[Federal Register Volume 67, Number 211 (Thursday, October 31, 2002)]
[Notices]
[Pages 66457-66461]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-27686]


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DEPARTMENT OF VETERANS AFFAIRS


Privacy Act of 1974; System of Records

AGENCY: Department of Veterans Affairs.

ACTION: Notice of new 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 the 
Department of Veterans Affairs (VA) is adding a new system of records 
entitled ``Patient Representation Program Records--VA'' (100VA10NS10).

DATES: Comments on the establishment of the new system of records must 
be received no later than December 2, 2002. If no public comment is 
received during the period allowed for comment or unless otherwise 
published in the Federal Register by the VA, the system will become 
effective December 2, 2002.

ADDRESSES: You may mail or hand-deliver written comments concerning the 
proposed new system of records to the Office of Regulations Management 
(02D), Department of Veterans Affairs, 810 Vermont Avenue, NW., 
Washington, DC 20420; or fax comments to (202) 273-9289; or email 
comments to [email protected]. All relevant material received 
before December 2, 2002, will be considered. 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 Ave., 
NW., Washington, DC 20420, at (727) 320-1839.

SUPPLEMENTARY INFORMATION:

I. Description of the Proposed System of Records

    The primary function of the Patient Representation Program is to 
serve as a direct channel of communication and mediation between VA 
healthcare facility management and individual patients, veterans who 
have applied for care, their friends, their families, VA healthcare 
providers and members of the community. A VA healthcare provider is 
anyone hired by VA and working at a VA facility be it a VA medical 
center (VAMC), Outpatient Clinic or Community-Based Outpatient Clinic. 
An employee may be full-time, part-time, or intermittent and includes 
temporary workers. Members of the community include congressional 
liaisons, veterans service organizations and attorneys. The program 
functions as the liaison between the patient and the healthcare system, 
ensures that patients receive entitled healthcare benefits and services 
in a dignified and compassionate manner, and ensures that healthcare 
facility policies and practices are in conformance with the VA 
Patients' Bill of Rights. The program is the primary source for 
response when veteran patients' expectations are not met within the VA 
healthcare system. The Patient Representatives' activities cross all 
organizational lines of authority at the healthcare facilities for the 
purpose of expressing patient concerns and resolution of patient 
complaints. Information collected from the program is integrated into 
the overall quality improvement plans and activities of the healthcare 
facility. The purpose of the system of records is to establish a 
repository for the information that is collected to accomplish the 
purposes described. Records are maintained at the local VA level on 
behalf of the veteran making the complaint or compliment so 
improvements may be made at the VA healthcare facility. Patient 
contacts are coded in order to facilitate tracking of these contacts to 
show where improvements might be made. Aggregate data are maintained at 
the Network and Headquarters levels for the development of reports to 
make systemwide changes. Records are collected and stored 
electronically for ease of retrieval by individual patient names and 
ease in compiling aggregate data.

II. Proposed Routine Use Disclosures of Data in the System

    We are proposing to establish the following routine use disclosures 
of information maintained in the system:
    1. To a member of Congress or staff person acting for the member 
when the member or staff person requests the records on behalf of and 
at the request of that individual.
    Individuals sometimes request the help of a member of Congress in 
resolving some issues relating to a matter before VA. The member of 
Congress then writes to VA, and VA must be able to give sufficient 
information to be responsive to the inquiry.
    2. To the National Archives and Record Administration (NARA) in 
records management inspections conducted under authority of Title 44, 
United States Code.
    NARA is responsible for archiving old records no longer actively 
used but which may be appropriate for preservation; it is responsible 
in general for the physical maintenance of the Federal Government's 
records. VA must be able to turn records over to this agency in order 
to determine the proper disposition of such records.
    3. Disclosure may be made to the Department of Justice and United 
States Attorneys in defense or prosecution of litigation involving the 
United States,

[[Page 66458]]

