80_FR_36717 80 FR 36595 - Privacy Act of 1974; System of Records

80 FR 36595 - Privacy Act of 1974; System of Records

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 80, Issue 122 (June 25, 2015)

Page Range36595-36599
FR Document2015-15351

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. The Department of Veterans Affairs (VA) is amending the system of records, known as ``Health Care Provider Credentialing and Privileging Records-VA'' (77VA10Q) as set forth in the Federal Register 73 FR 16097 dated 3/26/08. VA is amending the system notice by revising the paragraphs on System Number, System Location, Categories of Individuals Covered by the System, and Routine Uses of Records Maintained in the System. VA is republishing the system notice in its entirety at this time.

Federal Register, Volume 80 Issue 122 (Thursday, June 25, 2015)
[Federal Register Volume 80, Number 122 (Thursday, June 25, 2015)]
[Notices]
[Pages 36595-36599]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2015-15351]


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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. The Department of Veterans 
Affairs (VA) is amending the system of records, known as ``Health Care 
Provider Credentialing and Privileging Records-VA'' (77VA10Q) as set 
forth in the Federal Register 73 FR 16097 dated 3/26/08. VA is amending 
the system notice by revising the paragraphs on System Number, System 
Location, Categories of Individuals Covered by the System, and Routine 
Uses of Records Maintained in the System. VA is republishing the system 
notice in its entirety at this time.

DATES: Comments on the amendment of this system of records must be 
received no later than July 27, 2015. If no public comment is received, 
the new system will become effective July 27, 2015.

ADDRESSES: Written comments concerning the proposed amended system of 
records may be submitted by: mail or hand-delivery to Director, 
Regulations Management (02REG), Department of Veterans Affairs, 810 
Vermont Avenue NW., Room 1068, Washington, DC 20420; fax to (202) 273-
9026; or email to http://www.Regulations.gov. All comments received 
will be available for public inspection in the Office of Regulation 
Policy and Management, Room 1063B, between the hours of 8:00 a.m. and 
4:30 p.m., Monday through Friday (except holidays). Please call (202) 
461-4902 (this is not a toll-free number) for an appointment.

FOR FURTHER INFORMATION CONTACT: Veterans Health Administration (VHA) 
Privacy Act Officer, Department of Veterans Affairs, 810 Vermont Ave. 
NW., Washington, DC 20420, (704) 245-2492.

SUPPLEMENTARY INFORMATION: The system number is changed from 77VA10Q to 
77VA10A4 to reflect the current Organizational alignment. The System 
Location section is being amended to include the name change to the 
office maintaining the electronic records to the VHA Office of Quality, 
Safety and Value (OQSV).
    The Categories of Individuals Covered by the System is being 
amended to add registered kinesiotherapists.
    Routine use 6 is amended to allow the disclosure of information to 
academic affiliates. Routine use 17 and 18 are being amended to remove 
the Healthcare Integrity and Protection Data Bank (HIPD). Routine use 
24 was added in response to the Veterans Access, Choice, and 
Accountability Act of 2014 which requires VA to make publicly available 
on and through VA home pages physician information to include the name 
of the facility at which each physician underwent residency training in 
addition to the health care provider's name, gender, name of 
professional school, State of licensure, and board certification.
    The Report of Intent to Amend a System of Records Notice 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.

    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 May 27, 2015, for publication.

    Dated: June 1, 2015.
Kathleen M. Manwell,
VA Privacy Service, Office of Privacy and Records Management, 
Department of Veterans Affairs.
77VA10A4

SYSTEM NAME:
    Health Care Provider Credentialing and Privileging Records--VA.

SYSTEM LOCATION:
    Records are maintained at each Department of Veterans Affairs (VA) 
health care facility. Address locations for VA facilities are listed in 
VA Appendix 1 biennial publication of VA system of records. 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 and/or Veterans Integrated Service Network 
(VISN) Offices. Records for those health care providers who are 
contractors in a VA health care facility, or to VA for the delivery of 
health care to veterans and are credentialed by the contractor in 
accordance with Veterans Health Administration (VHA) policy, where 
credentialing information is received by VHA facilities, it will be 
maintained in accordance with this notice and VHA policy. Electronic 
copies of records may be maintained by VHA Office of Quality, Safety 
and Value (OQSV), a component thereof, or a contractor or subcontractor 
of VHA/OQSVOQP. Back-up copies of the electronic data warehouse are 
maintained at off-site locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The records include information concerning health care providers 
currently or formerly employed or otherwise utilized by VHA and 
individuals who apply to VHA for employment and are considered for 
employment or appointment as health care providers. These records will 
include information concerning individuals who through a contractual or 
other agreement may be, or are, providing health care to VA patients.
    This may include, but is not limited to, audiologists, dentists, 
dietitians, expanded-function dental auxiliaries, licensed practical or 
vocational nurses, nuclear medicine technologists, nurse

[[Page 36596]]

anesthetists, nurse practitioners, registered nurses, occupational 
therapists, optometrists, clinical pharmacists, licensed physical 
therapists, registered kinesiotherapists, physician assistants, 
physicians, podiatrists, psychologists, registered respiratory 
therapists, certified respiratory therapy technicians, diagnostic and 
therapeutic radiology technologists, social workers, and speech 
pathologists.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The records in the system consist of information related to:
    (1) The credentialing (the review and verification of an 
individual's qualifications for employment or utilization, which 
includes licensure, registration or certification, professional 
education and training, employment history, experience, appraisals of 
past performance, health status, etc.) of applicants who are considered 
for employment and/or appointment, for providing health services under 
a contract or other agreement, and/or for appointment to the 
professional staff at a VHA health care facility.
    (2) The privileging (the process of reviewing and granting or 
denying a provider's request for clinical privileges to provide medical 
or other patient care services, within well-defined limits, which are 
based on an individual's professional license, registration or 
certification, experience, training, competence, health status, 
ability, and clinical judgment) health care providers who are permitted 
by law and by the medical facility to provide patient care 
independently and individuals whose duties and responsibilities are 
determined to be beyond the normal scope of activities for their 
profession;
    (3) The periodic reappraisal of health care providers' professional 
credentials and the reevaluation of the clinical competence of 
providers who have been granted clinical privileges; and/or
    (4) Records generated as part or result of accessing and reporting 
to the National Practitioner Data Bank (NPDB), the Health Integrity and 
Protection Data Bank, and the Federation of State Medical Boards 
(FSMB).
    The records may include individually identifiable information 
(e.g., name, date of birth, gender, Social Security number, national 
provider number and associated taxonomy codes, and/or other personal 
identification number), address information (e.g., home and/or mailing 
address, home telephone number, email address, facsimile number), 
biometric data, information related to education and training (e.g., 
name of medical or professional school attended and date of graduation, 
name of training program, type of training, dates attended, and date of 
completion). The records may also include information related to: The 
individual's license, registration or certification by a State 
licensing board and/or national certifying body (e.g., number, 
expiration date, name and address of issuing office, status including 
any actions taken by the issuing office or any disciplinary board to 
include previous or current restrictions, suspensions, limitations, or 
revocations); citizenship; honors and awards; type of appointment or 
utilization; service/product line; professional society membership; 
professional performance, experience, and judgment (e.g., documents 
reflecting work experience, appraisals of past and current performance 
and potential); educational qualifications (e.g., name and address of 
institution, level achieved, transcript, information related to 
continuing education); Drug Enforcement Administration and/or State 
controlled dangerous substance certification (e.g., current status, any 
revocations, suspensions, limitations, restrictions); information about 
mental and physical status; evaluation of clinical and/or technical 
skills; involvement in any administrative, professional or judicial 
proceedings, whether involving VA or not, in which professional 
malpractice on the individual's part is or was alleged; any actions, 
whether involving VA or not, which result in the limitation, reduction, 
revocation, or acceptance of surrender or restriction of the 
individual's clinical privileges; and, clinical performance information 
that is collected and used to support a determination of an 
individual's request for clinical privileges. Some information that is 
included in the record may be duplicated in an employee's official 
personnel folder.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Title 38 U.S.C. 501(a) and section 7304(a)(2).

