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82–239 2014

LEGISLATIVE HEARING ON H.R. 1490, ‘VETERANS’ 

PRIVACY ACT;’ H.R. 1792, ‘INFECTIOUS DISEASE 

REPORTING ACT;’ AND H.R. 1804, ‘FOREIGN 

TRAVEL ACCOUNTABILITY ACT’ 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, JUNE 19, 2013 

Serial No. 113–23 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MARK E. AMODEI, Nevada 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

HELEN W. TOLAR, Staff Director and Chief Counsel 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

DAN BENISHEK, Michigan 

JACKIE WALORSKI, Indiana 

ANN KIRKPATRICK, Arizona, Ranking 

Minority Member 

MARK TAKANO, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

June 19, 2013 

Page 

Legislative Hearing On H.R. 1490, ‘Veterans’ Privacy Act;’ H.R. 1792, ‘Infectious Disease Reporting Act;’ and H.R. 1804, ‘Foreign Travel Accountability 

Act’ ......................................................................................................................... 1

OPENING STATEMENTS 

Hon. Mike Coffman, Chairman, Subcommittee on Oversight and Investigations ....................................................................................................................... 1 

Prepared Statement of Hon. Coffman ............................................................. 26 

Hon. Ann Kirkpatrick, Ranking Minority Member, Subcommittee on Oversight and Investigations ...................................................................................... 2 

Hon. Jackie Walorski, Member, Committee on Veterans’ Affairs, U.S. House 

of Representatives, Prepared Statement only ................................................... 27 

WITNESSES 

Hon. Jeff Miller, Chairman, Committee on Veterans’ Affairs, U.S. House 

of Representatives ................................................................................................ 3 

Prepared Statement of Chairman Miller ........................................................ 27 

Hon. Tim Huelskamp, Member, Committee on Veterans’ Affairs, U.S. House 

of Representatives ................................................................................................ 4 

Dr. Robert L. Jesse, Principal Deputy Under Secretary for Health, Veterans 

Health Administration, U.S. Department of Veterans Affairs ......................... 5 

Prepared Statement of Dr. Jesse .................................................................... 28 

Accompanied by: 

Ms. Jane Clare Joyner, Deputy Assistant General Counsel, U.S. Department of Veterans Affairs 

Dr. Timothy F. Jones, Tennessee State Epidemiologist, President, Council 

of State and Territorial Epidemiologists ............................................................ 16 

Prepared Statement of Dr. Jones .................................................................... 30 

Nick McCormick, Legislative Associate, Iraq and Afghanistan Veterans of 

America ................................................................................................................. 17 

Prepared Statement of Mr. McCormick .......................................................... 34 

Paul Etkind, Senior Director of Infectious Diseases, National Association 

of County and City Health Officials ................................................................... 19 

Prepared Statement of Dr. Etkind .................................................................. 36 

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LEGISLATIVE HEARING ON H.R. 1490, ‘VETERANS’ PRIVACY ACT;’ H.R. 1792, ‘INFECTIOUS DISEASE REPORTING ACT;’ AND H.R. 

1804, ‘FOREIGN TRAVEL ACCOUNTABILITY 

ACT’ 

Wednesday, June 19, 2013 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, Washington, D.C. 

The Subcommittee met, pursuant to notice, at 1:30 p.m., in Room 

334, Cannon House Office Building, Hon. Mike Coffman [Chairman 

of the Subcommittee] presiding. 

Present: Representatives Coffman, Roe, Huelskamp, Benishek, 

Walorski, Kirkpatrick, and O’Rourke. 

Also Present: Representative Miller. 

OPENING STATEMENT OF CHAIRMAN COFFMAN 

Mr. COFFMAN. Good afternoon. This hearing will come to order. 

I want to welcome everyone to today’s legislative hearing on H.R. 

1490, the Veterans’ Privacy Act; H.R. 1792, the Infectious Disease 

Reporting Act; and H.R. 1804, the Foreign Travel Accountability 

Act. 

The three bills we will consider today are the result of investigations conducted by this Subcommittee in the course of its oversight 

duties that have reported poor judgment and mismanagement by 

the Department of Veterans Affairs. 

These bills are intended to heighten the protections for our veterans at VA medical centers and prevent the recurrence of problems identified in the investigations. 

H.R. 1490, the Veterans’ Privacy Act, was introduced by the 

Chairman of the Full Committee, Representative Jeff Miller. The 

bill directs the secretary of Veterans Affairs to prescribe regulations to ensure that in the absence of informed consent by the patient or their legal representative and any visual recording can 

only be conducted under limited circumstances such as under a 

court order. 

In April, I introduced H.R. 1792, the Infectious Disease Reporting Act. Based on investigations conducted by this Subcommittee 

as well as a hearing in February, it is clear that VA needs to be 

held to the same standard for infectious disease reporting as its 

health care counterparts in each state. 