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.
    4. Disclosure may be made to any facility regarding the hiring, 
performance, or other personnel-related information 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.
    Federal, State, or local facilities with which VA healthcare 
facilities wish to enter sharing agreements or affiliations may require 
information regarding VA personnel, information on hiring and 
performance before entering into such relationships.
    5. Disclosure may be made 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 which maintains 
records concerning individual employment histories or concerning the 
issuance, retention or revocation of licenses, certifications, or 
registrations 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 or licensing 
board or the appropriate non-government entities about the healthcare 
practices of employees who resigned, were terminated or retired and 
whose professional healthcare 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.
    VA must be able to report information regarding the care a 
healthcare practitioner provides to agencies and boards charged with 
maintaining the health and safety of patients.
    6. 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.
    VA healthcare facilities undergo certification and accreditation by 
several national accreditation agencies or boards to comply with 
regulations and good medical practices. VA must be able to disclose 
information for program review purposes and the seeking of 
accreditation and/or certification of healthcare facilities and 
programs.
    7. 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 healthcare 
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 
healthcare professional.
    8. Disclosure of information to the Federal Labor Relations 
Authority (FLRA) (including its General Counsel) when requested in 
connection with the 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, in 
connection with matters before the Federal Service Impasses Panel, and 
to investigate representation petitions and conduct or supervise 
representation elections.
    The release of information to the FLRA from this Privacy Act system 
of records is necessary to comply with the statutory mandate under 
which FLRA operates. It has also been determined that the release of 
information for this purpose is a necessary and proper use of the 
information in this system of records.
    9. Disclosure of relevant information may be made to individuals, 
organizations, private or public agencies, etc., 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 or subcontractor to perform the services of the contract 
or agreement.
    VA occasionally contracts out certain of it functions when this 
would contribute to effective and efficient operations. VA must be able 
to give a contractor whatever information is necessary for the 
contractor to fulfill their duties. In these situations, safeguards are 
provided in the contract prohibiting the contractor from using or 
disclosing the information for any purpose other than that described in 
the contract.
    10. Disclosure may be made to a Federal agency, in response to its 
request, in connection with the hiring or retention of an employee, the 
issuance of a security clearance, the reporting of an investigation of 
an employee, the letting of a contract, or the issuance or continuance 
of a license, grant or other benefit given by that agency to the extent 
that the information is relevant and necessary to the requesting 
agency's decision on the matter.
    VA must be able to provide information to agencies conducting 
background checks on applicants for employment or licensure.
    11. Disclosure may be made to a Federal, State, or local agency 
maintaining civil or criminal violation records, or other pertinent 
information in order for VA to obtain information relevant to the 
hiring or retention of an employee, letting of a contract, granting of 
a security clearance, or the issuance of a grant.
    VA needs to obtain information from other agencies in order to 
conduct background and security clearance checks on applicants for 
employment to VA, contractors, or persons requesting a grant.
    12. 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-ethical practices.
    13. A record containing the name(s) and address(es) of present or 
former members of the armed services and/or their dependents may be 
disclosed under certain circumstances: (1) To any non-profit 
organization if the release is directly connected with the conduct of 
programs and the utilization of benefits under Title 38 U.S.C.; and, 
(2) to any criminal or civil law enforcement governmental agency or 
instrumentality charged under applicable law with the protection of the 
public health or safety if a qualified representative of such 
organization, agency or instrumentality has made a standing written 
request that such name(s) or address(es) be provided for a purpose 
authorized by law; provided, further, that the record(s) will not be 
used for any purpose other than that stated in the request and that 
organization, agency or instrumentality is aware of the penalty 
provision of 38 U.S.C. 5701(f).
    14. On its own initiative, VA may disclose information, except for 
the names and home addresses of veterans and their dependents, to a 
Federal, State, local, tribal or foreign agency

[[Page 66459]]

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. 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.
    VA must be able to comply with the requirements of agencies charged 
with enforcing the law and conducting investigations. VA must also be 
able to provide information to State or local agencies charged with 
protecting the public's health as set forth in State law.

