[Federal Register Volume 65, Number 227 (Friday, November 24, 2000)]
[Notices]
[Pages 70632-70636]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-29945]


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DEPARTMENT OF VETERANS AFFAIRS


Privacy Act of 1974; System of Records

AGENCY: Department of Veterans Affairs (VA).

ACTION: Notice of amendment to system of records.

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SUMMARY: The Privacy Act of 1974 (5 U.S.C. 552(e)(4)) requires that all 
agencies publish in the Federal Register a notice of the existence and 
character of their systems of records. Notice is hereby given that VA 
is amending the system of records currently entitled ``Decentralized 
Hospital Computer Program (DHCP) Medical Management Records'' (79VA162) 
as set forth in the

[[Page 70633]]

Federal Register 56 FR 6048. VA is amending the system by revising the 
System Name and number and the paragraphs for System Location, 
Categories of Records in the System, Authority for Maintenance of the 
System, Routine Uses of Records Maintained in the System, and System 
Manager. The change in name will more accurately identify the system 
and the change in number will reflect organizational changes. VA is 
republishing the system notice in its entirety.

DATES: Comments on the amendment of this system of records must be 
received no later than December 26, 2000. If no public comment is 
received, the new system will become effective December 26, 2000.

ADDRESSES: Written comments concerning the amendment to this system of 
records may be submitted to the Office of Regulations Management (02D), 
Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 
20420. Comments will be available for public inspection at the above 
address in the Office of Regulations Management, Room 1158, between the 
hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT: Veterans Health Administration (VHA) 
Privacy Act Officer, Department of Veterans Affairs, 810 Vermont 
Avenue, NW., Washington, DC 20420, telephone (727) 320-1839.

SUPPLEMENTARY INFORMATION: The name and number of the system is changed 
from ``Decentralized Hospital Computer Program (DHCP) Medical 
Management Records-VA'' (79VA162) to the ``Veterans Health Information 
Systems and Technology Architecture (VistA) Records-VA'' (79VA19). The 
change in name will more accurately reflect the new, open system, 
client-server based environment and the change in system number will 
reflect organizational changes. The System Location was amended to 
reflect the current organization structure with Veterans Integrated 
Service Network Offices having replaced Regional Director Offices. 
Categories of Records in the System were amended to add five new types 
of records maintained in VistA. The Authority for Maintenance of the 
System was amended to reflect current codification of the statute. The 
System Manager was amended to reflect organization changes.

Background

    In the 1980s the Veterans Health Administration (VHA) developed an 
electronic health care architecture called the Decentralized Hospital 
Computer Program (DHCP) that was comprised of software applications 
that were integrated into a complete hospital information system 
primarily for hospital-based activities. DHCP was installed at VA 
medical facilities to provide comprehensive support for clinical and 
administrative needs and for VA-wide management information. By 1990, 
VHA upgraded computer capacity at all medical facilities and 
implemented software on a national scale that supported integrated 
health care delivery. In 1996, VHA introduced the Veterans Health 
Information Systems and Technology Architecture (VistA), a client-
server architecture that tied together workstations and personal 
computers and supported the day-to-day operations at all health care 
facilities.
    The purpose of the system of records is to provide a repository for 
the administrative information that is used to accomplish the purposes 
described. The records include information provided by applicants for 
employment, employees, volunteers, trainees, contractors and 
subcontractors, consultants, maintenance personnel, students, patients, 
and information obtained in the course of routine work done. Quality 
assurance information that is protected by 38 U.S.C. 7311 and 38 CFR 
17.500-17.511 is not within the scope of the Privacy Act and, 
therefore, is not included in this system of records or filed in a 
manner in which the information may be retrieved by reference to an 
individual identifier.
    Data stored in VistA is used to prepare various management, 
tracking and follow-up reports that are used to assist in the 
management and operation of the health care facility, and the planning 
and delivery of patient medical care. Data may be used to track and 
evaluate patient care services; the distribution and utilization of 
resources; and the performance of vendors and employees. The data may 
also be used for such purposes as scheduling employees' tours of duty 
and for scheduling patient treatment services including nursing care, 
clinic appointments, surveys, diagnostic and therapeutic procedures. 
Data may also be used to track the ordering, delivery, maintenance and 
repair of equipment and for follow-up to determine if the actions were 
accomplished and to evaluate the results.
    Routine use disclosures have been added, as described below, to 
enable efficient administration and operation of health care facilities 
and to assist in the planning and delivery of patient medical care:
     Routine use twenty-three (23) states the social security 
number, universal personal identification number and other identifying 
information of a health care provider may be disclosed to a third party 
where the third party requires the agency to provide that information 
before it will pay for medical care provided by VA. VA, under Public 
Law 99-272, is required to recover costs for medical services in 
certain circumstances provided to the veteran from the veteran's third 
party insurance carrier. Third party insurance carriers may require VA 
to provide the social security number(s) of the health care provider(s) 
before reimbursing VA for medical services rendered.
     Routine use twenty-four (24) states relevant information 
may be disclosed to individuals, organizations, private or public 
agencies, etc., with whom VA has a contract or agreement to perform 
such services as VA may deem practical for the purposes of laws 
administered by VA, in order for the contractor to perform the services 
of the contract or agreement. This routine use is being added to allow 
for the disclosure of information to contractors when performing an 
agency function. VA must be able to share information with contractors.
     Routine use twenty-five (25) allows disclosure of relevant 
health care information to individuals or organizations (private or 
public) with whom VA has a contract or sharing agreement for the 
provision of health care, administrative or financial services. VA must 
be able to share information with other organizations participating in 
the care of veterans.
    The notice of intent to publish 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 (61 FR 
6428), February 20, 1996.

