01-30241. Privacy Act of 1974; System of Records

AGENCY:

Department of Veterans Affairs.

ACTION:

Notice of Amendment of System of Records “Health Care Provider Credentialing and Privileging Records—VA”.

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” (77VA11) as set forth in the Federal Register 55 FR 30790 dated 7/27/90. VA is changing the system number to 77VA10Q and amending the system notice by revising the paragraphs on System Location; Categories of Individuals Covered by the System; Categories of Records in the System; Purposes; Routine Uses; Storage; Retrievability; Safeguards; System Manager(s) and Address. 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 January 7, 2002. If no public comment is received, the changes will become effective January 7, 2002.

ADDRESSES:

Written comments concerning the proposed amendment of the system of records may be submitted to the Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420. Comments will be available for public inspection at the above address in the Office of Regulations Management, Room 1158, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT:

Veterans Health Administration (VHA) Privacy Act Officer, Department of Veterans Affairs, 810 Vermont Ave., NW., Washington, DC 20420, [phone].

SUPPLEMENTARY INFORMATION:

VA is renumbering the system of records from 77VA11 to 77VA10Q to reflect organizational changes in the Department. In addition, VA has decided, as a matter of policy, to automate and provide direct, on-line, remote access to data on the credentialing of health care practitioners appointed or otherwise utilized by the VHA. The automation and on-line access to credentialing data improves the quality, timeliness, and reliability of the credentialing process; promotes inter-facility sharing of health care resources; supports national readiness; facilitates the establishment of telemedicine initiatives; simplifies the process for covered health care practitioners; and reduces costs. An electronic credentials data file can cross facility and network boundaries and eliminate duplication.

VHA is responsible for the medical treatment of veterans and promotes the provision of quality health care through credentialing the education, training, and qualifications of the practitioners delivering this care. Historically, VHA has maintained these records in a paper format in each medical treatment facility or Veterans Integrated Service Network (VISN). When a practitioner transfers between facilities or the practitioner's services are shared among facilities, either all or portions of the paper record are transferred to the receiving facility. Some medical treatment facilities keep credentialing data in non-validated electronic formats to meet local needs. However, the exchange of paper and/or non-validated electronic data means that some of the practitioner's credentials must be re-verified with the primary source to ensure the adequate and appropriate education, training, and qualifications of the practitioner. This results in unnecessary use of resources by VA and the sources providing information to VA.

VHA is supplementing the paper record through the development of a centralized electronic data warehouse for the storage of credentialing data and the images of the primary source verification. This effort is a joint project between the VHA and the Department of Health and Human Services, Health Resources and Services Administration (HHS/HRSA). The electronic data warehouse will not only store the electronic data and images, but will cross-validate data provided by the practitioner with data received from the primary or secondary source. Primary source verification is that verification received from the source that provided the credential, i.e., Federal Register, educational or training institution, certifying or licensing agency. A secondary information source is one that provides credentialing data that is derived from a primary source, i.e., National Practitioners Data Bank (NPDB). Secondary information sources may require additional supporting documentation either from a primary source or additional secondary sources for corroboration. Providers shall enter data into the system through an Internet browser. Once data has been entered into the system, the credentialing staff initiate the primary source verification of the provider's education, training, and qualifications. To ensure provider identification, and appropriate matching of information entered into an electronic system, available unique identifiers which may include name, social security number, national provider identifier, unique physician identification number, etc. will be used for matching data, when available. In instances where electronic data is available from alternate sources and meets or exceeds VA credentialing requirements, it will be utilized.

Access to data in electronic files is controlled at the health care facility in accordance with nationally and locally established data security procedures. These standards include, but are not limited to, requiring a unique password for each user, restricting access to “need-to-know” data, and deactivating screen displays after short periods of time. All data transmitted across the Internet is supported by encryption, deactivation with the server after short periods of time without interaction, and insulation of the Internet server by a firewall.

VHA has determined that direct, real-time, remote access to the credentialing data of health care practitioners by authorized users should expedite the processing of health care practitioners for appointment, reappointment, rapid deployment and granting of privileges. VHA has also determined that the use of information technology and data warehousing of credentialing information should result in a more timely and accurate credentials file for ensuring practitioners' education, training, and qualifications while facilitating the accurate identification of providers to all interested parties. The availability will decrease the time it takes to address health care delivery needs met not only through the employment or appointment process, but also through contracting, sharing agreements, affiliations, etc. Valid electronic data will assist VA in meeting legislative mandates and executive orders such as Federal emergency responses. The availability of electronic data required for credentialing can also facilitate VA's requirements related to appointment, emergency response by the appropriate health care providers, telemedicine, or response to scarce medical needs.