III. Compatibility of the Proposed Routine Uses

    The Privacy Act permits VA to disclose information about 
individuals without their consent for a routine use when the 
information will be used for a purpose that is compatible with the 
purpose for which VA collected the information. In all of the routine 
use disclosures described above, the recipient of the information will 
use the information in connection with a matter relating to one of VA's 
programs, will use the information to provide a benefit to VA, or 
disclosure is required by law.
    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 the 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: October 11, 2002.
Anthony J. Principi,
Secretary of Veterans Affairs.
100VA10NS10

System Name:
    Patient Representation Program Records--VA.

System Location:
    Records are maintained at each Department of Veterans Affairs' (VA) 
healthcare facility (in most cases, back-up computer tape information 
is stored at off-site locations). Address locations for VA facilities 
are listed in VA 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, 20420; 
Veterans Integrated Service Networks (VISNs); and, Austin Automation 
Center (AAC), Austin, Texas.

Categories of Individuals Covered by the System:
    The records include information concerning individual patients, 
veterans who have applied for care, their friends, their families, VA 
healthcare providers and members of the community. Members of the 
community include congressional liaisons, veterans service 
organizations and attorneys.

Categories of Records in the System:
    The records may include information maintained in paper records, 
and entered into the Veterans Health Information Systems and Technology 
Architecture (VistA), related to concerns and complaints regarding an 
individual's medical care, VA benefits, and/or encounters with 
healthcare facility personnel. The records include information that is 
compiled to review, investigate, and resolve these issues.

Authority for Maintenance of the System:
    Title 38, United States Code, chapter 73, section 7301 (b).

Purpose(s):
    The records may be used for such purposes as producing various 
management and patient follow-up reports; responding to patient and 
other inquiries; conducting healthcare-related studies, statistical 
analysis, and resource allocation planning; providing clinical and 
administrative support to patient medical care; audits, reviews and 
investigations conducted by the staff of the healthcare facility, VISN, 
VHA Headquarters, and VA's Office of Inspector General (OIG); law 
enforcement investigations; quality improvement reviews and 
investigations; personnel management and evaluation; employee ratings 
and performance evaluations; employee disciplinary or other adverse 
action, including discharge; advising healthcare professional licensing 
or monitoring bodies or similar entities or activities of VA and former 
VA healthcare personnel; accreditation of a facility by an entity such 
as the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO); and, notifying medical schools of medical students' 
performance. The information is integrated into the overall quality 
improvement plans and activities of the facility and used to improve 
services and communications, as well as, to track categories of 
complaints and the locations of complaints in order to improve the 
delivery of healthcare.

Routine Uses of Records Maintained in the System Including Categories 
of Users and the Purposes of Such Uses:
    1. 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 written request of that individual.
    2. Disclosure may be made to the National Archives and Record 
Administration (NARA) for records management inspections conducted 
under authority of Title 44, United States Code.
    3. 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.
    4. Disclosure may be made to any facility regarding the hiring, 
performance, or other personnel-related information 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.
    5. Disclosure may be made 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 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 Federal agencies, licensing 
boards or the appropriate non-government entities about the healthcare 
practices of employees who resigned, were terminated, or retired and 
whose professional healthcare 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.
    6. For program review purposes and the seeking of accreditation 
and/or certification, disclosure may be made to survey teams of JCAHO, 
College of American Pathologists, American Association of Blood Banks, 
and similar

[[Page 66460]]