The Infectious Disease Reporting Act will require VA facilities 

nationwide to comply with state infectious disease reporting requirements. Once reported to the state, this data will be reported 

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to the Centers for Disease Control and Prevention and used to 

monitor public health. 

Each state faces its own unique challenges regarding infectious 

diseases and the Infectious Disease Reporting Act takes this into 

account. 

It is baffling to me that the University of Pittsburgh Medical 

Center Hospital which sits just a few hundred feet from the Pittsburgh VA Medical Center is required to report infectious diseases 

while the VA hospital is not. 

The news reports from Pittsburgh this last weekend detailing the 

extent of the Legionella problem and that it dates as far back as 

2007 underscore the need for this legislation. 

The fact that VA provided information to reporters that this Subcommittee has been requesting since January is unacceptable. This 

lack of transparency looks like an attempt to evade legislative oversight and makes me wonder whether there is more to the story 

than what VA has chosen to reveal. 

The need for the Infectious Disease Reporting Act is reflected not 

just in the Legionella Disease outbreak in Pittsburgh, just last 

month, almost 20 veterans tested positive for hepatitis A or B after 

a VA hospital in Buffalo admitted to reusing insulin pins on patients. 

Time and again, we have heard from VA that they are industry 

leaders in various areas, but infectious disease reporting, VA does 

not even compete. 

Our final bill today is H.R. 1804, the Foreign Travel Accountability Act, which was introduced by Congressman Tim 

Huelskamp, a Member of this Subcommittee. This bill directs the 

secretary to submit to Congress semi-annual reports on foreign 

travel. The reports will include among other things the purpose of 

each trip, the destination, and the total cost to the department. 

In January, after VA told him the State Department may have 

records on VA foreign travel, Chairman Miller sent a request to the 

State Department for more information. 

Just last week, he received the State Department’s two cents 

reply which referred him back to VA. This ridiculous finger pointing clearly exhibits the need for this legislation. 

It is important that taxpayer dollars appropriated to VA are 

properly spent on providing the care and benefits our veterans 

have earned, not sending VA employees abroad on taxpayer subsidized vacations that do little to improve the care veterans receive. 

I appreciate everyone’s participation in today’s hearing and now 

yield to the Ranking Member for her opening statement. 

[THE PREPARED STATEMENT OF CHAIRMAN COFFMAN APPEARS IN

THE APPENDIX]

OPENING STATEMENT OF HON. ANN KIRKPATRICK 

Mrs. KIRKPATRICK. Thank you, Mr. Chairman. 

Today we meet to hear testimony on H.R. 1490, the Veterans’ 

Privacy Act; H.R. 1792, the Infectious Disease Reporting Act; and 

H.R. 1804, the Foreign Travel Accountability Act. 

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H.R. 1490 seeks to ensure that any visual recording made in a 

VA health care facility is done so with the express permission of 

the veteran. 

H.R. 1792 requires the VA to report any instance of infectious 

disease within medical facilities to the appropriate state entity. 

And the third bill, H.R. 1804, requires that foreign travel of VA 

employees on official business be reported to Congress. 

As the Subcommittee on Oversight and Investigations, it is our 

primary duty to provide oversight of all VA programs and facilities 

to ensure they are run effectively, efficiently, and lawfully. 

Our mutual goal is to deliver the best possible services and protect eligible veterans and their dependents when they are in VA facilities receiving services. 

It is my hope through the oversight process not only to point out 

weaknesses in areas needing attention, but also to back the VA up 

in its mission to care for veterans. 

As times change and new challenges arise, we must work hard 

to provide VA with the tools it needs to be successful and meet 

those challenges. 

I look forward to the witness testimony today to examine how 

the changes embodied in each of the bills can help veterans. 

I thank the witnesses for being here and for answering our questions, and I thank the others who are here today for your interest. 

I yield back, Mr. Chairman. 

Mr. COFFMAN. Thank you, Ranking Member Kirkpatrick. 

We will now hear from our first panel of witnesses. At the dais, 

I am honored to have our Chairman, Jeff Miller, to discuss H.R. 

1490, the Veterans’ Privacy Act. 

Next we will hear from the Honorable Tim Huelskamp from Kansas, who will also be speaking from the dais, who is sponsoring 

H.R. 1804. 

Thank you both for joining us here today. Your complete written 

statements will be made part of the hearing record. 

Chairman Miller, you are now recognized for five minutes. 

STATEMENT OF HON. JEFF MILLER 

Mr. MILLER. Thank you very much, Mr. Chairman. 

Members, it is a pleasure to be here with you again. And you 

may know some of the details of what I am about to tell you, but 

others of you may not. 

