Privacy Act of 1974; Amendment of System of Records, 5033-5036 [2016-01701]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 81, Number 19 (Friday, January 29, 2016)]
[Notices]
[Pages 5033-5036]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-01701]



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DEPARTMENT OF VETERANS AFFAIRS


Privacy Act of 1974; Amendment of System of Records

AGENCY: Department of Veterans Affairs (VA).

ACTION: Notice of amendment of system of records.

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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 ``Ethics Consultation Web-based 
Database (ECWeb)-VA'' (152VA10E) as set forth in 76 FR 43386. VA is 
amending the system of records by revising the System Number, 
Categories of Individuals Covered by the System, Category of Records in 
the System, Purpose, Routine Uses of Records Maintained in the System, 
Safeguards, Retention and Disposal, and System Manager and Address. VA 
is republishing the system notice in its entirety.

DATES: Comments on this new system of records must be received no later 
than February 29, 2016. If no public comment is received during the 
period allowed for comment or unless otherwise published in the Federal 
Register by VA, the new system will become effective February 29, 2016.

ADDRESSES: Written comments concerning the amended system of records 
may be submitted through www.regulations.gov; by mail or hand-delivery 
to Director, Regulations Management (02REG), Department of Veterans 
Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; or by 
fax to (202) 273-9026. All comments received will be available for 
public inspection in the Office of Regulation Policy and Management, 
Room 1063B, between the hours of 8:00 a.m. and 4:30 p.m., Monday 
through Friday (except holidays). Please call (202) 461-4902 for an 
appointment. In addition, during the comment period, comments may be 
viewed online through the Federal Docket Management System (FDMS) at 
www.regulations.gov.

FOR FURTHER INFORMATION CONTACT: Kenneth Berkowitz, MD, Acting 
Executive Director, National Center for Ethics in Health Care (10P6), 
Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 
20420; telephone (202) 501-0364.

SUPPLEMENTARY INFORMATION: The system number is changed from 152VA10E 
to 152VA10P6 to reflect the current organizational alignment.
    The Category of Individuals Covered by the System is being amended 
to remove beneficiaries of other Federal agencies and replace it with 
other requesters or participants from outside VA for whom personal 
information will be collected.
    The Category of Records in the System is being amended to add that 
the ECWeb record documents the consultation request, relevant 
consultation specific information, a summary of the information 
including the ethical analysis and moral deliberation, the explanation 
of the findings to relevant parties and support of the consultation 
process. The ECWeb record also includes related notes and attachments.
    The Purpose in this system of records is being amended to include 
education, but will remove law enforcement investigations.
    Routine Uses of Records Maintained in the System being deleted are:

    2. Disclosure of health care information furnished and the 
period of care, as deemed necessary and proper, to accredited 
service organization representatives and other approved agents, 
attorneys, and insurance companies to aid claimants whom they 
represent in the preparation, presentation and prosecution of claims 
under laws administered by VA, state or local agencies.
    3. VA may disclose on its own initiative any information in this 
system, except the names and home addresses of Veterans and their 
dependents, which 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.
    5. Relevant information may be disclosed in the course of 
presenting evidence to a court, magistrate or administrative 
tribunal, in matters of guardianship, inquests and commitments; to 
private attorneys representing Veterans rated incompetent in 
conjunction with issuance of Certificates of Incompetency; and to 
probation and parole officers in connection with Court required 
duties.
    15. For program review purposes and the seeking of accreditation 
and/or certification, health care information may be disclosed to 
survey teams of The Joint Commission (TJC), and similar national 
accrediting 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.
    18. Patient identifying information may be disclosed to Federal 
agencies and VA and government-wide third party insurers responsible 
for payment of the cost of medical care for the identified patients, 
in order for VA to seek recovery of the medical care costs. These 
records may also be disclosed as part of a computer matching program 
to accomplish these purposes.
    19. Relevant health care information may be disclosed to health 
and welfare agencies, housing resources and utility companies, 
possibly to be combined with disclosures to other agencies, in 
situations where VA needs to act quickly in order to provide basic 
and/or emergency needs for the Veteran and Veteran's family where 
the family resides with the Veteran or serves as a caregiver.

