Privacy Act of 1974; System of Records, 16103-16108 [E8-6144]
Download as PDF
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
RECORD ACCESS PROCEDURES:
Individuals seeking information
regarding access to and contesting of
records in this system may write, call or
visit the VA facility location where they
made application for employment or
appointment, or are or were employed.
CONTESTING RECORDS PROCEDURES:
(See Record Access Procedures).
RECORD SOURCE CATEGORIES:
Information in this system of records
is provided by the applicant/employee,
or obtained from State licensing boards,
Federation of State Medical Boards,
National Council of State Boards of
Nursing, National Practitioner Data
Bank, Health Integrity and Protection
Data Bank, professional societies,
national certifying bodies, current or
previous employers, other health care
facilities and staff, references,
educational institutions, medical
schools, VA staff, patient, visitors, and
VA patient medical records.
[FR Doc. E8–6143 Filed 3–25–08; 8:45 am]
BILLING CODE 8320–01–P
DEPARTMENT OF VETERANS
AFFAIRS
Privacy Act of 1974; System of
Records
AGENCY:
Department of Veterans Affairs
(VA).
Notice of Amendment of
Systems of Records Notice ‘‘National
Patient Databases-VA.’’
pwalker on PROD1PC71 with NOTICES
ACTION:
SUMMARY: As required by the Privacy
Act of 1974 (5 U.S.C. 552a(e)(4)), notice
is hereby given that the Department of
Veterans Affairs (VA) is amending the
system of records entitled ‘‘National
Patient Databases-VA’’ (121VA19) as set
forth in 69 FR 18436. VA is amending
the system of records by revising the
System Location, Categories of Records
in the System, Purpose(s), Routine Uses
of Records Maintained in the System,
Including Categories of Users and the
Purposes of Such Uses, and Appendix 4.
VA is republishing the system notice in
its entirety.
DATES: Comments on this amended
system of records must be received no
later than April 25, 2008. If no public
comment is received during the period
allowed for comment or unless
otherwise published in the Federal
Register by VA, the amended system
will become effective April 25, 2008.
ADDRESSES: Written comments
concerning the proposed amended
system of records may be submitted
through www.Regulations.gov; by mail
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
or hand-delivery to Director,
Regulations Management (00REG1),
Department of Veterans Affairs, 810
Vermont Avenue, NW., Room 1068,
Washington, DC 20420; by fax to (202)
273–9026; or by e-mail to:
‘‘VAregulations@mail.va.gov’’. All
comments received will be available for
public inspection in the Office of
Regulation Policy and Management,
Room 1063B, between the hours of 8
a.m. and 4:30 p.m., Monday through
Friday (except holidays). Please call
(202) 273–9515 for an appointment. In
addition, during the comment period,
comments may be viewed online
through the Federal Docket Management
System (FDMS) at: https://
www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT:
Stephania H. Putt, Veterans Health
Administration (VHA) Privacy Officer,
Department of Veterans Affairs, 810
Vermont Avenue NW., Washington, DC
20420, telephone (704) 245–2492.
SUPPLEMENTARY INFORMATION:
Background: VHA is the largest health
care provider in the country. In order to
maintain this organization, VHA
collects health care information from its
local facilities to evaluate quality of
services, clinical resource utilization,
and patient safety, as well as to
distribute medical information, such as
alerts or recalls, track specific diseases,
and monitor patients. National-level
information is also needed for other
activities, such as medical research and
the development of National Best
Clinical Practice Guidelines and
National Quality Standards. VHA
gathers this information from a wide
variety of sources, including directly
from a veteran; from information
systems located at VHA medical centers,
Veterans Integrated Service Networks
(VISN), other VHA facilities, such as the
Health Eligibility Center; and Federal
departments and agencies such as the
U.S. Department of Defense and the
Food and Drug Administration. As the
data is collected, VHA stores it in
several national patient databases.
In this system of records the Category
of Records in the System is amended to
reflect the data Office of Quality and
Performance (OQP) is collecting, and to
include the Survey of the Healthcare
Experiences of Patients and External
Peer Review data capture. These data
include any patient-level records
created for evaluation as directed by the
VHA Performance Management Program
or accreditation purposes as defined by
the Joint Commission. This information
is collected so that OQP can assess,
without organizational bias, the
adherence of its treatment centers to
PO 00000
Frm 00139
Fmt 4703
Sfmt 4703
16103
established clinical protocol for
providing care to veterans and to
monitor the satisfaction of its patient
customers.
The Purpose in this system of records
is being amended to reflect that the
records and information may be used for
statistical analysis to produce various
management, workload tracking, and
follow-up reports; to track and evaluate
the ordering and delivery of equipment,
services and patient care; for the
planning, distribution and utilization of
resources; to monitor the performance of
Veterans Integrated Service Networks
(VISN); and to allocate clinical and
administrative support to patient
medical care. The data may be used for
VA’s extensive research programs in
accord with VA policy. In addition, the
data may be used to assist in workload
allocation for patient treatment services
including provider panel management,
nursing care, clinic appointments,
surgery, prescription processing,
diagnostic and therapeutic procedures;
to plan and schedule training activities
for employees; for audits, reviews and
investigations conducted by the
Network Directors Office and VA
Central Office; for quality assurance
audits, reviews and investigations; for
law enforcement investigations; and for
personnel management, evaluation and
employee ratings, and performance
evaluations. Survey data will be
collected for the purpose of measuring
and monitoring National, VISN and
Facility-Level performance on VHA’s
Veteran Health Care Service Standards
(VHSS). The VHSS are designed to
measure levels of patient satisfaction in
areas that patients have defined as
important in receiving quality, patientcentered healthcare. Results of the
survey data analysis are shared
throughout the VHA system. The
External Peer Review Program (EPRP)
data is collected in order to provide
medical centers and outpatient clinics
with diagnosis and procedure-specific
quality of care information. EPRP is a
contracted review of care, specifically
designated to collect data to be used to
improve the quality of care.
Routine Uses of Records Maintained
in the System, Including Categories of
Users and the Purposes of Such Uses is
being amended to reflect the addition of
protecting 38 U.S.C. 5705 Quality
Assurance Records, which may not be
disclosed under a routine use unless
there is also specific statutory authority
permitting the disclosure. Routine uses
numbers 1, 5, 10, 12, 13, 14, 15, and 17
have been revised for ease of readability
and clarification.
Routine use 19 was added to allow for
the disclosure of information to another
E:\FR\FM\26MRN1.SGM
26MRN1
pwalker on PROD1PC71 with NOTICES
16104
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
Federal agency for the purpose of
conducting research.
Routine use 20 was added to allow for
the disclosure of limited identification
information to another Federal agency
in order to obtain information to carry
out any purpose outlined in this system
of records.
