use of the technology/standard. Additional information on when the entry is projected to become unauthorized may be found on the Decision tab for the specific entry.
Black	Unauthorized: The technology/standard is not (currently) permitted to be used under any circumstances.
Blue	Authorized w/ Constraints (PLANNING/EVALUATION): The period of time this technology is currently being evaluated, reviewed, and tested in controlled environments. Use of this technology is strictly controlled and not available for use within the general population. If a customer would like to use this technology, please work with your local or Regional OI&T office and contact the appropriate evaluation office displayed in the notes below the decision matrix. The Local or Regional OI&T office should submit an inquiry to the TRM if they require further assistance or if the evaluating office is not listed in the notes below.

Release/Version Information:

VA decisions for specific versions may include a ‘.x’ wildcard, which denotes a decision that pertains to a range of multiple versions.

For example, a technology authorized with a decision for 7.x would cover any version of 7.(Anything) - 7.(Anything). However, a 7.4.x decision would cover any version of 7.4.(Anything), but would not cover any version of 7.5.x or 7.6.x on the TRM.

VA decisions for specific versions may include ‘+’ symbols; which denotes that the decision for the version specified also includes versions greater than what is specified but is not to exceed or affect previous decimal places.

For example, a technology authorized with a decision for 12.6.4+ would cover any version that is greater than 12.6.4, but would not exceed the .6 decimal ie: 12.6.401 is ok, 12.6.5 is ok, 12.6.9 is ok, however 12.7.0 or 13.0 is not.

Any major.minor version that is not listed in the VA Decision Matrix is considered Authorized w/ Constraints (POA&M).

<Past

CY2021

CY2022

CY2023

Future>

Release

17.x

Unapproved

18.x

DIVEST
[2, 9, 10]

Unapproved

19.x

DIVEST
[2, 9, 10]

Unapproved

20.x

Approved w/Constraints
[2, 9, 10]

DIVEST
[2, 9, 10]

DIVEST
[2, 10, 11]

DIVEST
[2, 10, 12]

Unapproved

21.x

Unapproved

Approved w/Constraints
[2, 9, 10]

Approved w/Constraints
[2, 10, 11]

DIVEST
[2, 10, 12]

DIVEST
[2, 12, 13]

DIVEST
[2, 13, 14, 15, 16]

Unapproved

22.x

Unapproved

Approved w/Constraints
[2, 10, 12]

Approved w/Constraints
[2, 12, 13]

DIVEST
[2, 13, 14, 15, 16]

DIVEST
[2, 14, 15, 16, 17]

23.x

Unapproved

Approved w/Constraints
[2, 13, 14, 15, 16]

Approved w/Constraints
[2, 14, 15, 16, 17]

24.x

Unapproved

Decision Constraints


[1]	Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. All instances of deployment using this technology should be reviewed by the local ISO (Information Security Officer) to ensure compliance with VA Handbook 6500.

[2]	Technology must remain patched and operated in accordance with Federal and Department security policies and guidelines in order to mitigate known and future security vulnerabilities.

[3]	Per the May 5th, 2015 memorandum from the VA Chief Information Security Officer (CISO) FIPS 140-2 Validate Full Disk Encryption (FOE) for Data at Rest in Database Management Systems (DBMS) and in accordance with Federal requirements and VA policy, database management must use Federal Information Processing Standards (FIPS) 140-2 compliant encryption to protect the confidentiality and integrity of VA information at rest at the application level. If FIPS 140-2 encryption at the application level is not technically possible, FIPS 140-2 compliant full disk encryption (FOE) must be implemented on the hard drive where the DBMS resides. Appropriate access enforcement and physical security control must also be implemented. All instances of deployment using this technology should be reviewed to ensure compliance with VA Handbook 6500 and National Institute of Standards and Technology (NIST) standards. It is the responsibility of the system owner to work with the local CIO (or designee) and Information Security Officer (ISO) to ensure that a compliant DBMS technology is selected and that if needed, mitigating controls are in place and documented in a System Security Plan (SSP).

[4]	Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. All instances of deployment using this technology should be reviewed by the local ISO (Information Security Officer) to ensure compliance with VA Handbook 6500.