Last June, a video camera disguised as a smoke detector was installed in the room of a brain damaged veteran at the James Haley 

VA Medical Center in Tampa. When the veteran’s family discovered the camera, they were understandably upset. 

When asked about the camera, VA officials first denied that the 

camera existed. Then they, in fact, admitted that the smoke detector was, in fact, a camera. Further when asked if the camera was 

recording, VA said, no, it was only there to monitor the patient. 

And only after inquiries by the media and this Committee did VA 

come clean and admit that the camera was, in fact, recording what 

was going on in the patient’s room. Ultimately, VA yielded to the 

pressure and removed the camera. 

When I learned about these events, needless to say, I was 

shocked at VA’s apparent disregard for the privacy rights of its vetVACREP180 with DISTILLER

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eran patients. VA failed to provide any justification for covertly recording this patient in his private room. 

In light of this incident, I asked VA under what legal authority 

did they place the camera in the patient’s room. And VA’s legal 

opinion was that the hidden camera did not, in fact, violate law 

and that they were looking at developing a national policy to address the issue of video surveillance of its patients. 

I have recently been told by VA that they do not intend to have 

this policy in place before September 2013. This is a year after, 

well over a year after I found out that the incident actually occurred. 

So in order to protect the privacy rights of veterans who receive 

medical care from VA hospitals, I have introduced what I call the 

Veterans’ Privacy Act. 

This bill directs the VA to prescribe regulations to ensure that 

any visual recording made of a patient during the course of their 

care by VA is carried out only with the full and informed consent 

of the patient or when appropriate that patient’s representative. 

Now the bill does contain some important exceptions. The secretary would be authorized to waive notice and consent for recordings upon determination by a physician or a psychologist that the 

recording is medically necessary or pursuant to a court order or 

when the recording would occur in a public setting where a person 

would not have a reasonable expectation of privacy such as in a 

waiting room or in a hallway. 

I look forward to working with Committee Members, our veteran 

service organization partners, the VA, and other stakeholders on 

this bill because protecting the privacy rights of patients while they 

are receiving care in VA must be among one of our constant priorities. 

I appreciate Chairman Coffman for holding this hearing today. 

Your hard work and leadership on the Subcommittee of Oversight 

and Investigation is greatly appreciated by me, the Ranking Member, and other Members of this Committee. And I appreciate the 

opportunity to be here with all of you today and I yield back my 

time. 

[THE PREPARED STATEMENT OF HON. JEFF MILLER APPEARS IN

THE APPENDIX]

Mr. COFFMAN. Chairman Miller, thank you so much for your testimony. 

Congressman Huelskamp, you are recognized for five minutes. 

STATEMENT OF TIM HUELSKAMP 

Mr. HUELSKAMP. Thank you, Mr. Chairman. 

It is a pleasure to be here with you today and the other Members 

of our Subcommittee on Oversight and Investigations. I also appreciate representatives from our VSO partners and other interested 

stakeholders to discuss H.R. 1804, the Foreign Travel Accountability Act. 

The bill is very simple and very straightforward and would direct 

the secretary of the VA to submit the House and Senate Veterans’ 

Affairs Committees a semi-annual report on all foreign travel made 

during the previous 180-day period. 

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Each report will be required to include the purpose of the travel, 

destination, name and title of each employee traveling, along with 

the duration and the total cost including transportation, lodging, 

and a multitude of other associated costs. 

I believe providing Congress information about foreign travel by 

VA employees is not an unreasonable requirement. In fact, I think 

receipt of this information is critical to making certain we do our 

job properly here, Mr. Chairman, in providing proper oversight of 

the VA’s expenditure of taxpayer dollars. 

I look forward to working hand in hand with other Committee 

Members, our VSO partners, and other stakeholders including the 

department on this bill as it is discussed this afternoon. I take our 

responsibility of oversight very seriously as stewards of not only 

taxpayer dollars but as stewards and advocates for veterans. I 

think this is a very critical bill. 

And, again, thank you for holding this hearing and I look forward to any questions you might have. And with that, I yield back. 

Mr. COFFMAN. Thank you, Mr. Huelskamp. 

Without objection, in the interest of time, there are no questions 

for the first panel. Any Members wishing to ask questions of the 

first panel may submit them for the record. Without objection, so 

ordered. 

On behalf of the Subcommittee, I thank you both for your testimony. You are now excused except for Mr. Huelskamp. 

I now invite our second panel to the witness table. First we will 

hear from Dr. Robert L. Jesse, Principal Director Under Secretary 

for Health for the Department of Veterans Affairs. 

Accompanying Dr. Jesse is Ms. Jane Clare Joyner, Deputy Assistant General Counsel for the Department of Veterans Affairs. 

Dr. Jesse, your complete written statement will be made part of 

the hearing record and you are now recognized for five minutes. 