Routine use number 21 was added to
allow for records to be disclosed to
appropriate agencies, entities, and
persons under the following
circumstances: when (1) it is suspected
or confirmed that the integrity or
confidentiality of information in the
system of records has been
compromised; (2) the Department has
determined that as a result of the
suspected or confirmed compromise
there is a risk of embarrassment or harm
to the reputations of the record subjects,
harm to economic or property interests,
identity theft or fraud, or harm to the
security, confidentiality, or integrity of
this system or other systems or
programs (whether maintained by the
Department or another agency or entity)
that rely upon the compromised
information; and (3) the disclosure is
made to such agencies, entities, and
persons who are reasonably necessary to
assist in connection with the
Department’s efforts to respond to the
suspected or confirmed compromise
and prevent, minimize, or remedy such
harm. This routine use allows
disclosure by the agency to respond to
a suspected or confirmed data breach,
including the conduct of any risks
analysis or provision of credit
protection services as provided in 38
U.S.C. 5724, as the terms are defined in
38 U.S.C. 5727.
Routine use 22 was added to
accommodate the disclosure of Primary
Care Management Module (PCMM) data
to the general public.
Appendix 4 has been amended to
include Cardiac Assessment Tracking
and Reporting for Cardiac Cauterization
Laboratories, Corporate Data
Warehouse, CMOP Centralized Database
System, Bidirectional Health
Information Exchange, Financial
Clinical Data Mart, Care Management
Information System, Parkinson’s Disease
Research, Education and Clinical
Centers Registry, Pharmacy Benefits
Management, VA Vital Status File, Short
Form Health Survey for Veterans and
Office of Quality Performance Data
Center. Also, the KLF Menu was
renamed to Veterans Integrated Service
Network Support Service Center
Database. Immunology Case Registry
was removed and Clinical Case Registry
was changed to Registries to represent
the Immunology Case Registry (ICR) and
Hepatitis C. There was also removal of
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
the National Patient Care Database
(NPCD), Patient Treatment File (PTF)
and the National Health Care
Practitioner Database (NHCPD) which
are now entered as a single system
called National Medical Information
System (NMIS).
The notice of amendment and an
advance copy of the system notice have
been sent to the appropriate
Congressional committees and to the
Director of Office of Management and
Budget (OMB) as required by 5 U.S.C.
552a(r) (Privacy Act) and guidelines
issued by OMB (65 FR 77677),
December 12, 2000.
Approved: March 12, 2008.
Gordon H. Mansfield,
Deputy Secretary of Veterans Affairs.
information related to medical
examination or treatment (e.g., location
of VA medical facility providing
examination or treatment, treatment
dates, medical conditions treated or
noted on examination); information
related to military service and status;
3. Medical benefit and eligibility
information;
4. Patient aggregate workload data
such as admissions, discharges, and
outpatient visits; resource utilization
such as laboratory tests, x-rays;
5. Patient Satisfaction Survey Data
which include questions and responses;
and
6. External Peer Review Program
(EPRP) data capture.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
121VA19
Title 38, United States Code, Section
501.
SYSTEM NAME:
PURPOSE(S):
National Patient Databases—VA.
SYSTEM LOCATION:
Records are maintained at Department
of Veterans Affairs (VA) medical
centers, VA data processing centers,
veterans integrated service networks
(VISN) and office of information (OI)
field offices. Address location for each
VA national patient database is listed in
VA Appendix 4 at the end of this
document.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:
The records contain information for
all individuals (1) Receiving health care
from the Veterans Health
Administration (VHA), and (2)
Providing the health care. Individuals
encompass veterans and their
immediate family members, members of
the armed services, current and former
employees, trainees, contractors, subcontractors, consultants, volunteers, and
other individuals working
collaboratively with VA.
CATEGORIES OF RECORDS IN THE SYSTEM:
The records may include information
and health information related to:
1. Patient medical record abstract
information including information from
Patient Medical Record—VA (24VA19).
2. Identifying information (e.g., name,
birth date, death date, admission date,
discharge date, gender, Social Security
number, taxpayer identification
number); address information (e.g.,
home and/or mailing address, home
telephone number, emergency contact
information such as name, address,
telephone number, and relationship);
prosthetic and sensory aid serial
numbers; medical record numbers;
integration control numbers;
PO 00000
Frm 00140
Fmt 4703
Sfmt 4703
The records and information may be
used for statistical analysis to produce
various management, workload tracking,
and follow-up reports; to track and
evaluate the ordering and delivery of
equipment, services and patient care; for
the planning, distribution and
utilization of resources; to monitor the
performance of Veterans Integrated
Service Networks (VISN); and to
allocate clinical and administrative
support to patient medical care. The
data may be used for VA’s extensive
research programs in accord with VA
policy. In addition, the data may be
used to assist in workload allocation for
patient treatment services including
provider panel management, nursing
care, clinic appointments, surgery,
prescription processing, diagnostic and
therapeutic procedures; to plan and
schedule training activities for
employees; for audits, reviews and
investigations conducted by the network
directors office and VA Central Office;
for quality assurance audits, reviews
and investigations; for law enforcement
investigations; and for personnel
management, evaluation and employee
ratings, and performance evaluations.
Survey data will be collected for the
purpose of measuring and monitoring
national, VISN and facility-Level
performance on VHA’s Veteran Health
Care Service Standards (VHSS) pursuant
to Executive Order 12862 and the
Veterans Health Administration
Customer Service Standards Directive.
The VHSS are designed to measure
levels of patient satisfaction in areas
that patients have defined as important
in receiving quality, patient-centered
healthcare. Results of the survey data
analysis are shared throughout the VHA
system. The External Peer Review
E:\FR\FM\26MRN1.SGM
26MRN1
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
Program (EPRP) data are collected in
order to provide medical centers and
outpatient clinics with diagnosis and
procedure-specific quality of care
information. EPRP is a contracted
review of care, specifically designated to
collect data to be used to improve the
quality of care.
pwalker on PROD1PC71 with NOTICES
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:
To the extent that records contained
in the system include information
protected by 38 U.S.C. 7332, i.e.,
medical treatment information related to
drug abuse, alcoholism or alcohol abuse,
sickle cell anemia or infection with the
human immunodeficiency virus;
information protected by 38 U.S.C 5705,
i.e., quality assurance records; or
information protected by 45 C.F.R. Parts
160 and 164, i.e., individually
identifiable health information, such
information cannot be disclosed under a
routine use unless there is also specific
statutory authority permitting the
disclosure. VA may disclose protected
health information pursuant to the
following routine uses where required
or permitted by law.
1. VA may disclose on its own
initiative any information in this
system, except the names and home
addresses of veterans and their
dependents, that is relevant to a
suspected or reasonably imminent
violation of law, whether civil, criminal
or regulatory in nature and whether
arising by general or program statute or
by regulation, rule or order issued
pursuant thereto, to a Federal, State,
local, tribal, or foreign agency charged
with the responsibility of investigating
or prosecuting such violation, or
charged with enforcing or implementing
the statute, regulation, rule or order. On
its own initiative, VA may also disclose
the names and addresses of veterans and
their dependents to a Federal agency
charged with the responsibility of
investigating or prosecuting civil,
criminal or regulatory violations of law,
or charged with enforcing or
implementing the statute, regulation,
rule or order issued pursuant thereto.
2. Disclosure may be made to any
source from which additional
information is requested (to the extent
necessary to identify the individual,
inform the source of the purpose(s) of
the request, and identify the type of
information requested), when necessary
to obtain information relevant to an
individual’s eligibility, care history, or
other benefits.
3. Disclosure may be made to an
agency in the executive, legislative, or
judicial branch, or the District of
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
Columbia government in response to its
request or at the initiation of VA, in
connection with disease tracking,
patient outcomes or other health
information required for program
accountability.