VHA may collect biometric information (i.e., fingerprint) for the verification of identity. A verification transaction involves the one-to-one matching of sample data against a particular record of the person presenting the sample. This can be done automatically based completely on biometric minutiae. Since the credentialing process is for the purpose of data validation, personal validation and the unequivocal link of a record to the individual reinforces the credentialing process. The use of a biometric data adds an additional level of patient safety by verifying that providers are who they say they are throughout their professional career. Additionally, a biometric identifier can add an additional level of security to the system in the verification of individuals making transactions in the electronic file at log-on.

Validated credentialing information may be shared with other established data systems such as Veterans Information Systems and Technology Architecture (VistA) and Decision Support System (DSS). The purpose of sharing credentialing data is to decrease the duplicative effort of both providers and staff in gathering the same information multiple times for various data bases used in VA. This data is required for such activities as emergency medical responses in the times of national disaster response, telemedicine, and medical cost care recovery and would be disclosed only to the extent it is reasonably necessary to assist in the accomplishment of legislative or executive order mandates.

Amendments to the System Location include that contractors may maintain the records of contractors who provide care in a VA health care facility in accordance with this notice and VHA policy. With the implementation of the electronic credentials data bank, the System Location is also amended so all the electronic records may be maintained by HHS, a component thereof, a contractor or subcontractor of HHS in accordance with the VA Interagency Agreement. The Categories of Individuals Covered by the System is amended to include those health care providers who are not employed by VA but providing care through contractual or other types of agreements to VA patients. The Category of Records in the System is amended to reflect the inclusion of those health care providers who are providing care through arrangements other than employment. The Category of Records in the System is also amended to more clearly specify the data elements collected, including items that will bring VA into compliance with the National Standard disseminated by HHS.

Routine use 1 was deleted. Former routine uses 2, 3, 5, 6, 10, 12, 18, and 20 are amended to clarify the inclusion of all individuals regardless of employment, utilization, or appointment to the professional staff. VA utilizes the services of numerous providers through various appointment processes beyond the employment process. Former routine use 2 (now 1) was amended to allow disclosure of information in response to scarce or emergency needs of the Department or other entities when specific skills are required. Former routine use 5 (now 4) was amended to delete the section numbers. Former routine use 7 (now 6) was amended to replace the word “private” with “non-Federal.” Former routine use 8 (now 7) was amended to delete “local Government” and “State.” Routine use 12 (now 11) was amended to specify that the relevant information is disclosed at VA's initiative and that names and addresses of veterans are to be excluded from the relevant information that could be disclosed. Former routine use 13 (now 16) is being modified to clarify the conditions under which data is disclosed to officials of labor organizations recognized under 5 U.S.C., chapter 71. The clarification ties such disclosures to the law authorizing such disclosures, i.e., 5 U.S.C. 7114(b)(4). The former version authorized disclosures to officials of labor organizations “ when relevant and necessary to their duties of exclusive representation concerning personnel policies, practices, and matters affecting working conditions.” An editorial change is being made to routine use 14 (now 13) to clarify the terminology used for fitness for duty examinations. Former routine use 16 (now 15) is being changed to delete the language concerning disclosures to the Equal Employment Opportunity Commission to ensure compliance with the Uniform Guidelines on Employee Selection Procedures, since VA has not chosen to adopt the Uniform Guidelines for use in its Title 38 employment procedures. Former routine use 17 (now 12) is amended to expand the purposes for which information may be disclosed to the Federal Labor Relations Authority to investigate representation petitions and conduct or supervise representation elections. Former routine use 17 (now 12) is also being clarified to indicate that disclosures to the Federal Labor Relations Authority and the Federal Service Impasses Panel may only be made after appropriate jurisdiction has been established. Matters arising out of (1) professional conduct or competence, (2) peer review, and (3) the establishment, determination or adjustment of compensation shall be decided by the Secretary of Veterans Affairs and is not itself subject to collective bargaining and may not be reviewed by another agency. See 38 U.S.C. 7422. One routine use is added to this System (new 20) to allow for the sharing of information and data on a need-to-know basis for providers who move between sites and/or provide care at multiple sites. The routine use disclosure statements are being renumbered.

VA is revising and updating the systems of record notice 77VA10Q, “Health Care Provider Credentialing and Privileging Records—VA”.

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

Approved: November 19, 2001.

Anthony J. Principi,

Secretary of Veterans Affairs.