    Approved: November 8, 2000.
Hershel W. Gober,
Acting Secretary of Veterans Affairs.
79VA19

SYSTEM NAME:
    Veterans Health Information Systems and Technology Architecture 
(VistA) Records-VA.

SYSTEM LOCATION:
    Records are maintained at each VA health care facility (in most 
cases, back-up computer tape information is stored at off-site 
locations). Address locations for VA facilities are listed in VA

[[Page 70634]]

Appendix 1. In addition, information from these records or copies of 
records may be maintained at the Department of Veterans Affairs, 810 
Vermont Avenue, NW., Washington, DC, VA Data Processing Centers, VA 
Chief Information Officer (CIO) Field Offices, and Employee education 
Systems.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The records include information concerning current and former 
employees, applicants for employment, trainees, contractors, sub-
contractors, contract personnel, students, providers and consultants, 
patients and members of their immediate family, volunteers, maintenance 
personnel, as well as individuals working collaboratively with VA.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The records may include information related to:
    1. Workload such as orders entered, verified, and edited (e.g., 
engineering work orders, doctors' orders for patient care including 
nursing care, the scheduling and delivery of medications, 
consultations, radiology, laboratory and other diagnostic and 
therapeutic examinations); results entered; items checked out and items 
in use (e.g., library books, keys, x-rays, patient medical records, 
equipment, supplies, reference materials); work plans entered and the 
subsequent tracking (e.g., construction projects, engineering work 
orders and equipment maintenance and repairs assigned to employees and 
status, duty schedules, work assignments, work requirements); reports 
of contact with individuals or groups; employees (including volunteers) 
work performance information (e.g., duties and responsibilities 
assigned and completed, amount of supplies used, time used, quantity 
and quality of output, productivity reports, schedules of patients 
assigned and treatment to be provided);
    2. Administrative procedures, duties, and assignments of certain 
personnel;
    3. Computer access authorizations, computer applications available 
and used, information access attempts, frequency and time of use; 
identification of the person responsible for, currently assigned, or 
otherwise engaged in various categories of patient care or support of 
health care delivery; vehicle registration (motor vehicles and 
bicycles) and parking space assignments; community and special project 
participants/attendees (e.g., sports events, concerts, National 
Wheelchair Games); employee work-related accidents. The record may 
include identifying information (e.g., name, date of birth, age, sex, 
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); information related to training (e.g., security, 
safety, in-service), education and continuing education (e.g., name and 
address of schools and dates of attendance, courses attended and 
scheduled to attend, grades, type of degree, certificate, etc.); 
information related to military service and status; qualifications for 
employment (e.g., license, degree, registration or certification, 
experience); vehicle information (e.g., type make, model, license and 
registration number); evaluation of clinical and/or technical skills; 
services or products purchased (e.g., vendor name and address, details 
about and/or evaluation of service or product, price, fee, cost, dates 
purchased and delivered, employee workload and productivity data); 
employee work-related injuries (cause, severity, type of injury, body 
part affected);
    4. Financial information, such as service line and clinic budgets, 
projected and actual costs;
    5. Supply information, such as services, materials and equipment 
ordered;
    6. Abstract information (e.g., data warehouses, environmental and 
epidemiological registries, etc.) is maintained in auxiliary paper and 
automated records;
    7. Electronic messages; and
    8. The social security number and universal personal identification 
number of health care providers.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Title 38, United States Code, section 7301(a).