4. Disclosure may be made to National
Archives and Records Administration
(NARA) for it to perform its records
management inspections
responsibilities in its role as Archivist of
United States under authority of title 44
United States Code (USC).
5. VA may disclose information in
this system of records to the Department
of Justice (DoJ), either on VA’s initiative
or in response to DoJ’s request for the
information, after either VA or DoJ
determines that such information is
relevant to DoJ’s representation of the
United States or any of its components
in legal proceedings before a court or
adjudicative body, provided that, in
each case, the agency also determines
prior to disclosure that disclosure of the
records to the Department of Justice is
a use of the information contained in
the records that is compatible with the
purpose for which VA collected the
records. VA, on its own initiative, may
disclose records in this system of
records in legal proceedings before a
court or administrative body after
determining that the disclosure of the
records to the court or administrative
body is a use of the information
contained in the records that is
compatible with the purpose for which
VA collected the records.
6. Records from this system of records
may be disclosed to a Federal agency or
to a State or local government licensing
board and/or to the Federation of State
Medical Boards or a similar nongovernment entity that maintains
records concerning individuals’
employment histories or concerning the
issuance, retention or revocation of
licenses, certifications, or registration
necessary to practice an occupation,
profession or specialty, in order for the
agency to obtain information relevant to
an agency decision concerning the
hiring, retention or termination of an
employee.
7. Records from this system of records
may be disclosed to inform a Federal
agency, licensing boards or the
appropriate non-government entities
about the health care practices of a
terminated, resigned or retired health
care employee whose professional
health care activity so significantly
failed to conform to generally accepted
standards of professional medical
practice as to raise reasonable concern
for the health and safety of patients
receiving medical care in the private
sector or from another Federal agency.
PO 00000
Frm 00141
Fmt 4703
Sfmt 4703
16105
8. For program review purposes and
the seeking of accreditation and/or
certification, disclosure may be made to
survey teams of the Joint Commission,
College of American Pathologists,
American Association of Blood Banks,
and similar national accreditation
agencies or boards with whom VA has
a contract or agreement to conduct such
reviews but only to the extent that the
information is necessary and relevant to
the review.
9. Disclosure may be made to a
national certifying body that has the
authority to make decisions concerning
the issuance, retention or revocation of
licenses, certifications or registrations
required to practice a health care
profession, when requested in writing
by an investigator or supervisory official
of the national certifying body for the
purpose of making a decision
concerning the issuance, retention or
revocation of the license, certification or
registration of a named health care
professional.
10. Records from this system that
contain information listed in 5 U.S.C.
7114(b)(4) may be disclosed to officials
of labor organizations recognized under
5 U.S.C. Chapter 71 when relevant and
necessary to their duties of exclusive
representation concerning personnel
policies, practices, and matters affecting
working conditions.
11. Disclosure may be made to the
representative of an employee of all
notices, determinations, decisions, or
other written communications issued to
the employee in connection with an
examination ordered by VA under
medical evaluation (formerly fitness-forduty) examination procedures or
Department-filed disability retirement
procedures.
12. VA may disclose information to
officials of the Merit Systems Protection
Board, or the Office of Special Counsel,
when requested in connection with
appeals, special studies of the civil
service and other merit systems, review
of rules and regulations, investigation of
alleged or possible prohibited personnel
practices, and such other functions,
promulgated in 5 U.S.C. 1205 and 1206,
or as may be authorized by law.
13. VA may disclose information to
the Equal Employment Opportunity
Commission when requested in
connection with investigations of
alleged or possible discriminatory
practices, examination of Federal
affirmative employment programs, or for
other functions of the Commission as
authorized by law or regulation.
14. VA may disclose information to
the Federal Labor Relations Authority
(including its General Counsel)
information related to the establishment
E:\FR\FM\26MRN1.SGM
26MRN1
pwalker on PROD1PC71 with NOTICES
16106
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
of jurisdiction, the investigation and
resolution of allegations of unfair labor
practices, or information in connection
with the resolution of exceptions to
arbitration awards when a question of
material fact is raised; to disclose
information in matters properly before
the Federal Services Impasses Panel,
and to investigate representation
petitions and conduct or supervise
representation elections.
15. Disclosure of medical record data,
excluding name and address, unless
name and address are furnished by the
requester, may be made to non-Federal
research facilities for research purposes
determined to be necessary and proper
when approved in accordance with VA
policy.
16. Disclosure of name(s) and
address(s) of present or former
personnel of the Armed Services, and/
or their dependents, may be made to: (a)
A Federal department or agency, at the
written request of the head or designee
of that agency; or (b) directly to a
contractor or subcontractor of a Federal
department or agency, for the purpose of
conducting Federal research necessary
to accomplish a statutory purpose of an
agency. When disclosure of this
information is made directly to a
contractor, VA may impose applicable
conditions on the department, agency,
and/or contractor to insure the
appropriateness of the disclosure to the
contractor.
17. Disclosure may be made to
individuals, organizations, private or
public agencies, or other entities or
individuals with whom VA has a
contract or agreement to perform such
services as VA may deem practicable for
the purposes of laws administered by
VA, in order for the contractor,
subcontractor, public or private agency,
or other entity or individual with whom
VA has an agreement or contract to
perform the services of the contract or
agreement. This routine use includes
disclosures by the individual or entity
performing the service for VA to any
secondary entity or individual to
perform an activity that is necessary for
individuals, organizations, private or
public agencies, or other entities or
individuals with whom VA has a
contract or agreement to provide the
service to VA.
18. Disclosure may be made to a
congressional office from the record of
an individual in response to an inquiry
from the congressional office made at
the request of that individual.
19. VA may disclose information to a
Federal agency for the conduct of
research and data analysis to perform a
statutory purpose of that Federal agency
upon the prior written request of that
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
agency, provided that there is legal
authority under all applicable
confidentiality statutes and regulations
to provide the data and the VHA Office
of Information (OI) has determined prior
to the disclosure that VHA data
handling requirements are satisfied.
20. Disclosure of limited individual
identification information may be made
to another Federal agency for the
purpose of matching and acquiring
information held by that agency for
VHA to use for the purposes stated for
this system of records.
21. VA may, on its own initiative,
disclose any information or records to
appropriate agencies, entities, and
persons when (1) VA suspects or has
confirmed that the integrity or
confidentiality of information in the
system of records has been
compromised; (2) the Department has
determined that as a result of the
suspected or confirmed compromise
there is a risk of embarrassment or harm
to the reputations of the record subjects,
harm to economic or property interests,
identity theft or fraud, or harm to the
security, confidentiality, or integrity of
this system or other systems or
programs (whether maintained by the
Department or another agency or entity)
that rely upon the potentially
compromised information; and (3) the
disclosure is to agencies, entities, or
persons whom VA determines are
reasonably necessary to assist or carry
out the Department’s efforts to respond
to the suspected or confirmed
compromise and prevent, minimize, or
remedy such harm. This routine use
permits disclosures by the Department
to respond to a suspected or confirmed
data breach, including the conduct of
any risk analysis or provision of credit
protection services as provided in 38
U.S.C. 5724, as the terms are defined in
38 U.S.C. 5727.
22. On its own initiative, the VA may
disclose to the general public via an
Internet Website, PCMM information,
including the names of its providers,
provider panel sizes and reports on
provider performance measures of
quality when approved in accordance
with VA policy.
identifiers of the individuals on whom
they are maintained.