PURPOSE(S):
    The information may be used for: Verifying the individual's 
credentials and qualifications for employment or utilization, 
appointment to the professional staff, and/or clinical privileges; 
advising prospective health care entity employers, health care 
professional licensing or monitoring bodies, the NPDB, or similar 
entities or activities of individuals covered by this system; 
accreditation of a facility by an entity such as the Joint Commission; 
audits, reviews and investigations conducted by staff of the health 
care facility, the Veterans Integrated Service Network (VISN) Directors 
and Division Offices, VA Central Office, VHA program offices, and the 
VA Office of Inspector General; law enforcement investigations; quality 
assurance audits, reviews and investigations; personnel management and 
evaluations; employee ratings and performance evaluations; and, 
employee disciplinary or other adverse action, including discharge. The 
records and information may be used for statistical analysis, to 
produce various management reports, evaluate services, collection, 
distribution and utilization of resources, and provide clinical and 
administrative support to patient medical care.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSES OF SUCH USES:
    1. A record from this system of records may be disclosed 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 or reappraisal of clinical privileges, 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; or in response to scarce or 
emergency needs of the Department or other entities when specific 
skills are required.
    2. A record from this system of records may be disclosed 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, information in connection with the hiring of an 
employee, appointment to the professional staff, 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 benefit by the agency, or the lawful 
statutory or administrative purpose of the agency to the extent that 
the information is relevant and necessary to the requesting agency's 
decision; or at the initiative of VA, to the extent the information is 
relevant and necessary to an investigative purpose of the agency.
    3. Disclosure may be made to a Congressional office from the record 
or an individual in response to an inquiry from the Congressional 
office made at the request of that individual.

[[Page 36597]]

    4. Disclosure may be made to NARA (National Archives and Records 
Administration) in records management inspections conducted under 
authority of title 44 United States Code.
    5. Information 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 which 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 Department to 
obtain information relevant to a Department decision concerning the 
hiring, utilization, appointment, retention or termination of 
individuals covered by this system or to inform a Federal agency or 
licensing boards or the appropriate non-government entities about the 
health care practices of a currently employed, appointed, otherwise 
utilized, terminated, resigned, or retired health care employee or 
other individuals covered by this system whose professional health care 
activity so significantly failed to meet generally accepted standards 
of clinical practice as to raise reasonable concern for the safety of 
patients. These records may also be disclosed as part of an ongoing 
computer-matching program to accomplish these purposes.
    6. Information may be disclosed to non-Federal sector (i.e., State, 
or local governments) agencies, academic affiliates, organizations, 
boards, bureaus, or commissions (e.g., the Joint Commission). Such 
disclosures may be made only when: (1) The records are properly 
constituted in accordance with VA requirements; (2) the records are 
accurate, relevant, timely, and complete; and (3) the disclosure is in 
the best interest of the Government (e.g., to obtain accreditation or 
other approval rating). When cooperation with the non-Federal sector 
entity, through the exchange of individual records, directly benefits 
VA's completion of its mission, enhances personnel management 
functions, or increases the public confidence in VA's or the Federal 
Government's role in the community, then the Government's best 
interests are served. Further, only such information that is clearly 
relevant and necessary for accomplishing the intended uses of the 
information as certified by the receiving entity is to be furnished.
    7. Information may be disclosed to a State 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.
    8. 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.
    9. Hiring, appointment, performance, or other personnel 
credentialing related information may be disclosed to any facility or 
agent with which there is, or there is proposed to be, an affiliation, 
sharing agreement, partnership, contract, or similar arrangement, where 
required for establishing, maintaining, or expanding any such 
relationship.
    10. Information concerning a health care provider's professional 
qualifications and clinical privileges may be disclosed to a VA 
patient, or the representative or guardian of a patient who due to 
physical or mental incapacity lacks sufficient understanding and/or 
legal capacity to make decisions concerning his/her medical care, who 
is receiving or contemplating receiving medical or other patient care 
services from the provider when the information is needed by the 
patient or the patient's representative or guardian in order to make a 
decision related to the initiation of treatment, continuation or 
discontinuation of treatment, or receiving a specific treatment that is 
proposed or planned by the provider. Disclosure will be limited to 
information concerning the health care provider's professional 
qualifications (professional education, training and current licensure/
certification status), professional employment history, and current 
clinical privileges.
    11. 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 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.
    12. To disclose to the Federal Labor Relations Authority (including 
its General Counsel) information related to the establishment 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 
Service Impasses Panel, and to investigate representation petitions and 
conduct or supervise representation elections.
    13. To disclose to the VA-appointed representative of an employee 
all notices, determinations, decision, or other written communications 
issued to the employee in connection with an examination ordered by VA 
under fitness-for-duty examination procedures or Agency-filed 
disability retirement procedures.
    14. To disclose information to officials of the Merit Systems 
Protection Board, 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. To disclose information to the Equal Employment Opportunity 
Commission when requested in connection with investigations of alleged 
or possible discriminatory practices, examination of Federal

[[Page 36598]]

