**Transcript of Cyberseminar**

**VIReC Database and Methods Seminar**

**Improving Mortality Ascertainment Using the VA Vital Status Datasets**

**Presenter: Elizabeth Tarlov, PhD, RN**

**July 22, 2013**

**Improving Mortality Ascertainment Using the VA Vital Status Datasets**

**July 22, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**virec@va.gov**.*

Moderator:Welcome to VIReCs Database and Methods Cyber Seminar entitled” Improving Mortality Ascertainment Using the VHA Vital Status File”. Thank you to CIDER for providing technical and promotional support for this series. Today’s speaker is Elizabeth Tarlov, Associate Director for VIReC at Edward Hines Jr. VA Hospital. Questions will be monitored during the talk in the Q & A portion of Go to Webinar and will be presented to Doctor Tarlov at the end of the session. A brief evaluation questionnaire will pop up when you close Go to Webinar. We would appreciate if you would take a few moments to complete it. I am pleased to welcome today’s speaker Doctor Tarlov. 

Doctor Elizabeth Tarlov:Thank you Erica and good afternoon or good morning everyone. Welcome to today’s session on Improving Mortality Ascertainment Using the VHA Vital Status File. Here is what you can expect to learn today. At the conclusion of today’s program, you will be able to identify data sources for Veteran vital status ascertainment; understand the contents and structure of the VA Vital Status Files and their appropriate use for mortality ascertainment and describe limitations of using the VHA Vital Status File to ascertain mortality. To accomplish these objectives I will first discuss available data sources for Veteran vital status ascertainment. This will include those from which the vital status file data come but also a few others that are not used in building the vital status file. Then to the principle focus of the seminar, the VHA vital status files, first discussing structure, contents, and then focus again on some particular challenges and vital status ascertainment. Finally, I will provide some resources for further information and assistance. 

First, we would like to take a short audience poll. In a moment, you will see the poll and we would appreciate your answering two questions. The first question – how would you rate your knowledge of methods to ascertain death dates for Veterans in the VA? Please rate yourself from one meaning no knowledge to five is expert knowledge. It looks like we have about a third and a third and a third almost, no knowledge two and three and a few rated themselves number four. Okay, that is useful to know. 

The second question is – have you ever used the VHA vital status file? Your choices are – yes, including the master file; yes only the mini file; or no. 

Heidi:Elizabeth I just wanted to break it, your audio is sounding a little shaky. It is kind of coming in and out a little bit, I am not sure what you can do, I think you are using the VOIP headset, but maybe if you pull the microphone a little bit closer to yourself or something hopefully it will help clear that up a little bit. 

Doctor Elizabeth Tarlov:Okay I will try that. I am going to try a different USB port. Can you hear me now?

Moderator:I can hear you yes, hopefully your audio will stay good. 

Doctor Elizabeth Tarlov:Okay. Let me know please. Answers to this second question – nineteen percent answered yes including the master file; another thirteen percent have used the file with just the mini and seventy percent neither. Okay, thank you very much. There we go, okay. Here we go. Our first topic, data sources for Veteran vital status ascertainment and I will first start with those that are sources that are included in the vital status files. 

First is the BIRLS Death File. The Beneficiary Identification and Records Locator System is a VBA database. The BIRLS Death File is an extract from that database. VBA obtains death dates from a variety of sources including Family; VHA hospitals; VA National Cemetery Administration and the Social Security Administration. Its coverage is any Veteran VBA knows about which will include any Veterans applied for or received benefits from any of the three administrations. That includes all Veterans who have used VA healthcare. VHA receives a new BIRLS desk file each month, it is a complete overlay which is important because it means that the VA’s copy of the desk file will contain all updates including new death dates and changes to existing information in the file. For example correction of any previously erroneous information. This file resides on the AITC mainframe computer. 

The VA CMS Vital Status File is more accurately referred to as the Medicare Vital Status File. It is received approximately annually from the Centers for Medicare and Medicaid Services or CMS. CMS obtains dates of death from multiple sources but chiefly the Social Security Administration. Death dates included in this file will be those for Veterans enrolled in Medicare which means principally those who are disabled, are sixty-five years or older or have end stage renal disease. Most Veteran deaths under age sixty-five will not be captured in this file. This file is updated annually; the VHA currently has the most recent file including deaths through March 2013. However, this file has just recently been received and so it has not yet been incorporated into the vital status files. The current vital status file was created using CMS data that was current through December 2011. CMS data meaning the vital status data. The file is available to researchers from VIReC as for operations use through the Medicare and Medicaid Analysis Center.

