Privacy Act of 1974; System of Records

AGENCY:

Department of Veterans Affairs (VA).

ACTION:

Notice of system of records: “Spinal Cord Dysfunction-Registry—VA”.

SUMMARY:

The Privacy Act of 1974 (5 U.S.C. 552a(e)(4)) requires that all agencies publish in the Federal Register a notice of the existence and character of their system of records. Notice is hereby given that the Department of Veterans Affairs (VA) is amending the system of records entitled “Spinal Cord Dysfunction-Registry (SCD-R)-VA” (108VA11S) as set forth in the Federal Register 66 FR 29209-29212 dated May 29, 2001. VA is amending the Routine Uses of Records Maintained in the System, including Categories of Users and the Purposes of Such Uses, the Policies and Practices for Storing, Retrieving, Accessing, Retaining and Disposing of Records in the System, and System Manager(s) and Address. VA is republishing the system notice in its entirety.

DATES:

Comments on the amendment of this system of records must be received no later than July 23, 2004. If no public comment is received, the new system will become effective July 23, 2004.

ADDRESSES:

Written comments concerning the proposed amended system of records may be submitted by: mail or hand-delivery to Director, Regulations Management (00REG1), Department of Veterans Affairs, 810 Vermont Avenue, NW., Room 1068, Washington, DC 20420; fax to (202) 273-9026; or e-mail to VAregulations@mail.va.gov. All comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 273-9515 for an appointment.

FOR FURTHER INFORMATION CONTACT:

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

SUPPLEMENTARY INFORMATION:

The Spinal Cord Dysfunction (SCD)-Registry provides a registry of veterans with spinal cord injury and disorders (SCI&D). This registry contains pertinent information on veterans with SCI&D and enables better coordination of care among VHA staff. The purpose of the registry is to assist clinicians, administrators, and researchers in identifying and tracking services for veterans with spinal cord dysfunction resulting from trauma or diseases. The SCD-Registry can also facilitate clinical, administrative, and research reports for medical center use. Local Veterans Health Information System and Technology Architecture (VistA) SCD-Registries provide aggregate data to the National SCD-Registry database at the Austin Automation Center (AAC). This centralized AAC registry is used to provide a VA-wide review of veteran demographics and clinical aspects of injury and disorders for administrative and research purposes.

VHA's Health Services Research and Development Service (HSR&D) and the congressionally-chartered Paralyzed Veterans of America (PVA) originally developed the SCD-Registry. However, these records are maintained exclusively by VA.

The Routine Uses of Records Maintained in the System, including Categories of Users and the Purposes of Such Uses are amended as described below.

• Routine use number seven (7) has been amended in its entirety. VA must be able to comply with the requirements of agencies charged with enforcing the law and conducting investigations. VA must also be able to provide information to state or local agencies charged with protecting the public's health as set forth in state law. The routine use will be as follows: On its own initiative, VA may disclose information, except for the names and home addresses of veterans and their dependents, to a Federal, state, local, tribal or foreign agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto. On its own initiative, VA may also disclose the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

The Privacy Act permits VA to disclose information about individuals without their consent for a routine use when the information will be used for a purpose that is compatible with the purpose for which we collected the information. In all of the routine use disclosures described, the recipient of the information will use the information in connection with a matter relating to one of VA's programs, will use the information to provide a benefit to VA, or disclosure is required by law.

Under section 264, Subtitle F of Title II of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Public Law 104-191, 100 Stat. 1936, 2033-34 (1996), the United States Department of Health and Human Services (HHS) published a final rule, as amended, establishing Standards for Privacy of Individually-Identifiable Health Information, 45 CFR Parts 160 and 164. VHA may not disclose individually-identifiable health information (as defined in HIPAA, 42 U.S.C. 1320(d)(6), and Privacy Rule, 45 CFR 164.501) pursuant to a routine use unless either: (a) The disclosure is required by law, or (b) the disclosure is also permitted or required by the HHS Privacy Rule. The disclosures of individually-identifiable health information contemplated in the routine uses published in this amended system of records notice are permitted under the Privacy Rule. However, to also have authority to make such disclosures under the Privacy Act, VA must publish these routine uses. Consequently, VA is publishing these routine uses and is adding a preliminary paragraph to the routine uses portion of the system of records notice stating that any disclosure pursuant to the routine uses in this system of records notice must be either required by law or permitted by the Privacy Rule before VHA may disclose the covered information.

The Safeguards section of Policies and Practices for Storing, Retrieving, Accessing, Retaining and Disposing of Records in the System has been amended to reflect the change in reference from VA Headquarters to VA Central Office.

System Manager(s) and Address has been amended to indicate that the SCD-Registry Coordinator is the official responsible for Spinal Cord Dysfunction “ Registry design, development, and maintenance.