SAFEGUARDS:
POLICIES AND PRACTICES FOR STORING,
RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
1. Access to and use of national
patient databases are limited to those
persons whose official duties require
such access, and VA has established
security procedures to ensure that
access is appropriately limited.
Information security officers and system
data stewards review and authorize data
access requests. VA regulates data
access with security software that
authenticates users and requires
individually unique codes and
passwords. VA provides information
security training to all staff and instructs
staff on the responsibility each person
has for safeguarding data
confidentiality.
2. VA maintains Business Associate
Agreements (BAA) and Non-Disclosure
Agreements with contracted resources
in order to maintain confidentiality of
the information.
3. Physical access to computer rooms
housing national patient databases is
restricted to authorized staff and
protected by a variety of security
devices. Unauthorized employees,
contractors, and other staff are not
allowed in computer rooms. The
Federal Protective Service or other
security personnel provide physical
security for the buildings housing
computer rooms and data centers.
4. Data transmissions between
operational systems and national patient
databases maintained by this system of
record are protected by state-of-the-art
telecommunication software and
hardware. This may include firewalls,
encryption, and other security measures
necessary to safeguard data as it travels
across the VA Wide Area Network. Data
may be transmitted via a passwordprotected spreadsheet and placed on the
secured share point Web portal by the
user that has been provided access to
their secure file. Data can only be
accessed by authorized personnel from
each facility within the Polytrauma
System of Care and the Physical
Medicine and Rehabilitation Program
Office.
5. In most cases, copies of back-up
computer files are maintained at off-site
locations.
STORAGE:
RETENTION AND DISPOSAL:
Records are maintained on electronic
storage media including magnetic tape,
disk, laser optical media.
The records are disposed of in
accordance with GRS 20, item 4. Item 4
provides for deletion of data files when
the agency determines that the files are
no longer needed for administrative,
legal, audit, or other operational
purposes.
RETRIEVABILITY:
Records are retrieved by name, Social
Security number or other assigned
PO 00000
Frm 00142
Fmt 4703
Sfmt 4703
E:\FR\FM\26MRN1.SGM
26MRN1
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
SYSTEMS AND MANAGER(S) AND ADDRESS:
Officials responsible for policies and
procedures; Chief Information Officer
(19), Department of Veterans Affairs,
810 Vermont Avenue, NW.,
Washington, DC 20420. Officials
maintaining this system of records;
Director, National Data Systems (19F4),
Austin Automation Center, 1615
Woodward Street, Austin, Texas 78772.
NOTIFICATION PROCEDURE:
Individuals who wish to determine
whether this system of records contains
information about them should contact
the Director of National Data Systems
(19F4), Austin Automation Center, 1615
Woodward Street, Austin, Texas 78772.
Inquiries should include the person’s
full name, Social Security number,
location and dates of employment or
location and dates of treatment, and
their return address.
RECORD ACCESS PROCEDURE:
Individuals seeking information
regarding access to and contesting of
records in this system may write or call
the Director of National Data Systems
(19F4), Austin Automation Center, 1615
Woodward Street, Austin, Texas 78772,
or call the VA Austin Automation
Center Help Desk and ask to speak with
the VHA Director of National Data
Systems at 512–326–6780.
CONTESTING RECORD PROCEDURES:
(See Record Access Procedures
above.)
RECORD SOURCE CATEGORIES:
Information in this system of records
is provided by veterans, VA employees,
16107
VA computer systems, Veterans Health
Information Systems and Technology
Architecture (VistA), VA medical
centers, VA Health Eligibility Center,
VA program offices, VISNs, VA Austin
Automation Center, the Food and Drug
Administration, the Department of
Defense, Survey of Healthcare
Experiences of Patients, External Peer
Review Program, and the following
Systems Of Records: ‘‘Patient Medical
Records—VA’’ (24VA19), ‘‘National
Prosthetics Patient Database—VA’’
(33VA113), ‘‘Healthcare Eligibility
Records—VA’’ (89VA16), VA Veterans
Benefits Administration automated
record systems (including the Veterans
and Beneficiaries Identification and
Records Location Subsystem—VA
(38VA23)), and subsequent iterations of
those systems of records.
VA APPENDIX 4
Database name
Location
Addiction Severity Index ...........................................................................
Veteran Affairs Medical Center, 7180 Highland Drive, Pittsburgh, PA
15206.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
VA Medical Center, 1055 Clermont Street, Denver, CO.
Bidirectional Health Information Exchange ..............................................
Cardiac Assessment Tracking and Reporting for Cardiac Cauterization
Laboratories.
Care Management Information System ...................................................
Clinical Case Registries ...........................................................................
CMOP Centralized Database System ......................................................
Continuous Improvement in Cardiac Surgery ..........................................
Corporate Data Warehouse .....................................................................
Creutzfeldt-Jakob Disease Lookback Dataset .........................................
Decision Support System .........................................................................
Eastern Pacemaker Surveillance Center Database .................................
Emerging Pathogens Initiative ..................................................................
Federal Health Information Exchange ......................................................
Financial Clinical Data Mart .....................................................................
Former Prisoner of War Statistical Tracking System ...............................
Functional Status and Outcome Database ..............................................
Home Based Primary Care ......................................................................
Mammography Quality Standards VA ......................................................
Master Patient Index ................................................................................
Medical SAS File (MDP) (Medical District Planning (MEDIPRO)) ...........
Missing Patient Register ...........................................................................
pwalker on PROD1PC71 with NOTICES
National Mental Health Database System ...............................................
National Medical Information System .......................................................
National Survey of Veterans ....................................................................
Office of Quality and Performance (OQP) ...............................................
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
PO 00000
Frm 00143
Fmt 4703
Veterans Affairs Medical Center, University and Woodland Aves.,
Philadelphia, PA 19104.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Southwest CMOP, 3675 East Britannia Drive, Tucson, AZ 85706.
Veteran Affairs Medical Center, 820 Clermont Street, Denver, CO
80220.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veteran Affairs Medical Center, 3200 Vine St., Cincinnati, Ohio 45220.
Austin Automation Center, 1615 Woodward Street, Austin, TX 78772.
Veteran Affairs Medical Center, 50 Irving Street, NW., Washington, DC
20422.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veteran Affairs Medical Center, 508 Fulton Street, Durham, NC 27705.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veteran Affairs Medical Center, 7180 Highland Drive, Pittsburgh, PA
15206.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
(OQP) Data Center, 601 Keystone Park Drive, Suite 800, Morrisville,
NC 27560.
Sfmt 4703
E:\FR\FM\26MRN1.SGM
26MRN1
16108
Federal Register / Vol. 73, No. 59 / Wednesday, March 26, 2008 / Notices
VA APPENDIX 4—Continued
Database name
Location
Parkinson’s Disease Research, Education and Clinical Centers Registry.
Patient Assessment File ...........................................................................