affirmative employment programs, or the other functions of the 
Commission as authorized by law or regulation.
    16. To disclose the information listed in 5 U.S.C. 7114(b)(4) 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.
    17. Identifying information in this system, including name, 
address, Social Security number and other information as is reasonably 
necessary to identify such individual, may be disclosed to the NPDB at 
the time of hiring, appointment, utilization, and/or clinical 
privileging/reprivileging of physicians, dentists and other health care 
practitioners, and other times as deemed necessary by VA, in order for 
VA to obtain information relevant to a Department decision concerning 
the hiring, appointment, utilization, privileging/reprivileging, 
retention or termination of the individual.
    18. Relevant information from this system of records may be 
disclosed to the NPDB and/or State Licensing Board in the State(s) in 
which a practitioner is licensed, in which the VA facility is located, 
and/or in which an act or omission occurred upon which a medical 
malpractice claim was based when VA reports information concerning: (1) 
Any payment for the benefit of a physician, dentist, or other licensed 
health care practitioner which was made as the result of a settlement 
or judgment of a claim of medical malpractice if an appropriate 
determination is made in accordance with agency policy that payment was 
related to substandard care, professional incompetence or professional 
misconduct on the part of the individual; (2) a final decision which 
relates to possible incompetence or improper professional conduct that 
adversely affects the clinical privileges of a physician or dentist for 
a period longer than 30 days; or, (3) the acceptance of the surrender 
of clinical privileges or any restriction of such privileges by a 
physician or dentist either while under investigation by the health 
care entity relating to possible incompetence or improper professional 
conduct, or in return for not conducting such an investigation or 
proceeding. These records may also be disclosed as part of a computer-
matching program to accomplish these purposes.
    19. In response to a request about a specifically identified 
individual covered by this system from a prospective Federal or non-
Federal health care entity employer, the following information may be 
disclosed: (a) Relevant information concerning the individual's 
professional employment history including the clinical privileges held 
by the individual; (b) relevant information concerning a final decision 
that results in a voluntary or involuntary limitation, reduction or 
loss of clinical privileges; and (c) relevant information concerning 
any payment that is made in settlement (or partial settlement) of, or 
in satisfaction of a judgment in, a medical malpractice action or claim 
and, when 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 the 
individual.
    20. Disclosure may be made to any Federal, State, local, tribal or 
private entity in response to a request concerning a specific provider 
for the purposes of credentialing providers who provide health care at 
multiple sites or move between sites. Such disclosures may be made only 
when: (1) The records are properly constituted in accordance with VA 
requirements; (2) the records are accurate, relevant, timely, and 
complete; and (3) disclosure is in the best interests of the Government 
(i.e., to meet the requirements of contracts, sharing agreements, 
partnerships, etc.). When exchange of credentialing information through 
the exchange of individual records, directly benefits VA's completion 
of its mission, enhances public confidence in VA's or Federal 
Government's role in the delivery of health care, then the best 
interests of the Government are served.
    21. 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.
    22. 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.
    23. 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.
    24. VA may disclose information concerning a health care provider's 
professional qualifications which may be published on publicly facing 
VA owned or managed internet Web sites. Information to be displayed 
include the name of provider, gender, name of professional school, 
post-graduate training program, State of licensure, and board 
certification.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Records are maintained on paper documents or in electronic format. 
Information included in the record may be stored on microfilm, magnetic 
tape or disk. Records are maintained at the employing VHA health care 
facility. If the individual transfers to another VHA health care 
facility, the record is transferred to the new location, if 
appropriate.

RETRIEVABILITY:
    Records are retrieved by the names and Social Security number or 
other assigned identifiers, e.g., the National Provider Identifier 
(NPI), of the individuals on whom they are maintained.

[[Page 36599]]

SAFEGUARDS:
    1. Access to VA working and storage areas in VA health care 
facilities 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 health care facilities 
are protected from outside access by the Federal Protective Service or 
other security personnel.
    2. Access to computer room within the health care facilities is 
generally limited by appropriate locking devices and restricted to 
authorized VA employees and vendor personnel. Automated data processing 
peripheral devices are generally placed in secure areas (areas that are 
locked or have limited access) or are otherwise protected. Information 
in the Veterans Information Systems Technology Architecture (VistA) 
system may be accessed by authorized VA employees. Access to file 
information is controlled at two levels; the system recognizes 
authorized employees by a 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 that is needed in the performance of their 
official duties.
    3. Access to records in VA Central Office and the VISN directors 
and division offices is only authorized to VA personnel on a ``need-to-
know'' basis. There is limited access to the building with visitor 
control by security personnel.
    4. The automated system is Internet enabled and will conform to all 
applicable Federal Regulations concerning information security. The 
automated system is protected by a generalized security facility and by 
specific security techniques used within the application that accesses 
the data file and may include individually unique passwords/codes and 
may utilize Public Key Infrastructure (PKI) personal certificates. Both 
physical and system security measures will meet or exceed those 
required to provide an adequate level of protection for host systems. 
Access to file information is limited to only that information in the 
file that is needed in the performance of official duties. Access to 
computer rooms is restricted generally by appropriate locking devices 
to authorized operational personnel. Information submitted to the 
automated electronic system is afforded the same protections as the 
data that are maintained in the original files. Remote on-line access 
from other agencies to the data storage site is controlled in the same 
manner. Access to the electronic data is supported by encryption and 
the Internet server is insulated by a firewall.

RETENTION AND DISPOSAL:
    Paper records are retired to the VA Records Center and Vault (VA 
RC&V) 3 years after the individual separates from VA employment or when 
no longer utilized by VA (in some cases, records may be maintained at 
the facility for a longer period of time) and are destroyed 30 years 
after separation. Paper records for applicants who are not selected for 
VA employment or appointment are destroyed 2 years after non-selection 
or when no longer needed for reference, whichever is sooner. Electronic 
records are transferred to the Director, Credentialing and Privileging 
Program, Office of Quality and Performance, VA Central Office, when the 
provider leaves the facility. Information stored on electronic storage 
media is maintained and disposed of in accordance with records 
disposition authority approved by the Archivist of the United States.

SYSTEM MANAGER(S) AND ADDRESS:
    Official responsible for policies and procedures: Director, 
Credentialing and Privileging Program, Office of Quality, Safety and 
Value (OQSV), Veterans Health Administration, Department of Veterans 
Affairs, 810 Vermont Avenue NW., Washington, DC 20420.
    Officials maintaining the system: (1) The chief of staff at the VA 
health care facility where the provider made application, is employed, 
or otherwise utilized; (2) the credentialing coordinator of the VA 
health care facility for individuals who made application for 
employment or other utilization, or providers currently or previously 
employed or otherwise utilized at; (3) human resources management 
offices of the VA health care facility for individuals who made 
application for employment or other utilization, or providers currently 
or previously employed or otherwise utilized; (4) VA Central Office or 
at a VISN location; The electronic data will be maintained by VHA/OQSV, 
a component thereof, or a contractor or subcontractor of VHA/OQSV.

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 made application for employment or appointment, or are or 
were employed. Inquiries should include the employee's full name, 
Social Security number, date of application for employment or 
appointment or dates of employment or appointment, and return address.