The Report of Intent to Publish an Amended System of Record Notice and an advance copy of the system notice have been sent to the appropriate Congressional committees and to the Director of Office of Management and Budget (OMB) as required by 5 U.S.C. 552a(r) (Privacy Act) and guidelines issued by OMB (65 FR 77677), December 12, 2000.

108VA11S

SYSTEM NAME:

Spinal Cord Dysfunction-Registry (SCD-R)-VA.

SYSTEM LOCATION:

All electronic and paper records are maintained at the Austin Automation Center (AAC), Department of Veterans Affairs (VA), 1615 Woodward Street, Austin, Texas 78772, and at VA health care facilities listed in VA Appendix 1 of the biennial publication of VA's Systems of Records. Each local medical center facility has a Veterans Health Information System and Technology Architecture (VistA)-based SCD-Registry software package. Data transmissions between VA health care facilities and the VA databases housed at the AAC are accomplished using the Department's wide area network.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

Veterans identified with spinal cord injury and disorders that have applied for VA health care services are included in the system. Occasionally, non-veterans who have received VA health care or rehabilitation services under sharing agreements, contracted care, or humanitarian emergencies will also have information recorded in the Spinal Cord Dysfunction (SCD)-Registry.

CATEGORIES OF RECORDS IN THE SYSTEM:

These records contain identifying information including name, social security number, date of birth, and registration date in the SCD-Registry. SCD-Registry registration information may include information about whether individuals are receiving services from VA's spinal cord system of care, neurologic level of injury, etiology, date of onset, type of cause, completeness of injury, and annual evaluation dates offered and received. The Outcomes File of the SCD-Registry has data fields for storing measures of impairment, activity, social role participation, and satisfaction with life. A registrant may have multiple entries in this file.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

Title 38, United States Code, Sections 501 and 7304.

PURPOSE(S):

The SCD-Registry provides a registry of veterans with spinal cord injury and disorders (SCI&D). This registry contains pertinent information on veterans with SCI&D and enables better coordination of care among VHA staff. The purpose of the registry is to assist clinicians, administrators, and researchers in identifying and tracking services for veterans with spinal cord dysfunction resulting from trauma or diseases. The SCD-Registry can also facilitate clinical, administrative, and research reports for medical center use. Local VistA SCD-Registries provide data extracts to the National SCD-Registry database at the AAC. This centralized AAC registry is used to provide a VA-wide review of veteran demographics and clinical aspects of injuries and disorders.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

VA may disclose protected health information pursuant to the following routine uses where required by law, or required or permitted by 45 CFR Parts 160 and 164.

1. The record of an individual who is covered by this system may be disclosed to a member of Congress or staff person, acting for the member, when they request the record on behalf of, and at the written request of, that individual.

2. Disclosure of records covered by this system, as deemed necessary and proper to named individuals serving as accredited veterans service organization representatives, and other individuals named as approved agents or attorneys for a documented purpose and period of time. These agents/attorneys must be aiding beneficiaries in the preparation/presentation of their cases during verification and/or due process procedures or in the presentation/prosecution of claims under laws administered by VA.

3. A record containing the name(s) and address(es) of present or former members of the armed services and/or their dependents may be released from this system of records under certain circumstances:

a. To any nonprofit organization if the release is directly connected with the conduct of programs and the utilization of benefits under Title 38, and

b. To any criminal or civil law enforcement governmental agency or instrumentality charged under applicable law with the protection of the public health or safety if a qualified representative of such organization, agency or instrumentality has made a written request that such name(s) or address(es) be provided for a purpose authorized by law; provided, further, that the record(s) will not be used for any purpose other than that stated in the request and that the organization, agency or instrumentality is aware of the penalty provision of 38 U.S.C. 5701(f).

4. Disclosure may be made to the National Archives and Records Administration (NARA) in records management inspections conducted under authority of Title 44 United States Code.

5. Disclosure of information, excluding name and address (unless name and address is furnished by the requester) for research purposes determined to be necessary and proper, to epidemiological and other research facilities approved by the Under Secretary for Health.

6. In order to conduct Federal research necessary to accomplish a statutory purpose of an agency, at the written request of the head of the agency, or designee of the head of that agency, the name(s) and address(es) of present or former personnel or the armed services and/or their dependents may be disclosed;

a. to a Federal department or agency; or

b. directly to a contractor of a Federal department or agency. When a disclosure of this information is to be made directly to the contractor, VA may impose applicable conditions on the department, agency, and/or contractor to ensure the appropriateness of the disclosure to the contractor.