Veterans Affairs Medical Center, 4150 Clement St., San Francisco, CA
94121.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veterans Affairs Medical Center, 5th Avenue and Roosevelt Road,
Hines, IL 60141.
Office of Information Field Office, 1335 East/West Hwy, Silver Spring
MD 20910.
Denver Distribution Center, 155 Van Gordon Street, Lakewood, CO
80228–1709.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veterans Affairs Medical Center, 200 Springs Rd., Bedford, MA 01730.
Veteran Affairs Medical Center, 4500 South Lancaster Road, Dallas,
TX 75216.
Austin Automation Center, 1615 Woodward Street, Austin, Texas
78772.
Veteran Affairs Medical Center, 50 Irving Street, NW., Washington, DC
20422.
Austin Automation Center, 1615 Woodward Street, Austin, TX 78772.
Pharmacy Benefits Management .............................................................
Radiation Exposure Inquiries Database ...................................................
Remote Order Entry System ....................................................................
Resident Assessment Instrument/Minimum Data Set ..............................
Short Form Health Survey for Veterans ...................................................
VA National Clozapine Registry ...............................................................
VA Vital Status File ..................................................................................
Veterans Central Cancer Registry ...........................................................
Veterans Integrated Service Network Support Service Center Databases.
[FR Doc. E8–6144 Filed 3–25–08; 8:45 am]
pwalker on PROD1PC71 with NOTICES
BILLING CODE 8320–01–P
VerDate Aug<31>2005
18:52 Mar 25, 2008
Jkt 214001
PO 00000
Frm 00144
Fmt 4703
Sfmt 4703
E:\FR\FM\26MRN1.SGM
26MRN1
Agencies
[Federal Register Volume 73, Number 59 (Wednesday, March 26, 2008)]
[Notices]
[Pages 16103-16108]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E8-6144]
-----------------------------------------------------------------------
DEPARTMENT OF VETERANS AFFAIRS
Privacy Act of 1974; System of Records
AGENCY: Department of Veterans Affairs (VA).
ACTION: Notice of Amendment of Systems of Records Notice ``National
Patient Databases-VA.''
-----------------------------------------------------------------------
SUMMARY: As required by the Privacy Act of 1974 (5 U.S.C. 552a(e)(4)),
notice is hereby given that the Department of Veterans Affairs (VA) is
amending the system of records entitled ``National Patient Databases-
VA'' (121VA19) as set forth in 69 FR 18436. VA is amending the system
of records by revising the System Location, Categories of Records in
the System, Purpose(s), Routine Uses of Records Maintained in the
System, Including Categories of Users and the Purposes of Such Uses,
and Appendix 4. VA is republishing the system notice in its entirety.
DATES: Comments on this amended system of records must be received no
later than April 25, 2008. If no public comment is received during the
period allowed for comment or unless otherwise published in the Federal
Register by VA, the amended system will become effective April 25,
2008.
ADDRESSES: Written comments concerning the proposed amended system of
records may be submitted through www.Regulations.gov; by mail or hand-
delivery to Director, Regulations Management (00REG1), Department of
Veterans Affairs, 810 Vermont Avenue, NW., Room 1068, Washington, DC
20420; by fax to (202) 273-9026; or by e-mail to:
``VAregulations@mail.va.gov''. All comments received will be available
for public inspection in the Office of Regulation Policy and
Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m.,
Monday through Friday (except holidays). Please call (202) 273-9515 for
an appointment. In addition, during the comment period, comments may be
viewed online through the Federal Docket Management System (FDMS) at:
https://www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Stephania H. Putt, Veterans Health
Administration (VHA) Privacy Officer, Department of Veterans Affairs,
810 Vermont Avenue NW., Washington, DC 20420, telephone (704) 245-2492.
SUPPLEMENTARY INFORMATION:
Background: VHA is the largest health care provider in the country.
In order to maintain this organization, VHA collects health care
information from its local facilities to evaluate quality of services,
clinical resource utilization, and patient safety, as well as to
distribute medical information, such as alerts or recalls, track
specific diseases, and monitor patients. National-level information is
also needed for other activities, such as medical research and the
development of National Best Clinical Practice Guidelines and National
Quality Standards. VHA gathers this information from a wide variety of
sources, including directly from a veteran; from information systems
located at VHA medical centers, Veterans Integrated Service Networks
(VISN), other VHA facilities, such as the Health Eligibility Center;
and Federal departments and agencies such as the U.S. Department of
Defense and the Food and Drug Administration. As the data is collected,
VHA stores it in several national patient databases.
In this system of records the Category of Records in the System is
amended to reflect the data Office of Quality and Performance (OQP) is
collecting, and to include the Survey of the Healthcare Experiences of
Patients and External Peer Review data capture. These data include any
patient-level records created for evaluation as directed by the VHA
Performance Management Program or accreditation purposes as defined by
the Joint Commission. This information is collected so that OQP can
assess, without organizational bias, the adherence of its treatment
centers to established clinical protocol for providing care to veterans
and to monitor the satisfaction of its patient customers.
The Purpose in this system of records is being amended to reflect
that the records and information may be used for statistical analysis
to produce various management, workload tracking, and follow-up
reports; to track and evaluate the ordering and delivery of equipment,
services and patient care; for the planning, distribution and
utilization of resources; to monitor the performance of Veterans
Integrated Service Networks (VISN); and to allocate clinical and
administrative support to patient medical care. The data may be used
for VA's extensive research programs in accord with VA policy. In
addition, the data may be used to assist in workload allocation for
patient treatment services including provider panel management, nursing
care, clinic appointments, surgery, prescription processing, diagnostic
and therapeutic procedures; to plan and schedule training activities
for employees; for audits, reviews and investigations conducted by the
Network Directors Office and VA Central Office; for quality assurance
audits, reviews and investigations; for law enforcement investigations;
and for personnel management, evaluation and employee ratings, and
performance evaluations. Survey data will be collected for the purpose
of measuring and monitoring National, VISN and Facility-Level
performance on VHA's Veteran Health Care Service Standards (VHSS). The
VHSS are designed to measure levels of patient satisfaction in areas
that patients have defined as important in receiving quality, patient-
centered healthcare. Results of the survey data analysis are shared
throughout the VHA system. The External Peer Review Program (EPRP) data
is collected in order to provide medical centers and outpatient clinics
with diagnosis and procedure-specific quality of care information. EPRP
is a contracted review of care, specifically designated to collect data
to be used to improve the quality of care.
Routine Uses of Records Maintained in the System, Including
Categories of Users and the Purposes of Such Uses is being amended to
reflect the addition of protecting 38 U.S.C. 5705 Quality Assurance
Records, which may not be disclosed under a routine use unless there is
also specific statutory authority permitting the disclosure. Routine
uses numbers 1, 5, 10, 12, 13, 14, 15, and 17 have been revised for
ease of readability and clarification.
Routine use 19 was added to allow for the disclosure of information
to another
[[Page 16104]]
Federal agency for the purpose of conducting research.
Routine use 20 was added to allow for the disclosure of limited
identification information to another Federal agency in order to obtain
information to carry out any purpose outlined in this system of
records.