STATEMENT OF ROBERT L. JESSE, PRINCIPAL DEPUTY UNDER 

SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY JANE CLARE JOYNER, DEPUTY ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. JESSE. Thank you, sir. 

Good afternoon, Chairman Coffman, Ranking Member Kirkpatrick, and Members of the Subcommittee and Chairman Miller. 

I am pleased to provide the department’s views on each of the 

bills on today’s agenda. Thank you for the opportunity to do so. 

And as you mentioned, today joining me is Deputy Assistant 

General Counsel Jane Clare Joyner. 

Chairman Coffman, we do appreciate your continued efforts and 

those of this Subcommittee to support and improve veterans’ health 

care. 

VA recognizes the importance of addressing the underlying 

issues related to each of these bills and looks forward to continued 

opportunities to work with you and the Members of the Subcommittee and Congress to enhance the impact that each of the 

bills will have on our ability to provide quality health care for our 

Nation’s veterans. 

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I will address a few key points for each bill today and a more 

detailed explanation is in that written testimony. 

To be very clear up front, we do support the intent of each of 

these bills and we will be committed to working with you to craft 

the best solution to meet those intents. 

I will start with H.R. 1490, the Veterans’ Privacy Act. The bill 

concerns video recording of veterans and procedures and is intended to ensure that such recordings are made only with the full 

and informed consent of the patient and his or her representative. 

VA supports the intent of H.R. 1490, too, but believes that the 

bill could be improved so that it does not have unintended consequences that might impair our ability to provide state-of-the-art 

health care that is increasingly dependent on technologies that connect patients and providers. 

Toward that end, we would recommend clarification of the term 

video recording and despite the three important exemptions carved 

out by the bill, the current definition still may have some ambiguity and as such could be open to interpretation. 

Such ambiguity could adversely impact patient care. For example, the term video recording could include certain x-rays, MRIs, 

and other clinical imaging studies such as catheterization, that 

under a strict interpretation could be seen in a way that could prevent such images from being sent remotely via secure channels for 

remote reading. 

VA has made great strides in our use of telehealth modalities to 

connect providers to patients and to other providers in ways that 

improve care across distance and time and we believe clarification 

is needed to ensure that we do not stall the deployment or utilization of such technologies through unintended interpretations of the 

current language in the bill. 

We believe the wording in the bill could actually in some respects 

have the effect of lowering the current standard of care in that it 

would allow a doctor or psychologist to conduct imaging without 

the patient’s consent if they deemed it medically necessary. And we 

are certain that this is not the intent of this legislation. 

So we fully agree with the intent and will work closely with you 

to ensure that the language is as precise and correct as possible. 

The second bill on the agenda, 1792, the Infectious Disease Reporting Act, would require VA to report certain infectious diseases 

that occur in VA medical facilities as defined by each state and according to the laws of the state where the facility is located. 

The legislation authorizes states to file civil actions against VA 

and for payment of penalties. VA absolutely supports that its facilities report infectious diseases to external health authorities in a 

manner comparable to reporting done by non-VA health care facilities. 

VA understands the reporting of selected infectious diseases has 

been widely accepted as mutually advantageous to both health care 

providers and to the recipients of the information. 

Public reporting of designated infectious diseases is necessary to 

inform local, state, and Federal health authorities about the current state of public health and about emerging threats. 

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And, therefore, VA is committed to expanding and making more 

consistent its reporting to the appropriate state and local authorities in a more standardized basis for all reported diseases. 

We believe we can create the assurances and transparency that 

will result in reliable, consistent, and timely compliance with these 

requirements. We believe this effort would be more effective than 

requiring VA, which is a national health care provider, to follow 

specific state law. 

And that would require a significant amount of administrative 

burden. But if the Committee determines it prefers this approach 

of individual state mandates, we do have some technical suggestions on H.R. 1792, which are outlined in the written testimony. 

H.R. 1804, the Foreign Travel Accountability Act, establishes a 

requirement for a semi-annual report of covered foreign travel. VA 

does not object to the idea of providing information to Congress and 

the taxpayers regarding these expenditures. 

However, VA does recommend that H.R. 1804 be amended as 

drafted. The requirements would be burdensome, especially in light 

of improvements made by VA on the amount it spent on foreign 

travel. 

We have exercised considerable restraint with regards to all travel and to be specific, this has resulted in a 40 percent decline in 

the use of medical funding for foreign travel from fiscal year 2011 

to fiscal year 2012. Twenty-five percent of this is for covering out 

of U.S. operations like the clinic in the Philippines. 

So speaking for VHA, we have worked hard to ensure that all 

travel both domestic and foreign is both essential and appropriately 

managed through the Federal travel system which captures all the 

information needed to manage employee travel in a transactional 

manner. 