7. VA may disclose on its own initiative any information in this system, except the names and home addresses of veterans and their dependents, which is relevant to a suspected or reasonably imminent violation of law, whether civil, criminal or regulatory in nature, and whether arising by general or program statute or by regulation, rule or order issued pursuant thereto, to a Federal, State, local, tribal, or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. On its own initiative, VA may also disclose the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

8. For program review purposes and the seeking of accreditation and/or certification, disclosure may be made to survey teams of the Rehabilitation Accreditation Commission, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), College of American Pathologists, American Association of Blood Banks, and similar national accreditation agencies or boards with whom VA has a contract or agreement to conduct such reviews, but only to the extent that the information is necessary and relevant to the review.

9. Records from this system of records may be disclosed in a proceeding before a court, adjudicative body, or other administrative body when the Department, or any Department component or employee (in his or her official capacity as a VA employee), is a party to litigation; when the Department determines that litigation is likely to affect the Department, any of its components or employees, or the United States has an interest in the litigation, and such records are deemed to be relevant and necessary to the legal proceedings; provided, however, that the disclosure is compatible with the purpose for which the records were collected.

10. Disclosure of relevant information may be made to individuals, organizations, private or public agencies, etc., with whom VA has a contract or agreement to perform such services as VA may deem practicable for the purposes of laws administered by VA, in order for the contractor or subcontractor to perform the services of the contract or agreement.

11. Relevant information may be disclosed to the Department of Justice and United States Attorneys in defense or prosecution of litigation involving the United States, and to Federal agencies upon their request in connection with review of administrative tort claims filed under the Federal Tort Claims Act, 28 U.S.C. 2672.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

Magnetic tapes/disks and optical discs. Electronic data are maintained on Direct Access Storage Devices at the AAC. The AAC stores registry tapes for disaster backup at a secure, off-site location.

RETRIEVABILITY:

Records are indexed by name of veteran, social security number, and unique patient identifiers.

SAFEGUARDS:

1. Data transmissions between VA health care facilities and the VA databases housed at the AAC are accomplished using the Department's wide area network. The SCD-Registry program and other programs at the respective facilities automatically flag records or events for transmission based upon functionality requirements. VA health care facilities control access to data by using VHA's VistA software modules. The Department's Telecommunications Support Service has oversight responsibility for planning, security, and management of the wide area network.

2. Access to records at VA health care facilities is only authorized to VA personnel on a “need-to-know” basis. Records are maintained in staffed rooms during working hours. During non-working hours, there is limited access to the building with visitor control by security personnel. Access to the AAC is generally restricted to AAC staff, VA Central Office employees, custodial personnel, Federal Protective Service, and authorized operational personnel through electronic locking devices. All other persons gaining access to the computer rooms are escorted. Backup records stored off-site for both the AAC and VA Central Office are safeguarded in secured storage areas.

3. Strict control measures are enforced to ensure that access to and disclosure from all records including electronic files and veteran-specific data elements are limited to VHA employees whose official duties warrant access to those files. The automated record system recognizes authorized users by keyboard entry of unique passwords, access, and verify codes.

RETENTION AND DISPOSAL:

Records will be maintained and disposed of in accordance with record disposition authority approved by the Archivist of the United States. Depending on the record medium, records are destroyed by either shredding or degaussing. Optical disks or other electronic media are deleted when no longer required for official duties.

VA has submitted a request for records disposition authority to the National Archives and Records Administration (NARA) for approval. Upon approval by NARA, VA will publish an amendment to this System of Records. In the interim, no records will be destroyed.

SYSTEM MANAGER(S) AND ADDRESS:

Official responsible for Spinal Cord Dysfunction—Registry design, development, and maintenance: SCD-Registry Coordinator (128N), 3350 La Jolla Village Drive, San Diego, California 92161. Official responsible for policies and procedures: Chief Consultant, Spinal Cord Injury and Disorders Strategic Healthcare Group (128N), 1660 South Columbian Way, Seattle, Washington 98108.

NOTIFICATION PROCEDURE:

An individual who wishes to determine whether a record is being maintained in this system under his or her name or other personal identifier, or wants to determine the contents of such record, should submit a written request or apply in person to the last VA facility where medical care was provided or submit a written request to the Chief Consultant, Spinal Cord Injury and Disorders Strategic Healthcare Group (128N), 1660 South Columbian Way, Seattle, Washington 98108. Inquiries should include the veteran's name, social security number, and return address.

RECORD ACCESS PROCEDURES:

An individual who seeks access to records maintained under his or her name may write or visit the nearest VA facility or write to the Chief Consultant, Spinal Cord Injury and Disorders Strategic Healthcare Group (128N), 1660 South Columbian Way, Seattle, Washington 98108.

CONTESTING RECORDS PROCEDURES:

(See Record Access Procedures.)

RECORD SOURCE CATEGORIES:

Various automated record systems providing clinical and managerial support to VA health care facilities, the veteran, family members, accredited representatives or friends, and “Patient Medical Records—VA” (24VA19) system of records.