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.
    7. 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 healthcare 
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 
healthcare professional.
    8. Disclosure of information to the Federal Labor Relations 
Authority (FLRA) (including its General Counsel) when requested in 
connection with the investigation and resolution of allegations of 
unfair labor practices, in connection with the resolution of exceptions 
to arbitration awards when a question of material fact is raised, in 
connection with matters before the Federal Service Impasses Panel, and 
to investigate representation petitions and conduct or supervise 
representation elections.
    9. Disclosure of relevant information may be made to individuals, 
organizations, private or public agencies, etc., 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 or subcontractor to perform the services of the contract 
or agreement.
    10. Disclosure may be made to a Federal agency, in response to its 
request, in connection with the hiring or retention of an employee, the 
issuance of a security clearance, the reporting of an investigation of 
an employee, the letting of a contract, or the issuance of a license, 
grant, or other benefit by the requesting agency, to the extent that 
the information is relevant and necessary to the requesting agency's 
decision on the matter.
    11. Disclosure may be made to a Federal, State or local agency 
maintaining civil, criminal or other relevant information such as 
current licenses, if necessary to obtain information relevant to any 
agency decision concerning the hiring or retention of an employee, the 
issuance of a security clearance, the letting of a contract, or the 
issuance of a license, grant or other health, educational or welfare 
benefit.
    12. 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-ethical practices.
    13. A record containing the name(s) and address(es) of present or 
former members of the armed services and/or their dependents may be 
disclosed under certain circumstances: (1) To any non-profit 
organization if the release is directly connected with the conduct of 
programs and the utilization of benefits under Title 38 U.S.C.; and (2) 
to any criminal or civil law enforcement governmental agency or 
instrumentality charged under applicable law with the protection of the 
public's health or safety, if a qualified representative of such 
organization, agency or instrumentality has made a standing written 
request that such name(s) or address(es) be provided for a purpose 
authorized by law; provided that the record(s) will not be used for any 
purpose other than that stated in the request and that organization, 
agency or instrumentality is aware of the penalty provision of 38 
U.S.C. 5701(f).
    14. 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 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.

Policies and Practices for Storing, Retrieving, Accessing, Retaining 
and Disposing of Records in the System:
Storage:
    Records are maintained on paper, magnetic tape, disk, or laser 
optical media. Information on automated storage media includes record 
information stored in the VistA system. In most cases, copies of back-
up computer files are maintained at off-site locations.

Retrievability:
    Records are retrieved by the names and social security numbers 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 VistA at healthcare facilities is generally limited by 
appropriate locking devices and restricted to authorized VA employees 
and vendor personnel. Peripheral devices are placed in secure areas 
(areas that are locked or have limited access) or are otherwise 
protected. Information in the VistA system may only be accessed by 
authorized VA employees and vendor personnel. Access to file 
information is controlled at two levels: the systems recognize 
authorized employees by series of individually unique passwords/codes 
as 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.
    3. Data maintained at the AAC can only be updated by authorized AAC 
personnel. Access is limited to authorized employees by individually 
unique access codes that are changed periodically. Physical access to 
the AAC is generally restricted to AAC staff, VA Headquarters' 
employees, custodial personnel, Federal Protective Service and 
authorized operational personnel through electronic locking devices. 
All other persons gaining access to the computer rooms are escorted.

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

[[Page 66461]]

System Manager(s) and Address:
    Official responsible for policies and procedures: Program Manager, 
National VA Patient Representation Program (10NS10), VA Medical Center, 
1900 E. Main, Danville, Illinois 61832. Officials maintaining the 
system: Director at the facility where the individuals made contact.

Notification Procedure:
    Individuals who wish to determine whether this system of records 
contains information about them should contact the VA facility location 
where they made or have contact. Inquiries should include the person's 
full name, social security number, 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 
location where they made contact.

Record Source Categories:
    The patient, family members, and friends, employers or other third 
parties when otherwise unobtainable from the patient or family; Patient 
Medical Records--VA (24VA136); private medical facilities and 
healthcare professionals; State and local agencies; other Federal 
agencies; VISNs, Veterans Benefits Administration automated record 
systems (including Veterans and Beneficiaries Identification and 
Records Location Subsystem--VA (38VA23) and the Compensation, Pension, 
Education and Rehabilitation Records--VA (58VA21/22); and various 
automated systems providing clinical and managerial support at VA 
healthcare facilities.

[FR Doc. 02-27686 Filed 10-30-02; 8:45 am]
BILLING CODE 8320-01-P