The VA also obtains Social Security Administration Death Master File data; SSA obtains the death date information from multiple sources including the National Center for Death Statistics, which creates the National Death Index containing death certificate data from state vital statics offices. The SSA Death Master File coverage is anyone who has obtained a Social Security card since 1936. This includes deaths occurring outside the U.S. However, the death data has been found to be more complete among the over sixty-five population and for beneficiaries. The VA data from SSA are updated weekly, annually a complete overlay file is received and just received this file for this year and it contains death dates through May 2013 and will be used in building the next version of vital status file at the end of this month. This file resides on the AITC mainframe. 

The three files I just discussed are all from outside VHA. The workload data also contains death dates when the death has occurred in the inpatient setting. The patient treatment file or PTF contains inpatient data from patients in VA hospitals and also for patients in non-VA hospitals when the stay is covered by the VA, referred to as fee basis care. The data originate in VistA file forty-five the PTF file. PTF data may be better known to many of you as the inpatient data contained in the Medical SAS data sets. I am referring to it as PTF here because that is how it is labeled in the vital status file and I want to be consistent with the terms that I will be using here. Workload data are extracted from VistA to the PTF weekly so new death dates may appear in this file weekly. 

This is preview of a new data source, the National Cemetery Administration, NCA. VHA will be receiving data death information for Veterans and information sources are multiple. Coverage is Veterans who have or families have applied for burial benefits. Data will be updated monthly. The National Cemetery Association is currently sending demographic information to VHA and it is incorporated into the Master Veteran Index, MVI and from there into the VHA Vital Status File. The MVI is owned by the VA Identity Management Services in the Office of Information and Analytics and I will tell you a little bit more about the MVI a bit later. We do not yet have a date for when we will start receiving the desk data from MCA. 

Other available sources for our vital status ascertainment. These are not among those included in building the vital status files. The first is the VA Corporate Data Warehouse. The CDW also contains data death information. It is in the Spatient Table; three columns are relevant – Date of Death; Date of Death Text and Deceased. The Deceased column contains a flag that sets ‘Y’ if there is information in the Data of Death Text column and ‘N’ if it is empty. 

The data are extracted from the VistA patient File, File (2) in the date of death field. Current policy on the source of the information has recently been published in the VHA Handbook 1906. It states that only information from the three sources you see here should be entered. The VHA facility where the patient died, a death certificate or the National Cemetery Administration. 

Not surprisingly then many Veterans death dates are not recorded in the CDW. A recent analysis that has not yet been published by the Data Quality Analysis Team of the Office of Information and Analytics examined Death Data in the Vital Status Files and CDW combined. They found that about thirty percent of all the SSNs with a death date did not have the date of death reported in the CDW Spatient table. On the other hand, the same analysis found that CDW has dates of death not in the Vital Status File. Principally these were either very recent deaths, deaths that occurred before 1992 or deaths where SSNs not in the Vital Status Files and mostly that would be due to having no VHA or VBA activity after the end of fiscal year 1999. 

I want to mention here a fairly new source of death data in the VA, the VHA Serious Mental Illness Treatment Resource and Evaluation Center or SMITREC acquired death data from the National Death Index. The NDI because it includes all death certificates from every State vital statistics office is considered the gold standard in terms of completeness. 

The data that the SMITREC has obtained will include death information for any Veteran who has used VHA inpatient or outpatient services during the 1998 to 2009 and has no indication of being alive based on having no VHA utilization. In addition, it will include deaths for Veterans in the OEF/OIF roster regardless of whether they have used VHA. The data is currently complete through the end of fiscal year 2009 and notably this is the only source of cause of death data in the VA. 

Finally, an SSA, Social Services Administration Epidemiologic Search is another resource for Veteran Vital Status ascertainment and of course, that was Social Security Administration, SSA. I am trying to remember to say out my acronyms. This is a service provided by the SSA, there are fees involved. It provides the date of death, also validates Social Security Numbers and provides a presume living status based on SSA administrative data. This can be useful in providing confirmation in the study subject vital status when a death date is not found thus avoiding needing to class by subject’s loss to follow up. Social Security Administration data includes deaths occurring outside the U.S.