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. 2015-15351 Filed 6-24-15; 8:45 am]
 BILLING CODE P



                                                                                   Federal Register / Vol. 80, No. 122 / Thursday, June 25, 2015 / Notices                                               36595

                                                    under 28 U.S.C. 991(b)(1)(B) and                         no later than July 27, 2015. If no public              document and authorized the undersigned to
                                                    Braxton v. United States, 500 U.S. 344                   comment is received, the new system                    sign and submit the document to the Office
                                                    (1991), to resolve conflicting                           will become effective July 27, 2015.                   of the Federal Register for publication
                                                    interpretations of the guidelines by the                                                                        electronically as an official document of the
                                                                                                             ADDRESSES: Written comments
                                                                                                                                                                    Department of Veterans Affairs. Robert L.
                                                    federal courts.                                          concerning the proposed amended                        Nabors, II, Chief of Staff, approved this
                                                       (12) Consideration of any                             system of records may be submitted by:                 document on May 27, 2015, for publication.
                                                    miscellaneous guideline application                      mail or hand-delivery to Director,
                                                    issues coming to the Commission’s                                                                                 Dated: June 1, 2015.
                                                                                                             Regulations Management (02REG),
                                                    attention from case law and other                        Department of Veterans Affairs, 810                    Kathleen M. Manwell,
                                                    sources.                                                 Vermont Avenue NW., Room 1068,                         VA Privacy Service, Office of Privacy and
                                                    The Commission hereby gives notice                       Washington, DC 20420; fax to (202)                     Records Management, Department of
                                                                                                                                                                    Veterans Affairs.
                                                    that it is seeking comment on these                      273–9026; or email to http://
                                                    tentative priorities and on any other                    www.Regulations.gov. All comments                      77VA10A4
                                                    issues that interested persons believe                   received will be available for public
                                                    the Commission should address during                     inspection in the Office of Regulation                 SYSTEM NAME:
                                                    the amendment cycle ending May 1,                        Policy and Management, Room 1063B,                       Health Care Provider Credentialing
                                                    2016. To the extent practicable, public                  between the hours of 8:00 a.m. and 4:30                and Privileging Records—VA.
                                                    comment should include the following:                    p.m., Monday through Friday (except
                                                                                                                                                                    SYSTEM LOCATION:
                                                    (1) A statement of the issue, including,                 holidays). Please call (202) 461–4902
                                                    where appropriate, the scope and                         (this is not a toll-free number) for an                  Records are maintained at each
                                                    manner of study, particular problem                      appointment.                                           Department of Veterans Affairs (VA)
                                                    areas and possible solutions, and any                                                                           health care facility. Address locations
                                                                                                             FOR FURTHER INFORMATION CONTACT:                       for VA facilities are listed in VA
                                                    other matters relevant to a proposed                     Veterans Health Administration (VHA)
                                                    priority; (2) citations to applicable                                                                           Appendix 1 biennial publication of VA
                                                                                                             Privacy Act Officer, Department of                     system of records. In addition,
                                                    sentencing guidelines, statutes, case                    Veterans Affairs, 810 Vermont Ave.
                                                    law, and constitutional provisions; and                                                                         information from these records or copies
                                                                                                             NW., Washington, DC 20420, (704) 245–                  of records may be maintained at the
                                                    (3) a direct and concise statement of                    2492.
                                                    why the Commission should make the                                                                              Department of Veterans Affairs, 810
                                                                                                             SUPPLEMENTARY INFORMATION: The                         Vermont Avenue NW., Washington, DC
                                                    issue a priority.                                        system number is changed from                          20420 and/or Veterans Integrated
                                                      Authority: 28 U.S.C. 994(a), (o); USSC                 77VA10Q to 77VA10A4 to reflect the                     Service Network (VISN) Offices.
                                                    Rules of Practice and Procedure 5.2.                     current Organizational alignment. The                  Records for those health care providers
                                                    Patti B. Saris,                                          System Location section is being                       who are contractors in a VA health care
                                                                                                             amended to include the name change to                  facility, or to VA for the delivery of
                                                    Chair.
                                                                                                             the office maintaining the electronic                  health care to veterans and are
                                                    [FR Doc. 2015–15622 Filed 6–24–15; 8:45 am]
                                                                                                             records to the VHA Office of Quality,                  credentialed by the contractor in
                                                    BILLING CODE 2210–40–P
                                                                                                             Safety and Value (OQSV).                               accordance with Veterans Health
                                                                                                                The Categories of Individuals Covered               Administration (VHA) policy, where
                                                                                                             by the System is being amended to add                  credentialing information is received by
                                                    DEPARTMENT OF VETERANS                                   registered kinesiotherapists.
                                                    AFFAIRS                                                                                                         VHA facilities, it will be maintained in
                                                                                                                Routine use 6 is amended to allow the
                                                                                                                                                                    accordance with this notice and VHA
                                                                                                             disclosure of information to academic
                                                    Privacy Act of 1974; System of                                                                                  policy. Electronic copies of records may
                                                                                                             affiliates. Routine use 17 and 18 are
                                                    Records                                                                                                         be maintained by VHA Office of
                                                                                                             being amended to remove the
                                                                                                                                                                    Quality, Safety and Value (OQSV), a
                                                    AGENCY:    Department of Veterans Affairs                Healthcare Integrity and Protection Data
                                                                                                                                                                    component thereof, or a contractor or
                                                    (VA).                                                    Bank (HIPD). Routine use 24 was added
                                                                                                                                                                    subcontractor of VHA/OQSVOQP. Back-
                                                    ACTION: Notice of amendment to system                    in response to the Veterans Access,
                                                                                                                                                                    up copies of the electronic data
                                                    of records.                                              Choice, and Accountability Act of 2014
                                                                                                                                                                    warehouse are maintained at off-site
                                                                                                             which requires VA to make publicly
                                                                                                                                                                    locations.
                                                    SUMMARY:   The Privacy Act of 1974 (5                    available on and through VA home
                                                    U.S.C. 552(e)(4)) requires that all                      pages physician information to include                 CATEGORIES OF INDIVIDUALS COVERED BY THE
                                                    agencies publish in the Federal Register                 the name of the facility at which each                 SYSTEM:
                                                    a notice of the existence and character                  physician underwent residency training                    The records include information
                                                    of their systems of records. The                         in addition to the health care provider’s              concerning health care providers
                                                    Department of Veterans Affairs (VA) is                   name, gender, name of professional                     currently or formerly employed or
                                                    amending the system of records, known                    school, State of licensure, and board                  otherwise utilized by VHA and
                                                    as ‘‘Health Care Provider Credentialing                  certification.                                         individuals who apply to VHA for
                                                    and Privileging Records-VA’’                                The Report of Intent to Amend a                     employment and are considered for
                                                    (77VA10Q) as set forth in the Federal                    System of Records Notice and an                        employment or appointment as health
                                                    Register 73 FR 16097 dated 3/26/08. VA                   advance copy of the system notice have                 care providers. These records will
                                                    is amending the system notice by                         been sent to the appropriate                           include information concerning
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                                                    revising the paragraphs on System                        Congressional committees and to the                    individuals who through a contractual
                                                    Number, System Location, Categories of                   Director of the Office of Management                   or other agreement may be, or are,
                                                    Individuals Covered by the System, and                   and Budget (OMB) as required by 5                      providing health care to VA patients.
                                                    Routine Uses of Records Maintained in                    U.S.C. 552a(r) (Privacy Act) and                          This may include, but is not limited
                                                    the System. VA is republishing the                       guidelines issued by OMB (65 FR                        to, audiologists, dentists, dietitians,
                                                    system notice in its entirety at this time.              77677), December 12, 2000.                             expanded-function dental auxiliaries,
                                                    DATES: Comments on the amendment of                        Signing Authority: The Secretary of                  licensed practical or vocational nurses,
                                                    this system of records must be received                  Veterans Affairs, or designee, approved this           nuclear medicine technologists, nurse


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                                                    36596                         Federal Register / Vol. 80, No. 122 / Thursday, June 25, 2015 / Notices