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; the planning, distribution and utilization of resources; 
the possession and/or use of equipment or supplies; the performance of 
vendors, equipment, and employees; and to provide clinical and 
administrative support to patient medical care. The data may be used 
for research purposes. The data may be used also for such purposes as 
assisting in the scheduling of tours of duties and job assignments of 
employees; the scheduling of patient treatment services, including 
nursing care, clinic appointments, surgery, diagnostic and therapeutic 
procedures; the repair and maintenance of equipment and for follow-up 
to determine that the actions were accomplished and to evaluate the 
results; the registration of vehicles and the assignment and 
utilization of parking spaces; to plan, schedule, and maintain rosters 
of patients, employees and others attending or participating in sports, 
recreational or other events (e.g., National Wheelchair Games, 
concerts, picnics); for audits, reviews and investigations conducted by 
staff of the health care facility, the Network Directors Office, VA 
Central Office, and the VA Office of Inspector General (OIG); for 
quality assurance audits, reviews, investigations and inspections; for 
law enforcement investigations; and for personnel management, 
evaluation and employee ratings, and performance evaluations.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSE 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, that 
information cannot be disclosed under a routine use unless there is 
also specific statutory authority permitting disclosure.
    1. In the event that a record maintained by VA to carry out its 
functions indicates a violation or potential violation of law, whether 
civil, criminal or regulatory in nature, and whether arising by general 
statute or particular program statute, or by regulation, rule or order 
issued pursuant thereto, information may be disclosed to the 
appropriate agency whether Federal State, local or foreign, charged 
with the responsibility of investigating or prosecuting such violation 
or charged with enforcing or implementing the statute or rule, 
regulation 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 to 
identify the type of information requested), when necessary to obtain 
information relevant to a Department decision concerning the hiring or 
retention of an employee, the issuance of a security clearance, the 
conducting of a security or suitability

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investigation of an individual, the letting of a contract, or the 
issuance of a license, grant, or other benefits.
    3. Disclosure may be made to an agency in the executive, 
legislative, or judicial branch, or the District of Columbia's 
government in response to its request or at the initiation of VA, in 
connection with the hiring of an employee, the issuance of a security 
clearance, the conducting of a security or suitability investigation of 
an individual, the letting of a contract, the issuance of a license, 
grant, or other benefits by the requesting agency, or the lawful 
statutory, administrative, or investigative purpose of the agency to 
the extent that the information is relevant and necessary to the 
requesting agency's decision.
    4. 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.
    5. Disclosure may be made to the National Archives and Records 
Administration (NARA) in records management inspections conducted under 
authority of 44 U.S.C. 2904 and 2906.
    6. Disclosure may be made 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. Hiring, performance, or other personnel-related information may 
be disclosed to any facility with which there is or there is proposed 
to be an affiliation, sharing agreement, contract, or similar 
arrangement for purposes of establishing, maintaining, or expanding any 
such relationship.
    8. Disclosure may be made to a Federal, State or local government 
licensing board and/or to the Federation of State Medical Boards or a 
similar non-government entity which maintains records concerning 
individual 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 
Department to obtain information relevant to a Department decision 
concerning the hiring, retention or termination of an employee; or 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. These records may 
also be disclosed as part of an ongoing computer matching program to 
accomplish these purposes.
    9. For program review purposes, and the seeking of accreditation 
and/or certification, disclosure may be made to survey teams of the 
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 
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.
    10. Disclosure may be made to a State or local government entity or 
national certifying body which 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 licensing entity or 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.
    11. Any information which is relevant to a suspected violation 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, may be 
disclosed to a Federal, State, local or foreign agency charged with the 
responsibility of investigating or prosecuting such violation, rule or 
order issued pursuant thereto.
    12. Disclosure may be made to officials of labor organizations 
under 5 U.S.C. chapter 71 when relevant and necessary to their duties 
of exclusive representation concerning personnel policies, practices, 
and matter affecting working conditions.
    13. Disclosure may be made to the VA-appointed representative of an 
employee, including all notices, determinations, decision, 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.
    14. Disclosure may be made to officials to the Merit Systems 
Protection Board, including the Office of the 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.
    15. Disclosure may be made to the Equal Employment Opportunity 
Commission when requested in connection with investigations of alleged 
or possible discrimination practices, examination of Federal 
affirmative employment programs, compliance with the Uniform Guidelines 
of Employee Selection Procedures, or other functions vested in the 
Commission by the President's Reorganization Plan No. 1 of 1978.
    16. Disclosure may be made to the Federal Labor Relations 
Authority, including its General Counsel, when requested in connection 
with investigation and resolution of allegations of unfair labor 
practices, in connection with the resolution of exceptions to 
arbitrator awards when a question of material fact is raised and 
matters before the Federal Service Impasses Panel.
    17. Disclosure may be made in consideration and selection of 
employees for incentive awards and other honors and to publicize those 
granted. This may include disclosure to other public and private 
organizations, including news media, which grant or publicize employee 
awards or honors.
    18. Disclosure may be made to consider employees for recognition 
through administrative and quality step increases and to publicize 
those granted. This may include disclosure to other public and private 
organizations, including news media, which grant or publicize employee 
recognition.
    19. Identifying information such as name, address, social security 
number and other information as is reasonably necessary to identify 
such individual, may be disclosed to the National Practitioner Data 
Bank at the time of hiring and/or clinical privileging/reprivileging of 
health care practitioners and at other times as deemed necessary by VA 
in order for VA to obtain information relevant to a Department decision 
concerning the hiring, privileging/reprivileging, retention or 
termination of the applicant or employee.
    20. Disclosure of relevant information may be made to the National 
Practitioner Data Bank or to a State or