I will move on to the structure and contents of the VHA Vital Status Files and I will start with a little bit of background. The impetus for creation of the VHA Vital Status Files was evidence from studies showing that existing sources of death data are incomplete on their own and therefore, provide conflicting information on whether a Veteran is deceased or not. 

This table presents sensitivity of each data source when compared to the National Death Index. The information is based on results of two studies one of which is VIReCs VA NDI Mortality Data Merge Project. The sensitivities vary by the age and gender so the numbers are ranges and note that BIRLS has been found to capture it most eighty percent of deaths are occurring among Vets known to the VA. 

VIReC undertook the VA NDI Mortality Data Merge Project in 2003 to investigate questions of completeness and conflicting information. By comparing information in each file and the files together to the gold standard, the National Death Index. This project found first the combined use of the BIRLS Death File, the SSA Death Master File, the Medicare Vital Status File, and Inpatient Medical SAS Data compared very favorably with the results of a National Death Index search. It also found that use of external sources specifically the Social Security Administration Death master File and Medicare Vital Status File increased the number of deaths identified by twenty-two percent over the use of only internal sources. A recommendation that came out of this study was the creation of a new VA file of combined mortality data. 

In 2006, National Data Systems built the first VHA Vital Status File. The files are updated quarterly and include information on all Veterans known to the VA who were alive on October 1, 1991 or were born since then. The Vital Status Files comprise two files that I will discuss in detail; a third file is a scrambled SSN to SSN crosswalk file. 

The Vital Status Master File includes records for both Veterans and non-Veterans who received VA services. For each Social Security Number there is at least one record. In fact, there is one record for each SSN, date of birth, sex combination found in the combined data. Currently the Vital Status Master File contains one hundred and twenty-two variables. The Vital Status Mini Files contains Veterans records only and just one record per SSN. That record contains combined data from all the Master File Records for the SSN. Currently the Vital Status Mini File contains sixteen variables. 

Understanding the construction of the files will help you to address some of the challenges that sometimes present themselves in ascertaining the Vital Status data. These are the base data sources and what I mean by that is those that are used to create a Vital Status File record. They comprise VBA and VHA sources and are listed in this table. In addition to Patient Treatment File Data, data from the Outpatient and Inpatient Encounter Files, fee basis files, decision support systems and pharmacy files, enrollment data and the Veterans Service network Corporate Mini Master File referred to as VETSNET. 

These files are merged on SSN Date of Birth and Sex. The result is a separate record for every SSN Date of Birth/Sex combination. I will note that a missing date of birth or sex is treated as a value in this merge. Information contributed by these sources includes Dates of Last Activity for example the last healthcare encounter or last VBA benefit payment. Also includes inpatient death dates from the Patient Treatment File. 

The remaining sources that contribute data to the Vital Status Files is data that nets records and I therefore refer to them as supplemental. They are merged on the SSN only to the existing records. This slide shows the addition of demographic data from the Master Veteran Index. Dates of death from the National Cemetery Administration will be added to the NDI and from there to the Vital Status Files as I mentioned earlier. Right now, it is the demographics only. Finally, death dates from VBA, CMS and SSA are added, merged to the Vital Status File Records on the SSN only. Death dates from CMS are from Medicare files not Medicaid. The SSA does not have sex information and because the merge is done on SSN, only the same death dates and demographics will be added to every record for that SSN. 

To kind of put this all together the Master File has one record for each VA SSN Date of Birth and Sex combination. Each record contains one set of date of birth/sex variables for each source of data, VA or not, on that record. All VA source variables on a single record will have the same date of birth and sex because that is how the file is constructed. The death dates from Medicare, BIRLS and SSA are the death dates for the SSN on that record. The date of birth and sex from those sources may not match other date of birth and sex values on the same record. 

For each record, a best date of death is derived using an algorithm. That algorithm is available in Appendix A at the end of this slide set. Each record on the Master File includes dates of last activity from each VA source and from Medicare. 

The Medicare last activity dates exclude information from unpaid carrier claims and there are actually last activity dates in the Medicare data. One excludes just the unpaid carrier claims and the other excludes DME, durable medical equipment and unpaid carrier claims. Variables from the sources shown here – outpatient, inpatient, enrollment and VBA indicates whether that source has identified the individual as a Veteran. 