                                                    anesthetists, nurse practitioners,                      attended and date of graduation, name                  facility, the Veterans Integrated Service
                                                    registered nurses, occupational                         of training program, type of training,                 Network (VISN) Directors and Division
                                                    therapists, optometrists, clinical                      dates attended, and date of completion).               Offices, VA Central Office, VHA
                                                    pharmacists, licensed physical                          The records may also include                           program offices, and the VA Office of
                                                    therapists, registered kinesiotherapists,               information related to: The individual’s               Inspector General; law enforcement
                                                    physician assistants, physicians,                       license, registration or certification by a            investigations; quality assurance audits,
                                                    podiatrists, psychologists, registered                  State licensing board and/or national                  reviews and investigations; personnel
                                                    respiratory therapists, certified                       certifying body (e.g., number, expiration              management and evaluations; employee
                                                    respiratory therapy technicians,                        date, name and address of issuing office,              ratings and performance evaluations;
                                                    diagnostic and therapeutic radiology                    status including any actions taken by                  and, employee disciplinary or other
                                                    technologists, social workers, and                      the issuing office or any disciplinary                 adverse action, including discharge. The
                                                    speech pathologists.                                    board to include previous or current                   records and information may be used for
                                                                                                            restrictions, suspensions, limitations, or             statistical analysis, to produce various
                                                    CATEGORIES OF RECORDS IN THE SYSTEM:
                                                                                                            revocations); citizenship; honors and                  management reports, evaluate services,
                                                       The records in the system consist of                 awards; type of appointment or                         collection, distribution and utilization
                                                    information related to:                                 utilization; service/product line;                     of resources, and provide clinical and
                                                       (1) The credentialing (the review and                professional society membership;                       administrative support to patient
                                                    verification of an individual’s                         professional performance, experience,                  medical care.
                                                    qualifications for employment or                        and judgment (e.g., documents
                                                    utilization, which includes licensure,                  reflecting work experience, appraisals of              ROUTINE USES OF RECORDS MAINTAINED IN THE
                                                    registration or certification, professional             past and current performance and                       SYSTEM, INCLUDING CATEGORIES OF USERS AND
                                                    education and training, employment                      potential); educational qualifications                 THE PURPOSES OF SUCH USES:
                                                    history, experience, appraisals of past                 (e.g., name and address of institution,                   1. A record from this system of
                                                    performance, health status, etc.) of                    level achieved, transcript, information                records may be disclosed to any source
                                                    applicants who are considered for                       related to continuing education); Drug                 from which additional information is
                                                    employment and/or appointment, for                      Enforcement Administration and/or                      requested (to the extent necessary to
                                                    providing health services under a                       State controlled dangerous substance                   identify the individual, inform the
                                                    contract or other agreement, and/or for                 certification (e.g., current status, any               source of the purpose(s) of the request,
                                                    appointment to the professional staff at                revocations, suspensions, limitations,                 and to identify the type of information
                                                    a VHA health care facility.                             restrictions); information about mental                requested), when necessary to obtain
                                                       (2) The privileging (the process of
                                                                                                            and physical status; evaluation of                     information relevant to a Department
                                                    reviewing and granting or denying a
                                                                                                            clinical and/or technical skills;                      decision concerning the hiring or
                                                    provider’s request for clinical privileges
                                                                                                            involvement in any administrative,                     retention of an employee, the issuance
                                                    to provide medical or other patient care
                                                                                                            professional or judicial proceedings,                  or reappraisal of clinical privileges, the
                                                    services, within well-defined limits,
                                                                                                            whether involving VA or not, in which                  issuance of a security clearance, the
                                                    which are based on an individual’s
                                                                                                            professional malpractice on the                        conducting of a security or suitability
                                                    professional license, registration or
                                                                                                            individual’s part is or was alleged; any               investigation of an individual, the
                                                    certification, experience, training,
                                                                                                            actions, whether involving VA or not,                  letting of a contract, the issuance of a
                                                    competence, health status, ability, and
                                                                                                            which result in the limitation,                        license, grant, or other benefits; or in
                                                    clinical judgment) health care providers
                                                                                                            reduction, revocation, or acceptance of                response to scarce or emergency needs
                                                    who are permitted by law and by the
                                                                                                            surrender or restriction of the                        of the Department or other entities when
                                                    medical facility to provide patient care
                                                                                                            individual’s clinical privileges; and,                 specific skills are required.
                                                    independently and individuals whose
                                                                                                            clinical performance information that is                  2. A record from this system of
                                                    duties and responsibilities are
                                                                                                            collected and used to support a                        records may be disclosed to an agency
                                                    determined to be beyond the normal
                                                                                                            determination of an individual’s request               in the executive, legislative, or judicial
                                                    scope of activities for their profession;
                                                       (3) The periodic reappraisal of health               for clinical privileges. Some information              branch, or the District of Columbia’s
                                                    care providers’ professional credentials                that is included in the record may be                  Government in response to its request,
                                                    and the reevaluation of the clinical                    duplicated in an employee’s official                   or at the initiation of VA, information in
                                                    competence of providers who have been                   personnel folder.                                      connection with the hiring of an
                                                    granted clinical privileges; and/or                     AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
                                                                                                                                                                   employee, appointment to the
                                                       (4) Records generated as part or result                                                                     professional staff, the issuance of a
                                                                                                              Title 38 U.S.C. 501(a) and section
                                                    of accessing and reporting to the                                                                              security clearance, the conducting of a
                                                                                                            7304(a)(2).
                                                    National Practitioner Data Bank (NPDB),                                                                        security or suitability investigation of an
                                                    the Health Integrity and Protection Data                PURPOSE(S):                                            individual, the letting of a contract, the
                                                    Bank, and the Federation of State                         The information may be used for:                     issuance of a license, grant, or other
                                                    Medical Boards (FSMB).                                  Verifying the individual’s credentials                 benefit by the agency, or the lawful
                                                       The records may include individually                 and qualifications for employment or                   statutory or administrative purpose of
                                                    identifiable information (e.g., name,                   utilization, appointment to the                        the agency to the extent that the
                                                    date of birth, gender, Social Security                  professional staff, and/or clinical                    information is relevant and necessary to
                                                    number, national provider number and                    privileges; advising prospective health                the requesting agency’s decision; or at
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                                                    associated taxonomy codes, and/or                       care entity employers, health care                     the initiative of VA, to the extent the
                                                    other personal identification number),                  professional licensing or monitoring                   information is relevant and necessary to
                                                    address information (e.g., home and/or                  bodies, the NPDB, or similar entities or               an investigative purpose of the agency.
                                                    mailing address, home telephone                         activities of individuals covered by this                 3. Disclosure may be made to a
                                                    number, email address, facsimile                        system; accreditation of a facility by an              Congressional office from the record or
                                                    number), biometric data, information                    entity such as the Joint Commission;                   an individual in response to an inquiry
                                                    related to education and training (e.g.,                audits, reviews and investigations                     from the Congressional office made at
                                                    name of medical or professional school                  conducted by staff of the health care                  the request of that individual.