[[Page 70636]]

local government licensing board which maintains records concerning the 
issuance, retention or revocation of licenses, certifications, or 
registrations necessary to practice an occupation, profession or 
specialty when under the following circumstances, through a peer review 
process that is undertaken pursuant to VA policy, negligence, 
professional incompetence, responsibility for improper care, and/or 
professional misconduct has been assigned to a physician or licensed or 
certified health care practitioner: (1) On any payment in settlement 
(or partial settlement) of, or in satisfaction of a judgment in a 
medical malpractice action or claim; or, (2) on any final decision that 
adversely affects the clinical privileges of a physician or 
practitioner for a period of more than 30 days. These records may also 
be disclosed as part of a computer matching program to accomplish these 
purposes.
    21. Disclosure of medical record data, excluding name and address, 
unless name and address is furnished by the requester, may be made to 
epidemiological and other research facilities for research purposes 
determined to be necessary and proper, and approved by the Under 
Secretary for Health.
    22. Disclosure of name(s) and address(es) 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, the VA may impose applicable conditions on the department, 
agency, and/or contractor to insure the appropriateness of the 
disclosure to the contractor.
    23. The social security number, universal personal identification 
number and other identifying information of a health care provider may 
be disclosed to a third party where the third party requires the agency 
to provide that information before it will pay for medical care 
provided by VA.
    24. Relevant information may be disclosed to individuals, 
organizations, private or public agencies, etc., with whom VA has a 
contract or agreement to perform such services as VA may deem practical 
for the purposes of laws administered by VA, in order for the 
contractor to perform the services of the contract or agreement.
    25. Disclosure of relevant health care information may be made to 
individuals or organizations (private or public) with whom VA has a 
contract or sharing agreement for the provision of health care, 
administrative or financial services.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Records are maintained on paper, microfilm, magnetic tape, disk, or 
laser optical media. In most cases, copies of back-up computer files 
are maintained at off-site locations.

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 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 VistA 
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 VistA 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. Access by Office of Inspector 
General (OIG) staff conducting an audit, investigation, or inspection 
at the health care facility, or an OIG office location remote from the 
health care facility, is controlled in the same manner.
    3. Information downloaded from VistA and maintained by the OIG 
headquarters and Field Offices on automated storage media is secured in 
storage areas for facilities to which only OIG staff have access. Paper 
documents are similarly secured. Access to paper documents and 
information on automated storage media is limited to OIG employees who 
have a need for the information in the performance of their official 
duties. Access to information stored on automated storage media is 
controlled by individually unique passwords/codes.

RETENTION AND DISPOSAL:
    Paper records and information stored on electronic storage media 
are maintained and disposed of in accordance with records disposition 
authority approved by the Archivist of the United States.

SYSTEM MANAGER(S) AND ADDRESS:
    The official responsible for policies and procedures is the 
Associate Chief Information Officer, Technical Services (192), 
Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 
20420. The local official responsible for maintaining the system is the 
Director of the facility where the individual is or was associated.

NOTIFICATION PROCEDURE:
    Individuals who wish to determine whether this system of records 
contains information about them should contact the VA facility location 
at which they are or were employed or made or have contact. Inquiries 
should include the person's full name, social security number, dates of 
employment, date(s) of contact, and return address.

RECORD ACCESS PROCEDURE:
    Individuals seeking information regarding access to and contesting 
of records in this system may write, call or visit the VA facility 
where they are or were employed or made contact.

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

RECORD SOURCE CATEGORIES:
    Information in this system of records is provided by the 
individual, supervisors, other employees, personnel records, or 
obtained from their interaction with the system.

[FR Doc. 00-29945 Filed 11-22-00; 8:45 am]
BILLING CODE 8320-01-M