[5]	Per the May 5th, 2015 memorandum from the VA Chief Information Security Officer (CISO) FIPS 140-2 Validate Full Disk Encryption (FOE) for Data at Rest in Database Management Systems (DBMS) and in accordance with Federal requirements and VA policy, database management must use Federal Information Processing Standards (FIPS) 140-2 compliant encryption to protect the confidentiality and integrity of VA information at rest at the application level. If FIPS 140-2 encryption at the application level is not technically possible, FIPS 140-2 compliant full disk encryption (FOE) must be implemented on the hard drive where the DBMS resides. Appropriate access enforcement and physical security control must also be implemented. All instances of deployment using this technology should be reviewed to ensure compliance with VA Handbook 6500 and National Institute of Standards and Technology (NIST) standards. It is the responsibility of the system owner to work with the local CIO (or designee) and Information Security Officer (ISO) to ensure that a compliant DBMS technology is selected and that if needed, mitigating controls are in place and documented in a System Security Plan (SSP).

[6]	This product is Class 2 or Class 3 VA-designed and built Local Software OR is a commercially-licensed software product purchased or leased that will run in a VA VISTA environment or integrate with Class 1 National VISTA Software. Presence of this software on the One-VA TRM does not equate to designation as a Class 1 National Software product and MUST NOT be assumed to comply with all VA programming standards, namespacing and interface control agreement standards, data management standards, documentation standards, information assurance standards, security standards and 508 compliance standards. As a Class 2 or Class 3 product, it MUST NOT be assumed to having been released into production through all OI&T product release and sustainment process controls for project management; requirements, development and testing management; and configuration, change, and release management necessary to satisfy OI&T process and product compliance. The OI&T Enterprise Program Management Office does not endorse nor support Class 2 and Class 3 products and does not support data usage or application programmer interfaces (APIs) between Class 1 National Software products and Class 2 or Class 3 products. Class 2 or Class 3 products must restrict their interfaces to Class 1 National Software to use of publicly-supported APIs ONLY. VA Directive 6402, Modifications to Standardized National Software, dictates the policy for Class 2 and Class 3 products and modifications to Class 1 National Software products. Local enhancements to, or modifications of, Class 1 Protected National Software (as listed in the Directive), in part or in whole, is PROHIBITED. Local enhancements to, or modifications of, Non-Protected Class 1 National Software is allowed ONLY with an authorized waiver by the Software Modification Waiver Committee (SMWC). Class 2 and Class 3 software that does not modify the Class 1 National Software in any way must still adhere to namespacing and interface control agreement standards as well as National Field Operations Processes.

[7]	It is advised that if this product is used within the Department of Veterans Affairs (VA) that the following constraints be applied: 1. Ensure use of a FIPS 140-2 validated cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. 2. VA must require that the vendor provide security patching and updates for AdoptOpenJDK in a timely manner. 3. Extended support for Java SE 8 is available until March 2025, and the vendor must manage the Java version upgrade roadmap.

[8]	Per the Initial Product Review, users must abide by the following constraints: Ensure use of a FIPS 140-2 validated cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. The vendor indicated that Nuance servers that run the Nuance Clintegrity software will be utilizing AdoptJDK on the vendors end. The vendor has ensured the VA that AdoptJDK will not be used on the client side. Additionally, the vendor has indicated that they will provide security patching and updates for AdoptJDK. The VA must require that the vendor provide security patching and updates in a timely manner. Extended support for Java SE 8 is available until March 2025, and the vendor must manage the Java version upgrade roadmap. Users must ensure that Microsoft Internet Explorer (IE) and Microsoft Structured Query Language (SQL) Server are implemented with VA-authorized baselines. (refer to the ‘Category’ tab under ‘Runtime Dependencies’)

[9]	Per the Initial Product Review, users must abide by the following constraints: Ensure use of a FIPS 140-2 validated cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. The vendor indicated that Nuance servers that run the Nuance Clintegrity software will be utilizing AdoptJDK on the vendors end. The vendor has ensured the VA that AdoptJDK will not be used on the client side. Additionally, the vendor has indicated that they will provide security patching and updates for AdoptJDK. The VA must require that the vendor provide security patching and updates in a timely manner. Extended support for Java SE 8 is available until March 2025, and the vendor must manage the Java version upgrade roadmap. Users must ensure that Microsoft Internet Explorer (IE) and Microsoft Structured Query Language (SQL) Server are implemented with VA-authorized baselines. (refer to the ‘Category’ tab under ‘Runtime Dependencies’)

[10]	Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. All instances of deployment using this technology should be reviewed by the local ISO (Information Security Officer) to ensure compliance with VA Handbook 6500.