77VA10Q

System Name:

Health Care Provider Credentialing and Privileging Records-VA.

System Location:

Records are maintained at each VA health care facility. Address locations for VA facilities are listed in VA Appendix 1 of the 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 VA contracted health care providers who are credentialed by the contractor in accordance with VHA policy, where credentialing information is received by VHA facilities will be maintained in accordance with this notice and VHA policy. Electronic copies of records may be maintained by the Department of Health and Human Services (HHS), a component thereof, a contractor, subcontractor of HHS, or by another entity in accordance with the VA Interagency Agreement. 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 VA, and individuals who make application to VA and are considered for employment or appointment as health care providers. These records will include information concerning individuals who through a contractual or other type of 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 anesthetists; nurse practitioners; nurses; occupational therapists; optometrists; clinical pharmacists; licensed physical therapists; 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 record consists 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 type of agreement, and/or for appointment to the professional staff.

(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) Accessing and reporting to the National Practitioner Data Bank (NPDB).

The record may include individual identifying information (e.g., name, date of birth, gender, social security number, national provider number, and/or other personal identification number), address information (e.g., home and/or mailing address, home telephone number, e-mail address, facsimile number), biometric data and 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 record 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 personnel folder.

Authority for Maintenance of the System:

Title 38 U.S.C. 501(a) and 7304(a)(2).

Purposes(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 of activities of individuals covered by this system; accreditation of a facility by an entity such as the Joint Commission on Accreditation of Healthcare Organizations; audits, reviews and investigations conducted by staff of the health care facility, the VISN Directors and Division Offices, VA Central Office, VHA program offices who require the credentialing information, 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 Uese 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.

4. Disclosure may be made to 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, organizations, boards, bureaus, or commissions (e.g., the Joint Commission on Accreditation of Healthcare Organizations). Such disclosures may be made only when: (a) The records are properly constituted in accordance with VA requirements; (b) the records are accurate, relevant, timely, and complete; and (c) 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. 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.

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. This information may also be disclosed to a VA patient, 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 Federal, State, local or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. On its own initiative, VA may also disclose the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

12. VA may 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. Information may be disclosed to the VA-appointed representative of an employee regarding all notices, determinations, decisions, 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. Information may be disclosed to officials of the Merit Systems Protection Board, including the Office of the Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of rules and regulations, investigation of alleged or possible prohibited personnel practices, and such other functions, promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.

15. Information may be disclosed to the Equal Employment Opportunity Commission when requested in connection with investigations of alleged or possible discriminatory practices, examination of Federal affirmative employment programs, or the other functions of the Commission as authorized by law or regulation.

16. Information listed in 5 U.S.C. 7114(b)(4) may be disclosed 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 nformation 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: (a) 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; (b) 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, (c) 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 which results in a voluntary or involuntary limitation, reduction or loss of clinical privileges; and (c) relevant information concerning any payment which 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: (a) The records are properly constituted in accordance with VA requirements; (b) the records are accurate, relevant, timely, and complete; and (c) disclosure is in the best interests of the Government (i.e., to meet the requirements of contracts, sharing agreements, partnerships, etc.). When the exchange of credentialing information through the exchange of individual records directly benefits VA's completion of its mission and enhances public confidence in VA's or the Federal Government's role in the delivery of health care, then the best interests of the Government are served.

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.

Retrievability:

Records are retrieved by the names and social security number or other assigned identifiers, e.g. the National Provider Identifier, of the individuals on whom they are maintained.

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 rooms 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 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, which 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. Records are maintained in manned rooms during working hours. During non-working hours, 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 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 which 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 is maintained in the original files. Access from remote locations, including 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:

Records are maintained at the employing VA facility. If the individual transfers to another VA facility location, the record is transferred to the new location, if appropriate. Paper records are retired to a Federal records center 3 years after the individual separates from VA employment or 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, VHA 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 and Performance (10Q), 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 VA Central Office or at a VISN location; and (3) HHS/HRSA, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20852, for the electronic data warehouse. In most cases, the electronic data will be maintained by the Department of Health and Human Services, Health Resources and Services Administration (HHS/HRSA), a component thereof (a contractor, subcontractor of HHS/HRSA, or by another entity) in accordance with the VA Interagency Agreement.

Notification Procedure:

Individuals who wish to determine whether this system of records contains information about them should contact the VA facility where they made application for employment or appointment, or to the VA facility where they 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 where they made application for employment or appointment, or the VA facility where they are or were employed.

Contesting Records Procedures:

(See Record Access Procedures above.)

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, 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.