    All of the Routine Uses of Records Maintained in the System are 
renumbered due to the deletions to allow for sequential numbers. 
Routine use 29 which stated: Assist in quality improvement efforts with 
respect to ethics consultation practices as part of approved research 
or ongoing quality improvement projects is now routine use 21 which is 
being clarified to state that disclosure of ethics consultation records 
to groups (e.g., American Society for Bioethics and the Humanities) 
performing improvement or quality assessments as part of approved 
research or ongoing quality improvement projects with respect to ethics 
consultation practices.
    Safeguards number 3 is being amended to remove access to the Austin 
VA Data Processing Center is generally restricted to Center employees, 
custodial personnel, Federal Protective Service and other security 
personnel.
    The Retention and Disposal is being amended to remove in accordance 
with the records is deposition authority approved by the Archivist of 
the United States, paper records and information stored on electronic 
storage media are maintained for 75 years after the last episode of 
patient care then destroyed/deleted. This section will now state that 
records that are stored within Computerized Patient Record System 
(CPRS) and Veterans Health Information Systems and Technology 
Architecture (VistA) will be maintained in accordance with Record 
Control Schedule (RCS) 10-1 Item # XLIII-2, Electronic Health Records, 
NARA job# N1-15-02-3. All other records maintained outside the 
Electronic Health Record will be maintained in accordance with General 
Records Schedule (GRS) 25 Ethics Program Records Item 1.a and 1.b (N1-
GRS-01-1 item 1a & 1b).
    The System Manager and Address is amending the official responsible 
for policies and procedures from the Chief

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Ethics in Health Care to the Executive Director.
    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.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Robert L. 
Nabors II, Chief of Staff, approved this document on January 12, 2016, 
for publication.

    Dated: January 13, 2016.
Kathleen M. Manwell,
Program Analyst, VA Privacy Service, Office of Privacy and Records 
Management, Department of Veterans Affairs.
152VA10P6

SYSTEM NAME:
    Ethics Consultation Web-based Database (ECWeb)-VA

SYSTEM LOCATION:
    Automated records within the Ethics Consultation Web-based Database 
(ECWeb) may be maintained on a VA-owned server administered by the 
Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The records include information concerning.
    1. Veterans who have applied for health care services under Title 
38, U.S.C., Chapter 17, and members of their immediate families.
    2. Spouse, surviving spouse, and children of Veterans who have 
applied for health care services under Title 38, U.S.C., Chapter 17.
    3. Other requesters or participants from outside VA for whom 
personal information will be collected.
    4. Individuals examined or treated under contract or resource 
sharing agreements.
    5. Individuals examined or treated for research or donor purposes.
    6. Individuals who have applied for Title 38 benefits, but who do 
not meet the requirements under Title 38 to receive such benefits.
    7. Individuals who were provided medical care under emergency 
conditions for humanitarian reasons.
    8. Pensioned members of allied forces provided health care services 
under Title 38, U.S.C., Chapter I.
    9. Current and former employees.
    10. Contractors employed by the Department of Veterans Affairs.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The ECWeb record documents the consultation request, relevant 
consultation specific information, a summary of the information 
including the ethical analysis and moral deliberation, the explanation 
of the findings to relevant parties and support of the consultation 
process. The ECWeb record also includes related notes and attachments.
    The records may include information related to ethics consultations 
performed in and for VHA medical treatment facilities. Information may 
include relevant information from a health record (a cumulative account 
of sociological, diagnostic, counseling, rehabilitation, drug and 
alcohol, dietetic, medical, surgical, dental, psychological, and/or 
psychiatric information compiled by VA professional staff and non-VA 
health care providers); subsidiary record information (e.g., tumor 
registry, dental, pharmacy, nuclear medicine, clinical laboratory, 
radiology, and patient scheduling information); identifying information 
(e.g., name, address, date of birth, partial social security number), 
military service information (e.g., dates, branch and character of 
service, service number, health information), family or authorized 
surrogate information (e.g., next-of-kin and person to notify in an 
emergency), employment information (e.g., occupation, employer name and 
address), and information pertaining to the individual's medical, 
surgical, psychiatric, dental, and/or treatment (e.g., information 
related to the chief complaint and history of present illness; 
information related to physical, diagnostic, therapeutic, special 
examinations, clinical laboratory, pathology and x-ray findings, 
operations, medical history, medications prescribed and dispensed, 
treatment plan and progress, consultations; photographs taken for 
identification and medical treatment, education and research purposes; 
facility locations where treatment is provided; observations and 
clinical impressions of health care providers to include identity of 
providers and to include, as appropriate, the present state of the 
patient's health, an assessment of the patient's emotional, behavioral, 
and social status, as well as an assessment of the patient's 
rehabilitation potential and nursing care needs). In addition the 
record may include the name and contact information for health care 
providers, and information regarding health care rendered by those 
providers.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Title 38, U.S.C., 501(b), 304, 7301, and 7304(a).