Routine use number 21 was added to allow for records to be
disclosed to appropriate agencies, entities, and persons under the
following circumstances: when (1) it is suspected or confirmed that the
integrity or confidentiality of information in the system of records
has been compromised; (2) the Department has determined that as a
result of the suspected or confirmed compromise there is a risk of
embarrassment or harm to the reputations of the record subjects, harm
to economic or property interests, identity theft or fraud, or harm to
the security, confidentiality, or integrity of this system or other
systems or programs (whether maintained by the Department or another
agency or entity) that rely upon the compromised information; and (3)
the disclosure is made to such agencies, entities, and persons who are
reasonably necessary to assist in connection with the Department's
efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm. This routine use allows
disclosure by the agency to respond to a suspected or confirmed data
breach, including the conduct of any risks analysis or provision of
credit protection services as provided in 38 U.S.C. 5724, as the terms
are defined in 38 U.S.C. 5727.
Routine use 22 was added to accommodate the disclosure of Primary
Care Management Module (PCMM) data to the general public.
Appendix 4 has been amended to include Cardiac Assessment Tracking
and Reporting for Cardiac Cauterization Laboratories, Corporate Data
Warehouse, CMOP Centralized Database System, Bidirectional Health
Information Exchange, Financial Clinical Data Mart, Care Management
Information System, Parkinson's Disease Research, Education and
Clinical Centers Registry, Pharmacy Benefits Management, VA Vital
Status File, Short Form Health Survey for Veterans and Office of
Quality Performance Data Center. Also, the KLF Menu was renamed to
Veterans Integrated Service Network Support Service Center Database.
Immunology Case Registry was removed and Clinical Case Registry was
changed to Registries to represent the Immunology Case Registry (ICR)
and Hepatitis C. There was also removal of the National Patient Care
Database (NPCD), Patient Treatment File (PTF) and the National Health
Care Practitioner Database (NHCPD) which are now entered as a single
system called National Medical Information System (NMIS).
The notice of amendment and an advance copy of the system notice
have been sent to the appropriate Congressional committees and to the
Director of Office of Management and Budget (OMB) as required by 5
U.S.C. 552a(r) (Privacy Act) and guidelines issued by OMB (65 FR
77677), December 12, 2000.
Approved: March 12, 2008.
Gordon H. Mansfield,
Deputy Secretary of Veterans Affairs.
121VA19
SYSTEM NAME:
National Patient Databases--VA.
SYSTEM LOCATION:
Records are maintained at Department of Veterans Affairs (VA)
medical centers, VA data processing centers, veterans integrated
service networks (VISN) and office of information (OI) field offices.
Address location for each VA national patient database is listed in VA
Appendix 4 at the end of this document.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
The records contain information for all individuals (1) Receiving
health care from the Veterans Health Administration (VHA), and (2)
Providing the health care. Individuals encompass veterans and their
immediate family members, members of the armed services, current and
former employees, trainees, contractors, sub-contractors, consultants,
volunteers, and other individuals working collaboratively with VA.
CATEGORIES OF RECORDS IN THE SYSTEM:
The records may include information and health information related
to:
1. Patient medical record abstract information including
information from Patient Medical Record--VA (24VA19).
2. Identifying information (e.g., name, birth date, death date,
admission date, discharge date, gender, Social Security number,
taxpayer identification number); address information (e.g., home and/or
mailing address, home telephone number, emergency contact information
such as name, address, telephone number, and relationship); prosthetic
and sensory aid serial numbers; medical record numbers; integration
control numbers; information related to medical examination or
treatment (e.g., location of VA medical facility providing examination
or treatment, treatment dates, medical conditions treated or noted on
examination); information related to military service and status;
3. Medical benefit and eligibility information;
4. Patient aggregate workload data such as admissions, discharges,
and outpatient visits; resource utilization such as laboratory tests,
x-rays;
5. Patient Satisfaction Survey Data which include questions and
responses; and
6. External Peer Review Program (EPRP) data capture.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Title 38, United States Code, Section 501.
PURPOSE(S):
The records and information may be used for statistical analysis to
produce various management, workload tracking, and follow-up reports;
to track and evaluate the ordering and delivery of equipment, services
and patient care; for the planning, distribution and utilization of
resources; to monitor the performance of Veterans Integrated Service
Networks (VISN); and to allocate clinical and administrative support to
patient medical care. The data may be used for VA's extensive research
programs in accord with VA policy. In addition, the data may be used to
assist in workload allocation for patient treatment services including
provider panel management, nursing care, clinic appointments, surgery,
prescription processing, diagnostic and therapeutic procedures; to plan
and schedule training activities for employees; for audits, reviews and
investigations conducted by the network directors office and VA Central
Office; for quality assurance audits, reviews and investigations; for
law enforcement investigations; and for personnel management,
evaluation and employee ratings, and performance evaluations. Survey
data will be collected for the purpose of measuring and monitoring
national, VISN and facility-Level performance on VHA's Veteran Health
Care Service Standards (VHSS) pursuant to Executive Order 12862 and the
Veterans Health Administration Customer Service Standards Directive.
The VHSS are designed to measure levels of patient satisfaction in
areas that patients have defined as important in receiving quality,
patient-centered healthcare. Results of the survey data analysis are
shared throughout the VHA system. The External Peer Review
[[Page 16105]]
Program (EPRP) data are collected in order to provide medical centers
and outpatient clinics with diagnosis and procedure-specific quality of
care information. EPRP is a contracted review of care, specifically
designated to collect data to be used to improve the quality of care.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OF USERS AND THE PURPOSES OF SUCH USES:
To the extent that records contained in the system include
information protected by 38 U.S.C. 7332, i.e., medical treatment
information related to drug abuse, alcoholism or alcohol abuse, sickle
cell anemia or infection with the human immunodeficiency virus;
information protected by 38 U.S.C 5705, i.e., quality assurance
records; or information protected by 45 C.F.R. Parts 160 and 164, i.e.,
individually identifiable health information, such information cannot
be disclosed under a routine use unless there is also specific
statutory authority permitting the disclosure. VA may disclose
protected health information pursuant to the following routine uses
where required or permitted by law.
1. VA may disclose on its own initiative any information in this
system, except the names and home addresses of veterans and their
dependents, that is relevant to a suspected or reasonably imminent
violation of law, whether civil, criminal or regulatory in nature and
whether arising by general or program statute or by regulation, rule or
order issued pursuant thereto, to a Federal, State, local, tribal, or
foreign agency charged with the responsibility of investigating or
prosecuting such violation, or charged with enforcing or implementing
the statute, regulation, rule or order. On its own initiative, VA may
also disclose the names and addresses of veterans and their dependents
to a Federal agency charged with the responsibility of investigating or
prosecuting civil, criminal or regulatory violations of law, or charged
with enforcing or implementing the statute, regulation, rule or order
issued pursuant thereto.
2. Disclosure may be made to any source from which additional
information is requested (to the extent necessary to identify the
individual, inform the source of the purpose(s) of the request, and
identify the type of information requested), when necessary to obtain
information relevant to an individual's eligibility, care history, or
other benefits.
3. Disclosure may be made to an agency in the executive,
legislative, or judicial branch, or the District of Columbia government
in response to its request or at the initiation of VA, in connection
with disease tracking, patient outcomes or other health information
required for program accountability.