The Medicare Analysis Center prepares the Medicare data for the Vital Status Files. Also included is race information from Medicare data and submission flags indicating for each year whether the SSN was included in the finder file that was sent to CMS and whether CMS records indicated the individual was enrolled in Medicare that year. The Master File also contains variables indicating the quality of each date. Note that a complete date may have default values from source data when the true date of birth is unknown. For example, there may be a one in the day position or January in the month position. There is also a presumed living indicator, which is based on whether there is a death date and also last activity dates. 

I am going to talk about the Construction of the Mini File. In brief, this is us selecting Veteran records using algorithms to select the best date of birth, sex and date of death for each SSN when there are multiple records and selecting a date of last activity. 

The Mini File contains Veterans records only. For the approximately sixty-five percent of SSNs for which there is one record only, there is no question about which date of birth and sex values get included in the Master File. The best date of birth previously selected through the algorithm is also included in the Mini File. For SSNs with multiple records on the Master File, remember this means there are multiple date of birth, sex combinations for that SSN an algorithm is run to select a best date of birth and sex, those values and the best date of birth are selected for inclusion in the Master File. 

What do I mean by selecting a ‘best’ something? The term refers to use of an algorithm to select the value for a demographic variable associated with a Social Security Number when more than one value for that variable is found in the source data. The goal is to select the true value for the variable in the majority of cases. The algorithm used to select the best date of birth is complex and it is detailed in Appendix C also at the end of this slide set. Dates from VA utilization sources are preferenced and a scoring method is used and gives a higher score for dates that are completed and the sex is not missing and they both match external sources. 

The sixth value for an SSN are consisting a best sex is selected. In the future, when VHA receives best dates from the Mater Veteran Index obtained from National Cemetery Association, the MVI death date will be selected over the algorithm selected ‘best date of death’ if the MVI data has high quality demographics. 

Contents for the Vital Status Mini File. The Mini File has one record per SSN. On that one record are three demographic variables, the best dates of birth and death and best sex. There are two dates of last activity, one for healthcare utilization and the other overall. The presumed living status variable is included. Finally, there are variables to indicate the data source for each date. On the Mini File the date of birth source from the Master Veteran Index replaces an algorithm derived best date of birth if the MVI data of birth is complete. 

In regard to the Master Veteran Index VHA Directive of 1906 was published this year it establishes the MVI as the Authoritative Identity Service within VA maintaining a synchronizing identity for VA clients, Veterans and beneficiaries. Those are often responsible the Identity Management Services, the office responsible for resolving conflicting identifying information. National Data Systems recently examined the impact of the MVA on dates of birth in the Mini File. They found that replacing the algorithm derived best date of birth with the Master Veteran Index date of birth resulted in an actual change in dates in the less than two percent of the record. 

This slide shows the data source for the dates of birth on the Mini File. This was from the Mini File created most recently, April twenty-eighth of this year and you can see the data sources and best date of birth was MVI in eighty-nine percent of cases.

The final selection of data from the Master File is Last Activity. Two dates are selected, one from utilization data and the other from all last activity including last utilization. When there are multiple records for an SSN these dates reflect last activity from all records combined. A presumed living status is assigned to each SSN and it can take on one of three values indicating presence of a death date and whether or not the last healthcare utilization date is more than thirty-one days after death. 

The last activity dates on the VHA Vital Status File can be used to reduce the number of patient’s last follow up. Using the VHA Vital Status Files of the patient in the study cohort may be classified as deceased; presumed living; or unknown or lost to follow up if there is no death date and no last activity date occurring after the end of the study period. 

Moving on to challenges in using the Vital Status Files, the potential challenges in using these files to ascertain deaths in research include demographics that do not match the demographic you have for an SSN in your study data; multiple dates of death for an SSN and healthcare of benefit activity after the date of death. 

VIReC recently examined some of these issues in the most recent version of the Vital Status Files created April twenty-eighth, there are twenty-four and a half million records that follow and 17.6 million unique SSNs. Sixty-six percent of the SSNs have one record and thirty-four percent have more than one record. 

Remember that multiple records occur when there is more than one date of birth/sex combination for an SSN in the base data sources. These variations can arise from missing or incomplete dates or from conflicting information. Some of the conflicting information arises from the use by some sources of default values in place of missing data as I mentioned previously. 