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                                                                                  Federal Register / Vol. 80, No. 122 / Thursday, June 25, 2015 / Notices                                            36597

                                                       4. Disclosure may be made to NARA                    revocation of licenses, certifications or              (professional education, training and
                                                    (National Archives and Records                          registrations required to practice a                   current licensure/certification status),
                                                    Administration) in records management                   health care profession, when requested                 professional employment history, and
                                                    inspections conducted under authority                   in writing by an investigator or                       current clinical privileges.
                                                    of title 44 United States Code.                         supervisory official of the licensing                     11. VA may disclose on its own
                                                       5. Information from this system of                   entity or national certifying body for the             initiative any information in this
                                                    records may be disclosed to a Federal                   purpose of making a decision                           system, except the names and home
                                                    agency or to a State or local government                concerning the issuance, retention or                  addresses of veterans and their
                                                    licensing board and/or to the Federation                revocation of the license, certification or            dependents, which is relevant to a
                                                    of State Medical Boards or a similar                    registration of a named health care                    suspected or reasonably imminent
                                                    non-government entity which maintains                   professional.                                          violation of law, whether civil, criminal
                                                    records concerning individuals’                           8. VA may disclose information in                    or regulatory in nature and whether
                                                    employment histories or concerning the                  this system of records to the Department               arising by general or program statute or
                                                    issuance, retention or revocation of                    of Justice (DoJ), either on VA’s initiative            by regulation, rule or order issued
                                                    licenses, certifications, or registration               or in response to DoJ’s request for the                pursuant thereto, to a State, local or
                                                    necessary to practice an occupation,                    information, after either VA or DoJ                    foreign agency charged with the
                                                    profession or specialty, in order for the               determines that such information is                    responsibility of investigating or
                                                    Department to obtain information                        relevant to DoJ’s representation of the                prosecuting such violation, or charged
                                                    relevant to a Department decision                       United States or any of its components                 with enforcing or implementing the
                                                    concerning the hiring, utilization,                     in legal proceedings before a court or                 statute, regulation, rule or order. On its
                                                    appointment, retention or termination of                adjudicative body, provided that, in                   own initiative, VA may also disclose the
                                                    individuals covered by this system or to                each case, the agency also determines                  names and addresses of veterans and
                                                    inform a Federal agency or licensing                    prior to disclosure that disclosure of the             their dependents to a Federal agency
                                                    boards or the appropriate non-                          records to the Department of Justice is                charged with the responsibility of
                                                    government entities about the health                    a use of the information contained in                  investigating or prosecuting civil,
                                                    care practices of a currently employed,                 the records that is compatible with the                criminal or regulatory violations of law,
                                                    appointed, otherwise utilized,                          purpose for which VA collected the                     or charged with enforcing or
                                                    terminated, resigned, or retired health                 records. VA, on its own initiative, may                implementing the statute, regulation,
                                                    care employee or other individuals                      disclose records in this system of                     rule or order issued pursuant thereto.
                                                    covered by this system whose                            records in legal proceedings before a                     12. To disclose to the Federal Labor
                                                    professional health care activity so                    court or administrative body after                     Relations Authority (including its
                                                    significantly failed to meet generally                  determining that the disclosure of the                 General Counsel) information related to
                                                    accepted standards of clinical practice                 records to the court or administrative                 the establishment of jurisdiction, the
                                                    as to raise reasonable concern for the                  body is a use of the information                       investigation and resolution of
                                                    safety of patients. These records may                   contained in the records that is                       allegations of unfair labor practices, or
                                                    also be disclosed as part of an ongoing                 compatible with the purpose for which                  information in connection with the
                                                    computer-matching program to                            VA collected the records.                              resolution of exceptions to arbitration
                                                    accomplish these purposes.                                9. Hiring, appointment, performance,                 awards when a question of material fact
                                                       6. Information may be disclosed to                   or other personnel credentialing related               is raised; to disclose information in
                                                    non-Federal sector (i.e., State, or local               information may be disclosed to any                    matters properly before the Federal
                                                    governments) agencies, academic                         facility or agent with which there is, or              Service Impasses Panel, and to
                                                    affiliates, organizations, boards,                      there is proposed to be, an affiliation,               investigate representation petitions and
                                                    bureaus, or commissions (e.g., the Joint                sharing agreement, partnership,                        conduct or supervise representation
                                                    Commission). Such disclosures may be                    contract, or similar arrangement, where                elections.
                                                    made only when: (1) The records are                     required for establishing, maintaining,                   13. To disclose to the VA-appointed
                                                    properly constituted in accordance with                 or expanding any such relationship.                    representative of an employee all
                                                    VA requirements; (2) the records are                      10. Information concerning a health                  notices, determinations, decision, or
                                                    accurate, relevant, timely, and complete;               care provider’s professional                           other written communications issued to
                                                    and (3) the disclosure is in the best                   qualifications and clinical privileges                 the employee in connection with an
                                                    interest of the Government (e.g., to                    may be disclosed to a VA patient, or the               examination ordered by VA under
                                                    obtain accreditation or other approval                  representative or guardian of a patient                fitness-for-duty examination procedures
                                                    rating). When cooperation with the non-                 who due to physical or mental                          or Agency-filed disability retirement
                                                    Federal sector entity, through the                      incapacity lacks sufficient                            procedures.
                                                    exchange of individual records, directly                understanding and/or legal capacity to                    14. To disclose information to
                                                    benefits VA’s completion of its mission,                make decisions concerning his/her                      officials of the Merit Systems Protection
                                                    enhances personnel management                           medical care, who is receiving or                      Board, when requested in connection
                                                    functions, or increases the public                      contemplating receiving medical or                     with appeals, special studies of the civil
                                                    confidence in VA’s or the Federal                       other patient care services from the                   service and other merit systems, review
                                                    Government’s role in the community,                     provider when the information is                       of rules and regulations, investigation of
                                                    then the Government’s best interests are                needed by the patient or the patient’s                 alleged or possible prohibited personnel
                                                    served. Further, only such information                  representative or guardian in order to                 practices, and such other functions,
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                                                    that is clearly relevant and necessary for              make a decision related to the initiation              promulgated in 5 U.S.C. 1205 and 1206,
                                                    accomplishing the intended uses of the                  of treatment, continuation or                          or as may be authorized by law.
                                                    information as certified by the receiving               discontinuation of treatment, or                          15. To disclose information to the
                                                    entity is to be furnished.                              receiving a specific treatment that is                 Equal Employment Opportunity
                                                       7. Information may be disclosed to a                 proposed or planned by the provider.                   Commission when requested in
                                                    State or national certifying body which                 Disclosure will be limited to                          connection with investigations of
                                                    has the authority to make decisions                     information concerning the health care                 alleged or possible discriminatory
                                                    concerning the issuance, retention or                   provider’s professional qualifications                 practices, examination of Federal


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                                                    36598                         Federal Register / Vol. 80, No. 122 / Thursday, June 25, 2015 / Notices