Thank you for the opportunity to testify before the Committee 

and I would be pleased to respond to your questions or the Members may have at this time. 

[THE PREPARED STATEMENT OF ROBERT L. JESSE APPEARS IN THE

APPENDIX]

Mr. COFFMAN. All right. Dr. Jesse, your testimony suggests VA 

encourages voluntary adherence to state mandated processes. 

If VA is prepared to accept the administrative burden associated 

with voluntary adherence, why is it prepared to accept the burden 

of mandated adherence to state reporting requirements? 

Dr. JESSE. I am sorry. I am not sure I understood. 

Mr. COFFMAN. Well, I think that is written. I am sorry. 

Dr. JESSE. Can I answer what I think you are asking? 

Mr. COFFMAN. Well, okay. So, yeah, go ahead. 

Dr. JESSE. Okay. So I think VA does not have a problem with 

reporting to states. And, in fact, the history is actually of us coming 

to you to ask for a legislative relief to allow that to happen. 

Mr. COFFMAN. Uh-huh. 

Dr. JESSE. Recent examples, as you would remember, are the reporting to the state prescribing counsels that engages VA in the 

monitoring particularly of opiate prescriptions and before that to 

report to the state cancer registries. 

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And so there are privacy rights built into the Title 38 legislation 

that all have to be considered and, I think, readdressed to do this. 

So whether we do it, you know, through legislation or whether 

we do it voluntarily, the burden is only that each state is different 

and making sure that we do that in a state-by-state way creates 

just—it is complex, but we will do it. We have done it in the past. 

We have proven that we are committed to doing so. 

Mr. COFFMAN. So you are not opposed to it? 

Dr. JESSE. No, no, no. 

Mr. COFFMAN. Okay. 

Dr. JESSE. Not at all. 

Mr. COFFMAN. Just wanted to make sure. 

Okay. Then let’s see. Dr. Jesse, in your testimony, VA states that 

H.R. 1792 would, quote, create administrative burdens by requiring 

compliance with many different state laws. I just think you answered that, so let’s skip that one. 

Ms. Joyner, VA has indicated that it has a legal basis for covert 

visual recording in patient rooms. 

Can you please describe the department’s purported legal authority in this regard? 

Ms. JOYNER. Well, I think any analysis would have to start with 

the Fourth Amendment, you know, the unlawful search and seizure. We would look at the case law which talks about the need 

for a particular search, the scope of the search, the manner in 

which a search would take place, and then, of course, the place of 

the search. 

I think if, my recommendation, if a facility wanted to do a covert 

observation would also be to talk to the assistant U.S. attorney just 

to discuss what was planned as well. 

Mr. COFFMAN. Okay. Mr. Miller. 

Mr. MILLER. So it begs the question in the Tampa facility, was 

that procedure followed? 

Ms. JOYNER. I am not sure. I can find that out for you and give 

it for the record. 

Mr. MILLER. Okay, because it has been a year. And I would hope 

that since this apparently is the only incident of its type that has 

occurred within the system that—and, again, we want to work—I 

do want to work with VA to solve this problem because obviously 

they felt there was a need. And I understand what the director 

says the need was. 

And so if you would take that for the record, I would appreciate 

it. 

Mr. COFFMAN. Ranking Member Kirkpatrick. 

Mrs. KIRKPATRICK. Thank you. 

Doctor, does HIPAA have an exemption for public health reporting where health staff is able to identify a person affected by a disease? 

Dr. JESSE. I am not absolutely positive about HIPAA, though I 

do know that we can report the—I think the legislation that gets 

in the way is not HIPAA. It is ours. It is the 5701 and 1733 part 

of Title 38. I hope I said that correctly. 

But I am not sure that HIPAA does because these are requirements for managing patients and generally one has a business reVACREP180 with DISTILLER

9 

lationship. There is a memorandum of understanding between the 

facilities and the state health departments that exist. 

And, in fact, those state health departments then, it is the authority and that is MOUs with the state health authorities that the 

CDC comes in under when they come in as part of an investigation. 

So I am not sure that HIPAA is the issue here, but you could 

probably answer that better. 

Ms. JOYNER. As we said in the testimony, the real stumbling 

block is Title 38 and it is similar to the changes that Congress 

made with regard to, as Dr. Jesse said, the state prescription monitoring programs. So it is 5701 and it is 7332 of Title 38. And so 

changes to that would make the process of reporting easier. 

Mrs. KIRKPATRICK. Well, Doctor, I have a concern. In your written testimony, you say there is a possibility that in reporting infectious diseases that personal information could be released. And so 

I just want to pursue that with you. 

How could that happen? 