PURPOSE(S):
    The automated records may be used for such purposes as: Ethics 
consultation concerning education; ongoing treatment of the patient; 
documentation of treatment provided; payment; health care operations 
such as producing various management and patient follow-up reports; 
responding to patient and other inquiries; for epidemiological research 
and other health care related studies; statistical analysis, resource 
allocation and planning; providing clinical and administrative support 
to patient health care; audits, reviews and investigations conducted by 
staff of the health care facility, the VISN's, VA Central Office, and 
the VA Office of Inspector General (OIG); sharing of health information 
between and among Veterans Health Administration (VHA), Department of 
Defense (DoD), Indian Health Services (IHS), and other government and 
private industry health care organizations; quality improvement/
assurance audits, reviews and investigations; personnel management and 
evaluation; employee ratings and performance evaluations, and employee 
disciplinary or other adverse action, including removal; advising 
health care professional licensing or monitoring bodies or similar 
entities of activities of VA and former VA health care personnel; and, 
accreditation of a VA health care facility by an entity such as TJC.

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. Sec.  5705, i.e., quality assurance 
records; or information protected by 45 CFR parts 160 and 164, i.e., 
individually identifiable health information (IIHI), 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.

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    1. Disclosure of health care information as deemed necessary and 
proper to Federal, state and local government agencies and national 
health organizations in order to assist in the development of programs 
that will be beneficial to claimants, to protect their rights under 
law, and assure that they are receiving all benefits to which they are 
entitled.
    2. Disclosure of individually identifiable health care information 
may be made by appropriate VA personnel to the extent necessary and on 
a need-to-know basis, consistent with good medical and ethical 
practices, to family members and/or the person(s) with whom the patient 
has a meaningful relationship.
    3. Relevant information may be disclosed to a guardian ad litem in 
relation to his or her representation of a claimant in any legal 
proceeding.
    4. Relevant information may be disclosed to attorneys, insurance 
companies, employers, third parties liable or potentially liable under 
health plan contracts, and to courts, boards, or commissions, only to 
the extent necessary to aid VA in preparation, presentation, and 
prosecution of claims authorized under Federal, state, or local laws, 
and regulations promulgated thereunder.
    5. Disclosure of health information, excluding name and home 
address, (unless name and address is furnished by the requester) for 
research purposes determined to be necessary and proper, to 
epidemiological and other research entities approved by the Under 
Secretary for Health.
    6. Relevant information may be disclosed to the Department of 
Justice and United States Attorneys in defense or prosecution of 
litigation involving the United States, and to Federal agencies upon 
their request in connection with review of administrative tort claims 
filed under the Federal Tort Claims Act, 28 U.S.C. 2672.
    7. Relevant health care information concerning a non-judicially 
declared incompetent patient may be disclosed to a third party upon the 
written authorization of the patient's next of kin in order for the 
patient or, consistent with the best interest of the patient, a member 
of the patient's family, to receive a benefit to which the patient or 
family member is entitled or, to arrange for the patient's discharge 
from a VA medical facility. Sufficient information to make an informed 
determination will be made available to such next of kin. If the 
patient's next of kin are not reasonably accessible, the Chief of 
Staff, Director, or designee of the custodial VA health care facility 
may make disclosure of health care information for these purposes.
    8. Relevant health care information may be disclosed to a non-VA 
nursing home facility that is considering the patient for admission, 
when information concerning the individual's medical care is needed for 
the purpose of preadmission screening under 42 CFR 483.20(f), for the 
purpose of identifying patients who are mentally ill or mentally 
retarded, so they can be evaluated for appropriate placement.
    9. Relevant health care information may be disclosed to a State 
Veterans Home for the purpose of medical treatment and/or follow-up at 
the State Home when VA makes payment of a per diem rate to the State 
Home for the patient receiving care at such home, and the patient 
receives VA medical care.