                                                    affirmative employment programs, or                     following information may be disclosed:                persons when (1) VA suspects or has
                                                    the other functions of the Commission                   (a) Relevant information concerning the                confirmed that the integrity or
                                                    as authorized by law or regulation.                     individual’s professional employment                   confidentiality of information in the
                                                       16. To disclose the information listed               history including the clinical privileges              system of records has been
                                                    in 5 U.S.C. 7114(b)(4) to officials of                  held by the individual; (b) relevant                   compromised; (2) the Department has
                                                    labor organizations recognized under 5                  information concerning a final decision                determined that as a result of the
                                                    U.S.C., chapter 71 when relevant and                    that results in a voluntary or                         suspected or confirmed compromise
                                                    necessary to their duties of exclusive                  involuntary limitation, reduction or loss              there is a risk of embarrassment or harm
                                                    representation concerning personnel                     of clinical privileges; and (c) relevant               to the reputations of the record subjects,
                                                    policies, practices, and matters affecting              information concerning any payment                     harm to economic or property interests,
                                                    working conditions.                                     that is made in settlement (or partial                 identity theft or fraud, or harm to the
                                                       17. Identifying information in this                  settlement) of, or in satisfaction of a                security, confidentiality, or integrity of
                                                    system, including name, address, Social                 judgment in, a medical malpractice                     this system or other systems or
                                                    Security number and other information                   action or claim and, when through a                    programs (whether maintained by the
                                                    as is reasonably necessary to identify                  peer review process that is undertaken                 Department or another agency or entity)
                                                    such individual, may be disclosed to the                pursuant to VA policy, negligence,                     that rely upon the potentially
                                                    NPDB at the time of hiring,                             professional incompetence,                             compromised information; and (3) the
                                                    appointment, utilization, and/or clinical               responsibility for improper care, and/or               disclosure is to agencies, entities, or
                                                    privileging/reprivileging of physicians,                professional misconduct has been                       persons whom VA determines are
                                                    dentists and other health care                          assigned to the individual.                            reasonably necessary to assist or carry
                                                    practitioners, and other times as deemed                   20. Disclosure may be made to any                   out the Department’s efforts to respond
                                                    necessary by VA, in order for VA to                     Federal, State, local, tribal or private               to the suspected or confirmed
                                                    obtain information relevant to a                        entity in response to a request                        compromise and prevent, minimize, or
                                                    Department decision concerning the                      concerning a specific provider for the                 remedy such harm. This routine use
                                                    hiring, appointment, utilization,                       purposes of credentialing providers who                permits disclosures by the Department
                                                    privileging/reprivileging, retention or                 provide health care at multiple sites or               to respond to a suspected or confirmed
                                                    termination of the individual.                          move between sites. Such disclosures                   data breach, including the conduct of
                                                       18. Relevant information from this                   may be made only when: (1) The                         any risk analysis or provision of credit
                                                    system of records may be disclosed to                   records are properly constituted in                    protection services as provided in 38
                                                    the NPDB and/or State Licensing Board                   accordance with VA requirements; (2)                   U.S.C. 5724, as the terms are defined in
                                                    in the State(s) in which a practitioner is              the records are accurate, relevant,                    38 U.S.C. 5727.
                                                    licensed, in which the VA facility is                   timely, and complete; and (3) disclosure                  23. Disclosure to other Federal
                                                    located, and/or in which an act or                      is in the best interests of the                        agencies may be made to assist such
                                                    omission occurred upon which a                          Government (i.e., to meet the                          agencies in preventing and detecting
                                                    medical malpractice claim was based                     requirements of contracts, sharing                     possible fraud or abuse by individuals
                                                    when VA reports information                             agreements, partnerships, etc.). When                  in their operations and programs.
                                                    concerning: (1) Any payment for the                     exchange of credentialing information                     24. VA may disclose information
                                                    benefit of a physician, dentist, or other               through the exchange of individual                     concerning a health care provider’s
                                                    licensed health care practitioner which                 records, directly benefits VA’s                        professional qualifications which may
                                                    was made as the result of a settlement                  completion of its mission, enhances                    be published on publicly facing VA
                                                    or judgment of a claim of medical                       public confidence in VA’s or Federal                   owned or managed internet Web sites.
                                                    malpractice if an appropriate                           Government’s role in the delivery of                   Information to be displayed include the
                                                    determination is made in accordance                     health care, then the best interests of the            name of provider, gender, name of
                                                    with agency policy that payment was                     Government are served.                                 professional school, post-graduate
                                                    related to substandard care, professional                  21. Disclosure may be made to                       training program, State of licensure, and
                                                    incompetence or professional                            individuals, organizations, private or                 board certification.
                                                    misconduct on the part of the                           public agencies, or other entities or
                                                    individual; (2) a final decision which                  individuals with whom VA has a                         POLICIES AND PRACTICES FOR STORING,
                                                    relates to possible incompetence or                     contract or agreement to perform such                  RETRIEVING, ACCESSING, RETAINING, AND
                                                    improper professional conduct that                      services as VA may deem practicable for                DISPOSING OF RECORDS IN THE SYSTEM:
                                                    adversely affects the clinical privileges               the purposes of laws administered by                   STORAGE:
                                                    of a physician or dentist for a period                  VA, in order for the contractor,                          Records are maintained on paper
                                                    longer than 30 days; or, (3) the                        subcontractor, public or private agency,               documents or in electronic format.
                                                    acceptance of the surrender of clinical                 or other entity or individual with whom                Information included in the record may
                                                    privileges or any restriction of such                   VA has an agreement or contract to                     be stored on microfilm, magnetic tape or
                                                    privileges by a physician or dentist                    perform the services of the contract or                disk. Records are maintained at the
                                                    either while under investigation by the                 agreement. This routine use includes                   employing VHA health care facility. If
                                                    health care entity relating to possible                 disclosures by the individual or entity                the individual transfers to another VHA
                                                    incompetence or improper professional                   performing the service for VA to any                   health care facility, the record is
                                                    conduct, or in return for not conducting                secondary entity or individual to                      transferred to the new location, if
                                                    such an investigation or proceeding.                    perform an activity that is necessary for
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                                                                                                                                                                   appropriate.
                                                    These records may also be disclosed as                  individuals, organizations, private or
                                                    part of a computer-matching program to                  public agencies, or other entities or                  RETRIEVABILITY:
                                                    accomplish these purposes.                              individuals with whom VA has a                           Records are retrieved by the names
                                                       19. In response to a request about a                 contract or agreement to provide the                   and Social Security number or other
                                                    specifically identified individual                      service to VA.                                         assigned identifiers, e.g., the National
                                                    covered by this system from a                              22. VA may, on its own initiative,                  Provider Identifier (NPI), of the
                                                    prospective Federal or non-Federal                      disclose any information or records to                 individuals on whom they are
                                                    health care entity employer, the                        appropriate agencies, entities, and                    maintained.