4. Disclosure may be made to National Archives and Records
Administration (NARA) for it to perform its records management
inspections responsibilities in its role as Archivist of United States
under authority of title 44 United States Code (USC).
5. VA may disclose information in this system of records to the
Department of Justice (DoJ), either on VA's initiative or in response
to DoJ's request for the information, after either VA or DoJ determines
that such information is relevant to DoJ's representation of the United
States or any of its components in legal proceedings before a court or
adjudicative body, provided that, in each case, the agency also
determines prior to disclosure that disclosure of the records to the
Department of Justice is a use of the information contained in the
records that is compatible with the purpose for which VA collected the
records. VA, on its own initiative, may disclose records in this system
of records in legal proceedings before a court or administrative body
after determining that the disclosure of the records to the court or
administrative body is a use of the information contained in the
records that is compatible with the purpose for which VA collected the
records.
6. Records from this system of records may be disclosed to a
Federal agency or to a State or local government licensing board and/or
to the Federation of State Medical Boards or a similar non-government
entity that maintains records concerning individuals' employment
histories or concerning the issuance, retention or revocation of
licenses, certifications, or registration necessary to practice an
occupation, profession or specialty, in order for the agency to obtain
information relevant to an agency decision concerning the hiring,
retention or termination of an employee.
7. Records from this system of records may be disclosed to inform a
Federal agency, licensing boards or the appropriate non-government
entities about the health care practices of a terminated, resigned or
retired health care employee whose professional health care activity so
significantly failed to conform to generally accepted standards of
professional medical practice as to raise reasonable concern for the
health and safety of patients receiving medical care in the private
sector or from another Federal agency.
8. For program review purposes and the seeking of accreditation
and/or certification, disclosure may be made to survey teams of the
Joint Commission, College of American Pathologists, American
Association of Blood Banks, and similar national accreditation agencies
or boards with whom VA has a contract or agreement to conduct such
reviews but only to the extent that the information is necessary and
relevant to the review.
9. Disclosure may be made to a national certifying body that has
the authority to make decisions concerning the issuance, retention or
revocation of licenses, certifications or registrations required to
practice a health care profession, when requested in writing by an
investigator or supervisory official of the national certifying body
for the purpose of making a decision concerning the issuance, retention
or revocation of the license, certification or registration of a named
health care professional.
10. Records from this system that contain information listed in 5
U.S.C. 7114(b)(4) may be disclosed to officials of labor organizations
recognized under 5 U.S.C. Chapter 71 when relevant and necessary to
their duties of exclusive representation concerning personnel policies,
practices, and matters affecting working conditions.
11. Disclosure may be made to the representative of an employee of
all notices, determinations, decisions, or other written communications
issued to the employee in connection with an examination ordered by VA
under medical evaluation (formerly fitness-for-duty) examination
procedures or Department-filed disability retirement procedures.
12. VA may disclose information to officials of the Merit Systems
Protection Board, or the Office of Special Counsel, when requested in
connection with appeals, special studies of the civil service and other
merit systems, review of rules and regulations, investigation of
alleged or possible prohibited personnel practices, and such other
functions, promulgated in 5 U.S.C. 1205 and 1206, or as may be
authorized by law.
13. VA may disclose information to the Equal Employment Opportunity
Commission when requested in connection with investigations of alleged
or possible discriminatory practices, examination of Federal
affirmative employment programs, or for other functions of the
Commission as authorized by law or regulation.
14. VA may disclose information to the Federal Labor Relations
Authority (including its General Counsel) information related to the
establishment
[[Page 16106]]
of jurisdiction, the investigation and resolution of allegations of
unfair labor practices, or information in connection with the
resolution of exceptions to arbitration awards when a question of
material fact is raised; to disclose information in matters properly
before the Federal Services Impasses Panel, and to investigate
representation petitions and conduct or supervise representation
elections.
15. Disclosure of medical record data, excluding name and address,
unless name and address are furnished by the requester, may be made to
non-Federal research facilities for research purposes determined to be
necessary and proper when approved in accordance with VA policy.
16. Disclosure of name(s) and address(s) of present or former
personnel of the Armed Services, and/ or their dependents, may be made
to: (a) A Federal department or agency, at the written request of the
head or designee of that agency; or (b) directly to a contractor or
subcontractor of a Federal department or agency, for the purpose of
conducting Federal research necessary to accomplish a statutory purpose
of an agency. When disclosure of this information is made directly to a
contractor, VA may impose applicable conditions on the department,
agency, and/or contractor to insure the appropriateness of the
disclosure to the contractor.
17. Disclosure may be made to individuals, organizations, private
or public agencies, or other entities or individuals with whom VA has a
contract or agreement to perform such services as VA may deem
practicable for the purposes of laws administered by VA, in order for
the contractor, subcontractor, public or private agency, or other
entity or individual with whom VA has an agreement or contract to
perform the services of the contract or agreement. This routine use
includes disclosures by the individual or entity performing the service
for VA to any secondary entity or individual to perform an activity
that is necessary for individuals, organizations, private or public
agencies, or other entities or individuals with whom VA has a contract
or agreement to provide the service to VA.
18. Disclosure may be made to a congressional office from the
record of an individual in response to an inquiry from the
congressional office made at the request of that individual.
19. VA may disclose information to a Federal agency for the conduct
of research and data analysis to perform a statutory purpose of that
Federal agency upon the prior written request of that agency, provided
that there is legal authority under all applicable confidentiality
statutes and regulations to provide the data and the VHA Office of
Information (OI) has determined prior to the disclosure that VHA data
handling requirements are satisfied.
20. Disclosure of limited individual identification information may
be made to another Federal agency for the purpose of matching and
acquiring information held by that agency for VHA to use for the
purposes stated for this system of records.
21. VA may, on its own initiative, disclose any information or
records to appropriate agencies, entities, and persons when (1) VA
suspects or has confirmed that the integrity or confidentiality of
information in the system of records has been compromised; (2) the
Department has determined that as a result of the suspected or
confirmed compromise there is a risk of embarrassment or harm to the
reputations of the record subjects, harm to economic or property
interests, identity theft or fraud, or harm to the security,
confidentiality, or integrity of this system or other systems or
programs (whether maintained by the Department or another agency or
entity) that rely upon the potentially compromised information; and (3)
the disclosure is to agencies, entities, or persons whom VA determines
are reasonably necessary to assist or carry out the Department's
efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm. This routine use permits
disclosures by the Department to respond to a suspected or confirmed
data breach, including the conduct of any risk analysis or provision of
credit protection services as provided in 38 U.S.C. 5724, as the terms
are defined in 38 U.S.C. 5727.
22. On its own initiative, the VA may disclose to the general
public via an Internet Website, PCMM information, including the names
of its providers, provider panel sizes and reports on provider
performance measures of quality when approved in accordance with VA
policy.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Records are maintained on electronic storage media including
magnetic tape, disk, laser optical media.
RETRIEVABILITY:
Records are retrieved by name, Social Security number or other
assigned identifiers of the individuals on whom they are maintained.
SAFEGUARDS:
1. Access to and use of national patient databases are limited to
those persons whose official duties require such access, and VA has
established security procedures to ensure that access is appropriately
limited. Information security officers and system data stewards review
and authorize data access requests. VA regulates data access with
security software that authenticates users and requires individually
unique codes and passwords. VA provides information security training
to all staff and instructs staff on the responsibility each person has
for safeguarding data confidentiality.