    10. Relevant health care information may be disclosed to (a) A 
Federal agency or non-VA health care provider or institution when VA 
refers a patient for hospital or nursing home care or medical services, 
or authorizes a patient to obtain non-VA medical services and the 
information is needed by the Federal agency or non-VA institution or 
provider to perform the services; or (b) a Federal agency or a non-VA 
hospital (Federal, state and local, public or private) or other medical 
installation having hospital facilities, blood banks, or similar 
institutions, medical schools or clinics, or other groups or 
individuals that have contracted or agreed to provide medical services, 
or share the use of medical resources under the provisions of 38 U.S.C. 
513, 7409, 8111, or 8153, when treatment is rendered by VA under the 
terms of such contract or agreement or the issuance of an 
authorization, and the information is needed for purposes of medical 
treatment and/or follow-up, determining entitlement to a benefit or, 
for VA to effect recovery of the costs of the medical care.
    11. Information from an ECWeb record which relates to the 
performance of a health care student or provider may be disclosed to a 
medical or nursing school, or other health care related training 
institution, or other facility with which there is an affiliation, 
sharing agreement, contract, or similar arrangement when the student or 
provider is enrolled at or employed by the school or training 
institution, or other facility, and the information is needed for 
personnel management, rating and/or evaluation purposes.
    12. Relevant health care information may be disclosed to 
individuals, organizations, private or public agencies, etc., with whom 
VA has a contract or sharing agreement for the provision of health care 
or administrative services.
    13. The record of an individual who is covered by a system of 
records may be disclosed to a Member of Congress, or a staff person 
acting for the Member, when the Member of staff person requests the 
record on behalf of and at the written request of the individual.
    14. Disclosure may be made to the National Archives and Records 
Administration in records management inspections conducted under 
authority of Title 44 U.S.C.
    15. VA may disclose information from 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 release of the records to the DoJ 
is a use of the information contained in the records that is compatible 
with the purpose for which VA collected 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.
    16. VA may disclose on its own initiative any information in the 
system, except the names and home addresses of Veterans and their 
dependents, that is relevant to a suspected or reasonably imminent 
violation of the 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. VA may also 
disclose on its own initiative 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 statutes, 
regulation, or order issued pursuant thereto.
    17. Disclosure to other Federal agencies may be made to assist such 
agencies in preventing and detecting possible fraud or abuse by 
individuals in their operations and programs.

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    18. 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 subject, harm to economic or property 
interests, identify theft or fraud, or harm to the security, 
confidentiality, or integrity of this system or other systems (entity) 
that rely upon the potentially compromised information; and (3) the 
disclosure is to agencies, entities, or persons whom VA determines as 
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 uses 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.
    19. For program review purposes and the seeking of accreditation 
and/or certification, disclosure may be made to survey teams of TJC 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.
    20. Disclosure of information may be made to the next-of-kin and/or 
the person(s) with whom the patient has a meaningful relationship to 
the extent necessary and on a need-to-know basis consistent with good 
medical and ethical practices.
    21. Disclosure of ethics consultation records to groups (e.g., 
American Society for Bioethics and the Humanities) performing 
improvement or quality assessments as part of approved research or 
ongoing quality improvement projects with respect to ethics 
consultation practices.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Records are maintained on electronic media in ECWeb on a centrally 
located VA-owned server. In most cases, copies of back-up computer 
files are maintained at off-site locations. Subsidiary record 
information is maintained at the various respective ethics consultation 
services within the health care facility and by individuals, 
organizations, and/or agencies with whom VA has a contract or agreement 
to perform such services, as the VA may deem practicable.