Dr. JESSE. So I think the context of that was and one of the reasons why we were so fastidious back on the reporting to the state 

cancer registries, because it turned out that some of those registries were, in fact, releasing patient level information and patients, VA patients, veterans, were being contacted by outside entities saying we understand you have cancer and we would like to 

help you. And that release as it turned out was coming somehow 

through the state authority. So we need, in terms of protecting our 

patients, we need to make very certain that when we release data 

to outside entities that there are clear agreements about how that 

data will be managed and kept private and protected. 

Mrs. KIRKPATRICK. So that is going to require an MOU with all 

of these different agencies? 

Dr. JESSE. Yeah. Generally it requires an MOU and with very 

specific statements about how data get handled, yes. 

Mrs. KIRKPATRICK. My other concern is the number of reports the 

VA has to make to Congress. 

Do you know how many of those reports are mandatory? 

Dr. JESSE. I have no idea. 

Mrs. KIRKPATRICK. Do you have any idea about the cost of that 

reporting? 

Dr. JESSE. I do not know about the cost, but I do know it requires extensive resources at times in order to compile information, 

particularly when that information is not retrievable out of an existing data set. 

So when we have to do things manually it takes an incredible 

amount of time and an incredible amount of person hours to do 

that. And it just depends on how big the request is. 

Mrs. KIRKPATRICK. Can you get back to me with that information? 

Dr. JESSE. I can try, certainly, yeah. 

Mrs. KIRKPATRICK. And also because now you are under the state 

reporting plan and the District of Columbia. So you have 51 reports 

you have to prepare. 

And are you advocating then for just one central reporting place 

so that you do not have to do all 51 states and the District of Columbia? 

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Dr. JESSE. Yeah, that is a great question. I actually asked that 

myself because it would be easier for us. The CDC annually puts 

out a list of reportable diseases and to my mind, it would seemingly be more straightforward to report directly to the CDC. 

But the answer that I got, and our infectious disease and public 

health people all agree with this, is that the public health knowledge base needs to be at the local level as quickly as possible. 

And so that is why it has been established that that reporting 

comes through local and state authorities and then rolls up to the 

CDC rather than going straight to the CDC and then going back 

down. 

It would be easier for us if we had an annual list from CDC of 

what needs to be reported and can report directly to them. The concern from the public health folk including ours is that bypassing 

the local authorities may actually create an asymmetry of information at their level where they need it most. 

Mrs. KIRKPATRICK. Okay. Thank you, Doctor. 

I yield back. 

Mr. COFFMAN. Mr. Huelskamp. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. 

I want to follow-up on a couple items. Dr. Jesse, you mentioned 

the incidents where cancer patients had been solicited by outside 

companies. 

Were you able to determine exactly where they had received that 

information with certitude? 

Dr. JESSE. I do not remember the precise details, but we did 

know it had come through a release from one of the state boards. 

Now, whether that was voluntary or accidental, I do not know. But 

it certainly redoubled our efforts to get the appropriate legislative 

relief to allow that to happen. 

Mr. HUELSKAMP. Okay. I appreciate that. And as you recall, the 

Committee had a hearing, I believe two weeks ago, about the VA 

database and 20 million veterans and personal medical information 

that was potentially hacked and many details of follow-up on that. 

One question I had at that hearing which did not get answered, 

and I do not know if I submitted it, was the follow-up that apparently the department provides credit monitoring services for those 

they believe whose information had been hacked. 

Do you know and can you provide, and I am sure you can, how 

many folks that you provided and identified that needed that service? 

Dr. JESSE. The hacking that you are referring to, I do not know 

about because, frankly, I cannot say that we know who was. 

When we have a breach of information and we have had, as you 

know, you get monthly reports on these, we do provide credit monitoring to people who we believe that their information, particularly 

Social Security numbers, have been compromised. 

And I am sure we can tell you that. That is a matter of record 

because I think we report that to you on a monthly basis. But I 

do not know any incidents from the recent hearing and the talk 

about being hacked. I just do not know. 

Mr. HUELSKAMP. Yeah. And you might. It was in quite a few of 

the local newspapers and made reference to that and state sponsored actors in the database and information that was encrypted 

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on the way out. And so, yeah, I would like to see what numbers 

of those you have identified as potentially having that problem. 

The second question would be, you do note in your testimony 

that H.R. 1792 would, quote, create administrative burdens by requiring compliance with many different state laws. As I understand 

it, every private facility has to meet these requirements. 

Are you saying the VA should be exempt from these requirements when private facilities are not? I do not understand. 

Dr. JESSE. And I think that actually comes back to the Ranking 

Member’s question. Would the reporting on a national level 

through one central authority be easier and more straightforward. 

From a national level, we have to look across 50 states and the 

District of Columbia and maybe even some out of U.S. areas of operation, Puerto Rico, Virgin Islands, Philippines, for instances. And 

all of those states have themselves individual regulations and 

methods of reporting. 