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                                                                                  Federal Register / Vol. 80, No. 122 / Thursday, June 25, 2015 / Notices                                                  36599

                                                    SAFEGUARDS:                                             same manner. Access to the electronic                  appointment or dates of employment or
                                                       1. Access to VA working and storage                  data is supported by encryption and the                appointment, and return address.
                                                    areas in VA health care facilities is                   Internet server is insulated by a firewall.
                                                                                                                                                                   RECORD ACCESS PROCEDURES:
                                                    restricted to VA employees on a ‘‘need
                                                    to know’’ basis; strict control measures                RETENTION AND DISPOSAL:                                  Individuals seeking information
                                                    are enforced to ensure that disclosure to                 Paper records are retired to the VA                  regarding access to and contesting of
                                                    these individuals is also based on this                 Records Center and Vault (VA RC&V) 3                   records in this system may write, call or
                                                    same principle. Generally, VA file areas                years after the individual separates from              visit the VA facility location where they
                                                    are locked after normal duty hours and                  VA employment or when no longer                        made application for employment or
                                                    the health care facilities are protected                utilized by VA (in some cases, records                 appointment, or are or were employed.
                                                    from outside access by the Federal                      may be maintained at the facility for a
                                                                                                                                                                   CONTESTING RECORDS PROCEDURES:
                                                    Protective Service or other security                    longer period of time) and are destroyed
                                                    personnel.                                              30 years after separation. Paper records                 (See Record Access Procedures).
                                                       2. Access to computer room within                    for applicants who are not selected for                RECORD SOURCE CATEGORIES:
                                                    the health care facilities is generally                 VA employment or appointment are
                                                    limited by appropriate locking devices                  destroyed 2 years after non-selection or                  Information in this system of records
                                                    and restricted to authorized VA                         when no longer needed for reference,                   is provided by the applicant/employee,
                                                    employees and vendor personnel.                         whichever is sooner. Electronic records                or obtained from State licensing boards,
                                                    Automated data processing peripheral                    are transferred to the Director,                       Federation of State Medical Boards,
                                                    devices are generally placed in secure                  Credentialing and Privileging Program,                 National Council of State Boards of
                                                    areas (areas that are locked or have                    Office of Quality and Performance, VA                  Nursing, National Practitioner Data
                                                    limited access) or are otherwise                        Central Office, when the provider leaves               Bank, Health Integrity and Protection
                                                    protected. Information in the Veterans                  the facility. Information stored on                    Data Bank, professional societies,
                                                    Information Systems Technology                          electronic storage media is maintained                 national certifying bodies, current or
                                                    Architecture (VistA) system may be                      and disposed of in accordance with                     previous employers, other health care
                                                    accessed by authorized VA employees.                    records disposition authority approved                 facilities and staff, references,
                                                    Access to file information is controlled                by the Archivist of the United States.                 educational institutions, medical
                                                    at two levels; the system recognizes                                                                           schools, VA staff, patient, visitors, and
                                                    authorized employees by a series of                     SYSTEM MANAGER(S) AND ADDRESS:                         VA patient medical records.
                                                    individually unique passwords/codes as                    Official responsible for policies and                [FR Doc. 2015–15351 Filed 6–24–15; 8:45 am]
                                                    a part of each data message, and the                    procedures: Director, Credentialing and                BILLING CODE P
                                                    employees are limited to only that                      Privileging Program, Office of Quality,
                                                    information in the file that is needed in               Safety and Value (OQSV), Veterans
                                                    the performance of their official duties.               Health Administration, Department of                   DEPARTMENT OF VETERANS
                                                       3. Access to records in VA Central                                                                          AFFAIRS
                                                                                                            Veterans Affairs, 810 Vermont Avenue
                                                    Office and the VISN directors and
                                                                                                            NW., Washington, DC 20420.
                                                    division offices is only authorized to VA                                                                      Notice of Availability of a Final
                                                    personnel on a ‘‘need-to-know’’ basis.                    Officials maintaining the system: (1)                Environmental Impact Statement for
                                                    There is limited access to the building                 The chief of staff at the VA health care               the San Francisco VA Medical Center
                                                    with visitor control by security                        facility where the provider made                       Long Range Development Plan
                                                    personnel.                                              application, is employed, or otherwise
                                                       4. The automated system is Internet                  utilized; (2) the credentialing                        AGENCY:   Department of Veterans Affairs.
                                                    enabled and will conform to all                         coordinator of the VA health care                      ACTION:   Notice of availability.
                                                    applicable Federal Regulations                          facility for individuals who made
                                                    concerning information security. The                    application for employment or other                    SUMMARY:   The Department of Veterans
                                                    automated system is protected by a                      utilization, or providers currently or                 Affairs (VA), San Francisco VA Medical
                                                    generalized security facility and by                    previously employed or otherwise                       Center (SFVAMC) announces the
                                                    specific security techniques used within                utilized at; (3) human resources                       availability of the Final Environmental
                                                    the application that accesses the data                  management offices of the VA health                    Impact Statement (EIS) for the Long
                                                    file and may include individually                       care facility for individuals who made                 Range Development Plan (LRDP).
                                                    unique passwords/codes and may                          application for employment or other                    Pursuant to the National Environmental
                                                    utilize Public Key Infrastructure (PKI)                 utilization, or providers currently or                 Policy Act (NEPA) of 1969, as amended
                                                    personal certificates. Both physical and                previously employed or otherwise                       (42 U.S.C. 4331 et seq.), the Council on
                                                    system security measures will meet or                   utilized; (4) VA Central Office or at a                Environmental Quality Regulations for
                                                    exceed those required to provide an                     VISN location; The electronic data will                Implementing the Procedural
                                                    adequate level of protection for host                   be maintained by VHA/OQSV, a                           Requirements of NEPA (40 CFR parts
                                                    systems. Access to file information is                  component thereof, or a contractor or                  1500–1508) and VA’s implementing
                                                    limited to only that information in the                 subcontractor of VHA/OQSV.                             Regulations (38 CFR part 26), VA has
                                                    file that is needed in the performance of                                                                      considered comments received on the
                                                                                                            NOTIFICATION PROCEDURE:                                Supplemental Draft EIS and has
                                                    official duties. Access to computer
                                                    rooms is restricted generally by                          Individuals who wish to determine                    prepared the Final EIS. The LRDP
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                                                    appropriate locking devices to                          whether this system of records contains                describes development and construction
                                                    authorized operational personnel.                       information about them should contact                  of patient care buildings, research
                                                    Information submitted to the automated                  the VA facility location at which they                 buildings, business occupancy
                                                    electronic system is afforded the same                  made application for employment or                     buildings, and parking structures, as
                                                    protections as the data that are                        appointment, or are or were employed.                  well as retrofitting seismically deficient
                                                    maintained in the original files. Remote                Inquiries should include the employee’s                buildings. The Final EIS identifies and
                                                    on-line access from other agencies to the               full name, Social Security number, date                addresses environmental impacts
                                                    data storage site is controlled in the                  of application for employment or                       associated with the Proposed Action.


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Document Created: 2015-12-15 14:16:49
Document Modified: 2015-12-15 14:16:49
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice of amendment to system of records.
DatesComments on the amendment of this system of records must be received no later than July 27, 2015. If no public comment is received, the new system will become effective July 27, 2015.
ContactVeterans Health Administration (VHA) Privacy Act Officer, Department of Veterans Affairs, 810 Vermont Ave. NW., Washington, DC 20420, (704) 245-2492.
FR Citation80 FR 36595 

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