RETRIEVABILITY:
    Records are retrieved by consultation number, name of ethics 
consultant, requester, ethics domain or topic, facility, keywords or 
phrases.

SAFEGUARDS:
    1. Access to VA working and storage areas is restricted to VA 
employees on a ``need-to-know'' basis; strict control measures are 
enforced to ensure that disclosure to these individuals is also based 
on this same principle. Generally, VA file areas are locked after 
normal duty hours and the facilities are protected from outside access 
by the Federal Protective Service or other security personnel.
    2. Access to computer rooms at health care facilities is generally 
limited by appropriate locking devices and restricted to authorized VA 
employees and vendor personnel. Automated Data Processing (ADP) 
peripheral devices are placed in secure areas (areas that are locked or 
have limited access) or are otherwise protected. Information in ECWeb 
may be accessed by authorized VA employees. Access to file information 
is controlled at two levels; the systems recognize authorized employees 
by series of individually unique passwords/codes as a part of each data 
message, and the employees are limited to only that information in the 
file, which is needed in the performance of their official duties. 
Information that is downloaded from ECWeb and maintained on personal 
computers is afforded similar storage and access protections as the 
data that is maintained in the original files. Access to information 
stored on automated storage media at other VA locations is controlled 
by individually unique passwords/codes.
    3. Access to computer rooms is restricted to authorized operational 
personnel through electronic locking devices. All other persons gaining 
access to computer rooms are escorted. Information stored in the 
computer may be accessed by authorized VA employees at remote locations 
including VA health care facilities, Information Systems Centers, VA 
Central Office, and Veteran Integrated Service Networks. Access is 
controlled by individually unique passwords/codes, which must be 
changed periodically by the employee.

RETENTION AND DISPOSAL:
    Records that are stored within Computerized Patient Record System 
(CPRS) and Veterans Health Information Systems and Technology 
Architecture (VistA) will be maintained in accordance with Record 
Control Schedule (RCS) 10-1 Item # XLIII-2, Electronic Health Records, 
NARA job# N1-15-02-3. All other records maintained outside the 
Electronic Health Record will be maintained in accordance with General 
Records Schedule (GRS) 25 Ethics Program Records Item 1.a and 1.b (N1-
GRS-01-1 item 1a & 1b).

SYSTEMS AND MANAGER(S) AND ADDRESS:
    Official responsible for policies and procedures: Executive 
Director, National Center for Ethics in Health Care, Veterans Health 
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW., 
Washington, DC 20420. Official maintaining the system: Director at the 
VA health care facility where the individuals are associated.

NOTIFICATION PROCEDURE:
    Individuals seeking information regarding access to and contesting 
of ECWeb records may write, call or visit the last VA health care 
facility where health care was provided or by writing the National 
Center for Ethics in Health Care.

RECORD ACCESS PROCEDURE:
    Individuals seeking information regarding access to and contesting 
of records in this system may write, call or visit the VA health care 
facility location where they are or were employed or made contact or 
they may write the National Center for Ethics in Health Care.

CONTESTING RECORD PROCEDURES:
    (See Record Access Procedures above.)

RECORD SOURCE CATEGORIES:
    Information in this system of records is provided by the patient, 
family members or accredited representative, and friends, authorized 
surrogates, health care agents, employees, contractors, medical service 
providers, and various automated systems providing clinical and 
managerial support at VA health care facilities.
[FR Doc. 2016-01701 Filed 1-28-16; 8:45 am]
 BILLING CODE 8320-01-P