[11]	Per the Initial Product Review, users must abide by the following constraints: Ensure use of a FIPS 140-2 validated cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. The vendor indicated that Nuance servers that run the Nuance Clintegrity software will be utilizing AdoptJDK on the vendors end. The vendor has ensured the VA that AdoptJDK will not be used on the client side. Additionally, the vendor has indicated that they will provide security patching and updates for AdoptJDK. The VA must require that the vendor provide security patching and updates in a timely manner. Extended support for Java SE 8 is available until March 2025, and the vendor must manage the Java version upgrade roadmap. Users must ensure that Firefox, Google Chrome, Apache Tomcat, Adobe Acrobat Reader Document Cloud (DC), Microsoft Internet Explorer (IE) and Microsoft Structured Query Language (SQL) Server are implemented with VA-authorized baselines. (refer to the ‘Category’ tab under ‘Runtime Dependencies’) Microsoft Internet Explorer, a dependency of this technology, is in a Divested status at the time of writing.

[12]	Per the Initial Product Review, users must abide by the following constraints: Ensure use of a FIPS 140-2 validated cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. The vendor indicated that Nuance servers that run the Nuance Clintegrity software will be utilizing AdoptOpenJDK on the vendors end. The vendor has ensured the VA that AdoptOpenJDK will not be used on the client side. Additionally, the vendor has indicated that they will provide security patching and updates for AdoptOpenJDK. The VA must require that the vendor provide security patching and updates in a timely manner. Extended support for Java SE 8 is available until March 2025, and the vendor must manage the Java version upgrade roadmap. Users must ensure that Firefox, Google Chrome, Apache Tomcat, Adobe Acrobat Reader Document Cloud (DC), Microsoft Internet Explorer (IE) and Microsoft Structured Query Language (SQL) Server are implemented with VA-authorized baselines. (refer to the ‘Category’ tab under ‘Runtime Dependencies’) Users must Divest the use of Internet Explorer with this technology. Other authorized internet browsers are available. See Category Tab for details. AdoptOpenJDK is unapproved on the TRM and will not be used on the VA client side.

[13]	Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. All instances of deployment using this technology should be reviewed by the local ISSO (Information System Security Officer) to ensure compliance with VA Handbook 6500.

[14]	Users must ensure that Apache Tomcat, Citrix Virtual Apps and Desktops (CVAD) and Microsoft Structured Query Language (SQL) Server are implemented with VA-authorized baselines. (refer to the ‘Category’ tab under ‘Runtime Dependencies’) Users must utilize authorized internet browsers, as Microsoft Internet Explorer has reached End of Life status. See Category Tab for details. Users must not utilize AdoptOpenJDK, as it is at the time of writing, unapproved in the TRM. Per the Initial Product Review, users must abide by the following constraints: Ensure use of a FIPS 140-2 certified cryptographic module to secure VA sensitive data in applications and devices that use Nuance Clintegrity. The vendor indicated that Nuance servers that run the Nuance Clintegrity software will be utilizing AdoptJDK on the vendors end. The vendor has ensured the VA that AdoptJDK will not be used on the client side. Additionally, the vendor has indicated that they will provide security patching and updates for AdoptJDK. The VA must require that the vendor provide security patching and updates in a timely manner. Extended support for Java SE 8 is available until March 2025, and the vendor has agreed to manage the Java version upgrade roadmap.

[15]	Per the May 5th, 2015 memorandum from the VA Chief Information Security Officer (CISO) FIPS 140-2 Validate Full Disk Encryption (FOE) for Data at Rest in Database Management Systems (DBMS) and in accordance with Federal requirements and VA policy, database management must use Federal Information Processing Standards (FIPS) 140-2 compliant encryption to protect the confidentiality and integrity of VA information at rest at the application level. If FIPS 140-2 encryption at the application level is not technically possible, FIPS 140-2 compliant full disk encryption (FOE) must be implemented on the hard drive where the DBMS resides. Appropriate access enforcement and physical security control must also be implemented. All instances of deployment using this technology should be reviewed to ensure compliance with VA Handbook 6500 and National Institute of Standards and Technology (NIST) standards. It is the responsibility of the system owner to work with the local CIO (or designee) and Information System Security Officer (ISSO) to ensure that a compliant DBMS technology is selected and that if needed, mitigating controls are in place and documented in a System Security Plan (SSP).

[16]	The Federal Information Processing standards (FIPS) 140-2 certification status of this technology was not able to be verified. This technology will require a 3rd party FIPS 140-2 or 140-3 certified solution for any data containing PHI/PII or VA sensitive information, where applicable. More information regarding the Cryptographic Module Validation Program (CMVP) can be found on the NIST website.

[17]	Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. All instances of deployment using this technology should be reviewed by the local ISSO (Information System Security Officer) to ensure compliance with both VA Handbook 6500 and VA Directive 6500.

Note:

At the time of writing, version 24.1.1 is the most current version.

Technology Components

Note: This list may not be complete. No component, listed or unlisted, may be used outside of the technology in which it is released. The usage decision for a component is found in the Decision and Decision Constraints.