We looked at the consistency on the Master File. This table shows results of that analysis which used Veteran records in the file created in June 2010. This was a couple of years ago. There were nearly twenty million Veteran records on the Master File at that time and those twenty million records contain fourteen million unique SSNs. Also, 1.4 percent of those SSNs have more than one gender value and thirty-six percent have more than one date of birth value. Remember that a missing date or missing part of the date is treated as a unique value. If we ignore the missing value and look for conflicting date information, we found that 8.6 percent of the fourteen million SSNs had data that was actually conflicting. Most of those had conflicting gender values only and about seventeen percent were conflicting date of birth values. 

When there is more than one date of death for a Veteran SSN on the Master File the best date of death algorithm selects one and that is the one date of death on the Vital Status Mini File. This file contains the information from the most recently created Vital Status File. It shows the data source for the best dates of death on the Mini File and again when I use the term ‘best’ I am referring to the algorithm selected date of death that was on the Mini File. There were 5.1 million dates of death on this file, fifty-seven percent come from the Medicare source, twenty-five percent from the Social Security Administration Death Master File and less than fourteen percent from Patient Treatment Files. Remaining are from BIRLS and fee basis. This distribution of course changed when death data from NCA is incorporated and in some cases where it will trump the algorithm selected best date of death. 

Multiple dates of death can be one reason for last activity dates that are after the date of the best date of death. We looked at last activity dates in relation to the best date of death on the Mini File and we found that 19.6 percent of Mini File Records with a date of death have healthcare or benefit activity after the best date of death. Also 11.8 percent have healthcare activity specifically. Less than one percent have Medicare activity after death. Activity dates are very reliable, occasionally they may be off by a day due to accounting or other administrative processes, but in general, they are very reliable. 

Some, perhaps the majority of activity after death is attributable to billing cycles of other administrative processes that resulted in activity dates that is actually and legitimately after the date of death. For example the wheelchair that is returned by family after the patient’s death or VA beneficiary claim activity. In other cases, activity after death is due to a problem in the death date. In cases where there is just one death date for an SSN, the date may be wrong because of bad data. Other activity after death may occur when there are multiple death dates for an individual and the dates selected as best comes from a different source than the source for the last activity date.

 The two sources may also disagree in date of birth and/or gender and may be the two records represent different individuals. Regardless of the cause in most cases, the discrepancy in dates is small as show in this table. This table shows data from Medicare activity after the best date of death. This analysis was conducted on records for the death dates before 2010 so that we had enough data to look for activity after death at least one year after the death date. This Medicare activity excludes DME, durable medical equipment claims and unpaid carrier claims. 

The left column is the length of time in months between the best date of death and the Medicare last activity date among Veterans with CMS activity who died in 2009 or earlier. Of those with activity after death, the discrepancy in dates was less than one month in the vast majority, that represents the twenty-three thousand eight hundred seventy-three represents about eighty percent of all those with any activity after death on this table. Very few had activity more than one month, less than or equal to a year after the date of death. Over five thousand or eighteen percent had CMS activity more than a year after the best date of death. 

This slide focuses in on that five thousand three hundred and twenty-nine with activity more than a year after the best date of death. It looks at the source for that best date. The left column shows what files contributed the date of death that the algorithm selected as the best. Percent of AAD, or percent of Activity After Death shows the distribution of the best data sources for all those the CMS activity more than twelve months after the death date. In almost ninety percent of these cases, the best date of death came from BIRLS or the patient treatment file. The right column shows numbers that I showed in a previous slide, it is the distribution of best date of death sources for all records in the Mini File. Clearly, BIRLS is the source for a disproportionate number of the records with activity more than twelve months after death and CTS is also over represented among those with activity long after death. In most cases, this is a function of the algorithm for selecting the best date of death, which gives preference to internal over external dates in certain circumstances. 

So these issues of multiple sets of demographics death dates and activity after death present complexities when using the Vital Status File to ascertain deaths in a research cohort or sample. There are several decisions to be made where we use the Mini the Master File, how will we identify the records for the individuals in our cohort where we merge on SSN only by some combination of SSN date of birth and gender. If it is the latter how conservative will the mass criteria be. In other words, what if any partial matches will be accepted. Mismatched demographics and activity after death are some of the issues that can come up in this regard and there is no one right way to answer these questions and resolve discrepancies. 

Some points to consider are you may find inconsistencies between the VHA Vital Status File Demographics and your Cohort Demographics. To resolve these inconsistencies the Master File will be useful and a note here regarding non-research work, the VHA Vital Status File should not be used for business operations regarding individual Veterans best ascertainment. 