Now, the facilities in those states will know them and in many 

cases are already complying with those state regulations. It is difficult to manage on our perspective because we have got to get 

these up-feeds from every individual facility. 

And one of the challenges is, well, is that remember the structure of the VA in terms of particularly the regional, the VA medical 

centers that do the more complex things often pull from multiple 

states. 

So in VISN 6 which is Virginia, West Virginia, and North Carolina, the patient seen in Richmond would be coming from other 

states on a regular basis. 

And then, you know, how does that information then get back to 

the state where the patient resides? And in that case, so I have 

asked this question, and apparently that is something that the 

state health authorities would do on a point-to-point basis. 

But then it becomes kind of out of our hands. And so that from 

a single national reporting perspective, there may be some sense of 

that. But, again, I am told that reporting locally is probably the 

most important thing and then entrusting the states when they 

know the state of residence is different than the state of diagnosis 

to get that information back. 

Mr. HUELSKAMP. Yeah. I appreciate that difficulty and I think it 

is becoming clear as we look at some of the proposed regulations. 

HHS for the President’s health care plan, that would require, I believe, the VA to provide information to the national database and 

this hub. And then that is part of that. 

You are going to have to provide that for the hub already; is that 

correct? 

Dr. JESSE. We are going to provide it through these hubs, yes. 

Mr. HUELSKAMP. Yeah. Okay. 

Dr. JESSE. So it is, yeah, it is—— 

Mr. HUELSKAMP. How far along are you? Are you ready to implement that by January 1st as required under the law or not? 

Dr. JESSE. Well, I cannot say for certain, but I would sure hope 

so. 

Mr. HUELSKAMP. Yeah. Well, the law is pretty clear. 

Dr. JESSE. Yeah. 

Mr. HUELSKAMP. There is no hope so. That is a requirement. 

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One other thing, for your superiors, I have 23 outstanding questions from early September that are basic budget data and they 

have yet to answer those questions. 

And it is pretty hard to hear you mention a monthly report that 

you are providing information, when I have outstanding questions 

submitted through the Committee that you all have refused to answer, Dr. Jesse, so you might ask your superiors in the budget division about that. 

Dr. JESSE. I will do that. 

Mr. HUELSKAMP. I yield back. 

Mr. COFFMAN. Thank you, Mr. Huelskamp. 

Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

On the subject of infectious disease reporting—— 

Dr. JESSE. Yes, sir. 

Mr. O’ROURKE. —for the veteran in the community that I represent in El Paso, Texas, if he wants to find out about a potential 

outbreak, for example, in the VA clinic in El Paso or one of the regional hospitals that serve that population there, how would he go 

about doing that? How is that information made available to the 

public and to the veterans that we serve? 

Dr. JESSE. So that question can be asked of the local facility. And 

every VA facility has an infection control nurse who has a tie to 

the national infectious disease program. 

But it is the job of that person to keep track of all of the infections, both the ones, as you might guess, coming through the emergency department like flus because these get reported up as well 

as hospital acquired infections which, as I am sure you know, this 

health care system, the entire country is working hard to eliminate. 

But that information is available at the facility and then when 

reported, when the reportable diseases go out, that can be received, 

gotten from the local health authorities as well, who will know by 

hospital, who that is. 

I am presuming that they release it by facility, but they do know 

it for the community. But the VA information is transparent. In 

fact, we report our hospital acquired infections through a Web site 

run by HHS called Hospitals Compare. 

And the problem with that is that that data set, the HHS data 

set is about 18 to 24 months in lags. So VA has a mirror site which 

is called VA Hospitals Compare where we report our data currently 

and both are publicly facing Web sites. 

And we also have a Web site called ASPIRE and ASPIRE is 

named because we do not report how we are doing relative to other 

people. We report how we are doing relative to what the expected 

outcome, our expectations of the outcome should be. 

So, for instance, we do not believe it is sufficient to be in the top 

ten percent of people with hospital acquired infections. We believe 

they should be zero and our reporting and how it appears in ASPIRE looks at that. 

So those are publicly facing Web sites. You can drill down to 

every facility and they are available as well. 

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Mr. O’ROURKE. Great. And just to be clear, I think you have 

touched on this, but what is the lag time between an outbreak and 

when that is reported on these publicly facing Web sites? 

Dr. JESSE. So the publicly reported go up monthly, I believe. It 

may be quarterly, but I believe it is monthly. 

But when you say an outbreak, when incidents—and so in public 

health terms, it is the difference between incidents and prevalence 

meaning incidents is each individual event. And those should be reported as they occur. And then the prevalence is essentially what 

is there at the time. And so you are looking at two different things 

and need to be a little bit cautious of what you are looking at. 