2. VA maintains Business Associate Agreements (BAA) and Non-
Disclosure Agreements with contracted resources in order to maintain
confidentiality of the information.
3. Physical access to computer rooms housing national patient
databases is restricted to authorized staff and protected by a variety
of security devices. Unauthorized employees, contractors, and other
staff are not allowed in computer rooms. The Federal Protective Service
or other security personnel provide physical security for the buildings
housing computer rooms and data centers.
4. Data transmissions between operational systems and national
patient databases maintained by this system of record are protected by
state-of-the-art telecommunication software and hardware. This may
include firewalls, encryption, and other security measures necessary to
safeguard data as it travels across the VA Wide Area Network. Data may
be transmitted via a password-protected spreadsheet and placed on the
secured share point Web portal by the user that has been provided
access to their secure file. Data can only be accessed by authorized
personnel from each facility within the Polytrauma System of Care and
the Physical Medicine and Rehabilitation Program Office.
5. In most cases, copies of back-up computer files are maintained
at off-site locations.
RETENTION AND DISPOSAL:
The records are disposed of in accordance with GRS 20, item 4. Item
4 provides for deletion of data files when the agency determines that
the files are no longer needed for administrative, legal, audit, or
other operational purposes.
[[Page 16107]]
SYSTEMS AND MANAGER(S) AND ADDRESS:
Officials responsible for policies and procedures; Chief
Information Officer (19), Department of Veterans Affairs, 810 Vermont
Avenue, NW., Washington, DC 20420. Officials maintaining this system of
records; Director, National Data Systems (19F4), Austin Automation
Center, 1615 Woodward Street, Austin, Texas 78772.
NOTIFICATION PROCEDURE:
Individuals who wish to determine whether this system of records
contains information about them should contact the Director of National
Data Systems (19F4), Austin Automation Center, 1615 Woodward Street,
Austin, Texas 78772. Inquiries should include the person's full name,
Social Security number, location and dates of employment or location
and dates of treatment, and their return address.
RECORD ACCESS PROCEDURE:
Individuals seeking information regarding access to and contesting
of records in this system may write or call the Director of National
Data Systems (19F4), Austin Automation Center, 1615 Woodward Street,
Austin, Texas 78772, or call the VA Austin Automation Center Help Desk
and ask to speak with the VHA Director of National Data Systems at 512-
326-6780.
CONTESTING RECORD PROCEDURES:
(See Record Access Procedures above.)
RECORD SOURCE CATEGORIES:
Information in this system of records is provided by veterans, VA
employees, VA computer systems, Veterans Health Information Systems and
Technology Architecture (VistA), VA medical centers, VA Health
Eligibility Center, VA program offices, VISNs, VA Austin Automation
Center, the Food and Drug Administration, the Department of Defense,
Survey of Healthcare Experiences of Patients, External Peer Review
Program, and the following Systems Of Records: ``Patient Medical
Records--VA'' (24VA19), ``National Prosthetics Patient Database--VA''
(33VA113), ``Healthcare Eligibility Records--VA'' (89VA16), VA Veterans
Benefits Administration automated record systems (including the
Veterans and Beneficiaries Identification and Records Location
Subsystem--VA (38VA23)), and subsequent iterations of those systems of
records.
VA Appendix 4
------------------------------------------------------------------------
Database name Location
------------------------------------------------------------------------
Addiction Severity Index............... Veteran Affairs Medical Center,
7180 Highland Drive,
Pittsburgh, PA 15206.
Bidirectional Health Information Austin Automation Center, 1615
Exchange. Woodward Street, Austin, Texas
78772.
Cardiac Assessment Tracking and VA Medical Center, 1055
Reporting for Cardiac Cauterization Clermont Street, Denver, CO.
Laboratories.
Care Management Information System..... Veterans Affairs Medical
Center, University and
Woodland Aves., Philadelphia,
PA 19104.
Clinical Case Registries............... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
CMOP Centralized Database System....... Southwest CMOP, 3675 East
Britannia Drive, Tucson, AZ
85706.
Continuous Improvement in Cardiac Veteran Affairs Medical Center,
Surgery. 820 Clermont Street, Denver,
CO 80220.
Corporate Data Warehouse............... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Creutzfeldt-Jakob Disease Lookback Veteran Affairs Medical Center,
Dataset. 3200 Vine St., Cincinnati,
Ohio 45220.
Decision Support System................ Austin Automation Center, 1615
Woodward Street, Austin, TX
78772.
Eastern Pacemaker Surveillance Center Veteran Affairs Medical Center,
Database. 50 Irving Street, NW.,
Washington, DC 20422.
Emerging Pathogens Initiative.......... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Federal Health Information Exchange.... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Financial Clinical Data Mart........... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Former Prisoner of War Statistical Austin Automation Center, 1615
Tracking System. Woodward Street, Austin, Texas
78772.
Functional Status and Outcome Database. Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Home Based Primary Care................ Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Mammography Quality Standards VA....... Veteran Affairs Medical Center,
508 Fulton Street, Durham, NC
27705.
Master Patient Index................... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Medical SAS File (MDP) (Medical Austin Automation Center, 1615
District Planning (MEDIPRO)). Woodward Street, Austin, Texas
78772.
Missing Patient Register............... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
National Mental Health Database System. Veteran Affairs Medical Center,
7180 Highland Drive,
Pittsburgh, PA 15206.
National Medical Information System.... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
National Survey of Veterans............ Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Office of Quality and Performance (OQP) (OQP) Data Center, 601 Keystone
Park Drive, Suite 800,
Morrisville, NC 27560.
[[Page 16108]]
Parkinson's Disease Research, Education Veterans Affairs Medical
and Clinical Centers Registry. Center, 4150 Clement St., San
Francisco, CA 94121.
Patient Assessment File................ Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Pharmacy Benefits Management........... Veterans Affairs Medical
Center, 5th Avenue and
Roosevelt Road, Hines, IL
60141.
Radiation Exposure Inquiries Database.. Office of Information Field
Office, 1335 East/West Hwy,
Silver Spring MD 20910.
Remote Order Entry System.............. Denver Distribution Center, 155
Van Gordon Street, Lakewood,
CO 80228-1709.
Resident Assessment Instrument/Minimum Austin Automation Center, 1615
Data Set. Woodward Street, Austin, Texas
78772.
Short Form Health Survey for Veterans.. Veterans Affairs Medical
Center, 200 Springs Rd.,
Bedford, MA 01730.
VA National Clozapine Registry......... Veteran Affairs Medical Center,
4500 South Lancaster Road,
Dallas, TX 75216.
VA Vital Status File................... Austin Automation Center, 1615
Woodward Street, Austin, Texas
78772.
Veterans Central Cancer Registry....... Veteran Affairs Medical Center,
50 Irving Street, NW.,
Washington, DC 20422.
Veterans Integrated Service Network Austin Automation Center, 1615
Support Service Center Databases. Woodward Street, Austin, TX
78772.
------------------------------------------------------------------------
[FR Doc. E8-6144 Filed 3-25-08; 8:45 am]
BILLING CODE 8320-01-P