Given all this which files should researchers use? The Mini File is far simpler to use than the Master, but there is a certain amount of guesswork involved in the demographics including the death dates on the file. There is no one right way to use these files. One strategy is to use the Mini File initially to search for deaths matching on the SSN only. Then check the agreement between your patient date of birth/sex or your study subject date of birth/sex and the Mini File record date of birth/sex. If they do not match, it may be worth checking the Master File since there may be a Master File record for that SSN that has a date of birth or sex combination that match the study subject. It is possible that that record also has a different date of death. 

Another scenario where checking the Master File would be a good idea is in cases where the Mini File record indicates activity after death. Look at the date of birth/sex resources that provided death dates. If there is another date of death for this SSN on the file, there is a possibility that there is no activity after that death date. 

Depending on the specific needs of the study, you may want to consider additional, supplementary data sources. Use the National Death Index or State Vital Statistic Offices for cases lost or file loss. Those where there is no death date or no VHA or VBA activity after the end of follow up. Remember the Corporate Data Warehouse may have records of death dates that are not available in the Vital Status File. 

That concludes the substantive part of the lecture and where to go to for more help. Here are some helpful resources. Dorothea Garrett is very knowledgeable about the Vital Status Files and is willing to help. VIReC websites have a lot of this information about the Vital Status Files and the source data. 

Do not forget the HSRData Listserv. If you are not familiar, this is a discussion forum for VA data users. You might be behind the VA firewalls to participate. You can post questions and get responses from people with a lot of experience on HSRdata. Past messages are archived and searchable and you can go to the VIReC website to join. 

Also, VIReC has a help desk and the help desk is happy to answer questions when we can or direct you to where you can get an answer. 

Now I will open it up to questions. 

Heidi:Thank you Doctor Tarlov. We have a couple of questions. Here is the first – you refer to a Mini VSF file and a Master VSF file. Is the Mini file the one inside CDW that is listed on the domain checklist and the Master file in the VINCI database?

Doctor Elizabeth Tarlov:I do not know the answer to that. I am not aware of the Vital Status File, can you hear me? Hello. 

Moderator:I can hear you fine. I am sorry did you hear my question.

Doctor Elizabeth Tarlov:I did, I did. I am not aware of the VHA Vital Status Files either Master or Mini or the crosswalk being in the Corporate Data Warehouse. Maybe there is a copy stored on the VINCI server. I am not aware of that. The death data that I refer to in the Spatient table is not from the Vital Status file. 

Moderator:Great. Can you summarize why to use any other external source other than the SSA Desk Master File?

Doctor Elizabeth Tarlov:Other than the SSA Desk Master File. In what circumstances you would want to do that is it entirely depends on your study. I am just thinking of the SSA Epidemiological Search, which does return a presumed moving status. That can be useful again for the new thing the number of study subjects that need to be classified as having been lost to follow up. That would be one example. Again, it entirely depends on the specific needs of the study. One of those could be the age of study subjects, younger Veterans, the death dates  are less likely to be found in the SSA Death Master File. That may be a reason to go some other sources, say the National Death Index. Those would be a couple of things that I can think of. Of course, if you need cause of death data, that is entirely different story and you would need a National Death Index Data for that. 

Heidi:Great. That is it for the questions that are typed in so far. If any of the attendees have any questions, please type them in now. You can put those in the Q & A screen on the Go to Webinar dashboard, it is on the right hand side of you screen. If it has collapsed against the side of your monitor, just click on that orange arrow in the upper right hand corner to open it back up and just type your questions into the Q & A screen there. 

Moderator:here is another question. Does NDI cost money?

Doctor Elizabeth Tarlov:The NDI data that is here in the VA with the SMITREC does not cost, it has already been paid for shall we say so it would be free to researchers approved to receive the data. NDI data from the National Center for Health Statistics there are fees for that and they can be substantial. 

Moderator:Okay it looks like that is it for questions. If anyone has any further questions, please contact VIReC at VIReC@VA.gov. Thank you to our speaker for developing and presenting today. Please join us for our series on Good Data Practices in September. I hope everyone has a great afternoon. 

Heidi:Thank you everyone for joining us. As you leave today’s session, you will be prompted with a feedback form. If you can take a few moments to fill that out, we will definitely appreciate it. As Erica said we will be having Good Data Practices Series, starting in September and we will send registration information out to everyone as we get closer to that date. Thank you everyone for joining us for today’s VIReC Database and Methods Seminar. We hope to see you at a future session. Thank you. 

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