Name	Description
AdoptOpen Java Development Kit (JDK)	This component is an open source library composed of build and test systems for Open Java Development Kit (OpenJDK). Implementation of this component is constrained by conditions set within the Initial Product Review (IPR) associated with Nuance Clintegrity alone.
Clintegrity Abstracting	This module includes functionality to create coding queries and reports.
Clintegrity Coding	The Encoder consists of facility coding using International Classification of Diseases (ICD)-10 and Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS) coding standards, reporting, and references. This is a web-based application accessed through Microsoft (MS) Internet Explorer (IE).
Clintegrity Compliance	The Compliance module improves the quality of data and acts as an early warning system to identify potential areas of noncompliance. Compliance supports long-term success by helping to prioritize and customize edits and educate staff. This application can also be used for outpatient Clinical Documentation Improvement (CDI) reviews.
Clintegrity Interface Engine (CIE)	The Clintegrity Interface Engine (CIE) plugs into an enterprise-wide healthcare integration system. The CIE facilitates Health Level Seven (HL7) transactions using several industry-wide protocols.
Clintegrity Interlink	Interlink is an interface between the user modules and the Encoder.
Clintegrity Record Management	This module oversees deficient encounters and generates reports, as determined by each facility`s internal requirements. The information generated is shown in real-time from the Veterans Health Information Systems and Technology Architecture (VistA) Text Integration Utility (TIU) package.
Clintegrity VA Clinical Document Improvement (CDI) Pro	The Clintegrity VA Clinical Document Improvement (CDI) Pro module helps improve a facility`s inpatient clinical documentation and facilitates the gathering of pertinent clinical indicators to accurately represent the patient`s severity, acuity, and risk of mortality.
Clintegrity VA DocuViewer	The VA DocuViewer allows end users to view Veterans Health Information Systems and Technology Architecture (VistA) Text Integration Utility (TIU) notes within the Clintegrity Coding Screen Graphical User Interface (GUI).
Clintegrity Veteran Equitable Resource Allocation (VERA) Analyzer	This module targets inpatient admissions that may need coding revisions or clinical documentation improvements to ensure a patient is assigned to the appropriate VERA Patient Class and Price Group.


Collaboration and Electronic Workplace Productivity Software	Accounting and Finance
Health Care Administrative	Health Delivery Support

General Analysis

Adoption Benefits

This technology supports role-based authentication and authorization capabilities.
At the time of writing, no National Institute of Standards and Technology (NIST) vulnerabilities had been reported and no VA Cyber Security Operations Center (CSOC) bulletins had been issued for the latest versions of this technology.

Adoption Risks

The potential exists to store Personally Identifiable Information (PII), Protected Health Information (PHI) and/or VA Sensitive data and proper security standards must be followed in these cases.
There is limited publicly available technical documentation for this technology.
The product is not Federal Information Processing Standards (FIPS) 140-2 certified.
Nuance Clintegrity uses AdoptJDK which is unapproved on the VA TRM.
The product has a dependency on Java SE 8 which is approaching End of Life (EOL).
The technology requires the purchase of licenses from vendor, which could potentially lead to vendor lock-in.
Due to the rapid release schedule of this technology, the VA may be unable to update to the most recent patch and may require a deployment model requiring the use of specific versions.
This technology can integrate with and alter database technologies.
There is no indication based on either the vendor documentation or the Cryptographic Module Validation Program (CMVP) that this technology is Federal Information Processing Standard (FIPS) 140-2 compliant.

Architectural Benefits

This technology can use a VA-preferred database.
This technology is compatible with virtual machines, therefore consistent with the enterprise Server Virtualize First Policy (VAIQ 7266972 08-27-2012).
This technology supports deployment in a virtualized Citrix environment.

Architectural Risks

This technology is not portable as it runs only on Windows platforms.

- The information contained on this page is accurate as of the Decision Date (04/22/2024 at 17:37:29 UTC).

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VA Technical Reference Model v 24.11

General Information

Vendor Release Information

Current Decision Matrix (04/17/2024)

Decision Constraints

References

Technology Components

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General Analysis

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VA Technical Reference Model v 24.11

General Information

Vendor Release Information

Current Decision Matrix (04/17/2024)

Decision Constraints

References

Technology Components

VA Categories View the VA Categorization Framework

Operating Systems Supported by the Technology

Technologies/Standards Relationships

Runtime Dependencies:

Optional Dependencies:

Comparable Technologies:

Companion Technologies/Supported Standards:

General Analysis

Adoption Benefits

Adoption Risks

Architectural Benefits

Architectural Risks

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