So an outbreak would imply a cluster of incidents in a period of 

time as opposed to events that occur over a longer period of time 

where you are aggregating them. 

Mr. O’ROURKE. Okay. And then I do not have the specific information that Chairman Miller was referring to in terms of covert 

surveillance within VA facilities, but wanted to know if you or Ms. 

Joyner could describe a scenario in which that would be appropriate. And I guess I am mostly interested in being able to be responsive to veterans that I represent. 

Would that ever take place in the examination room where I 

think someone could arguably have an expectation of privacy? 

Dr. JESSE. So the broad answer is it should not. Now, there was 

a time when the Joint Commission, I believe, and this does no 

longer exist, but there was a standard that said patients that were 

being monitored, meaning EKG monitoring in ICUs, should be in 

direct line of sight of the nursing station. And if not, they had to 

have video cameras to look at them. 

That no longer exists, but the Joint Commission does have a 

standard that says if you are recording a patient, the patient has 

to be aware of it and signed consent on that. 

I cannot think of an incident where we would do covert surveillance as any matter of routine. 

Mr. O’ROURKE. Or without a warrant—— 

Dr. JESSE. Without a warrant, yeah. 

Mr. O’ROURKE. —in a place where—— 

Dr. JESSE. As I said—— 

Mr. O’ROURKE. —someone has a reasonable expectation? 

Dr. JESSE. Yeah. I just cannot come up with an instance where 

we would want to do that. 

So an interesting thing is we do now have essentially a tele-ICU. 

And what happens in these is there is a control station that has 

physicians, intensivists, and nurses literally one state covering— 

one place can cover a broad geographic area. 

And all of those patients who are being remotely monitored, 

there is a camera in those rooms, actually a very high-fidelity camera that allows the physician in the remote site literally almost to 

do a physical exam. 

Mr. O’ROURKE. But not covert? 

Dr. JESSE. But it is not covert. And people who are in those systems, they are well aware that this is an ICU space that is monitored by a tele-ICU operation, markedly improves patient safety. 

It is a great force multiplier for high-level intensivist care in 

places where we simply do not always have that standard. But it 

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is not covert. Your question about covert, I just cannot imagine 

something that would not require a warrant. 

Mr. O’ROURKE. Okay. Thank you. 

Thank you, Mr. Chair. 

Mr. COFFMAN. Dr. Benishek. 

Mr. BENISHEK. Thank you, Mr. Chairman. 

Ms. Joyner, the VA raised a legal objection to the waiver of sovereign immunity in the bill because it would subject VA to the 

same civil penalties that would be imposed against other medical 

facilities in the state for failing to report. 

Why is that an unreasonable request? 

Ms. JOYNER. I think it probably came down to the use of fiscal 

monies to be spending it to that rather than directly to patient 

care. 

Mr. BENISHEK. Well, it is just that it seems to me that sometimes 

there is, you know, noncompliance and we are just trying to think 

of a compliance motivator, I guess—— 

Ms. JOYNER. Uh-huh. 

Mr. BENISHEK. —because I know in my experience it seems 

sometimes that things do not just get done. I know Dr. Jesse and 

I have had conversations in the past about, you know, the response 

to IG reports—— 

Ms. JOYNER. Uh-huh. 

Mr. BENISHEK. —that do not get done, you know, and you agree 

with that report. And they say they are going to do it and it never 

happens. And nobody seems to be responsible. Those are the kind 

of issues I think that are in the legislation trying to fix that. 

Dr. Jesse, do you have a comment on that? 

Dr. JESSE. Other than what Ms. Joyner said, I guess the one 

question is, does that binding authority that the state health authorities, the local health authorities have over the non-VA hospitals. Is it used often and does it have an effect? 

Mr. BENISHEK. Yeah. I mean, everybody wants the money to be 

used for patient care. I mean, even the state facility, you know, 

that would be fine. I think it is a method of compliance. I do not 

know exactly a better way of inducing compliance with regulations 

or the IG requests that we have seen in the past, but trying to figure out a way of doing that. 

Dr. JESSE. The attention of this Committee is a pretty good way 

to get—— 

Mr. BENISHEK. Well, I know, but just need to work in the sense 

of the issue that we brought up before with, you know, the doctor 

plan within the VA, the IG report. You know, there was 30 years 

of no plan with eight IG reports, you know, asking for a plan. So 

I still have not seen, you know, that plan. But I guess that is the 

best answer that I can get here today. 

Let me ask you another question. Can you explain what information is contained in the data submitted to the e-government travel 

service system? What kind of data is there? 

Dr. JESSE. So in what is called fed travel or the electronic Federal travel system, the first thing that has to go in there is actually, I guess the equivalent of a travel order, so who is the traveler 

and where are they going and why. And then all of the travel arrangements get made through that. 

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So you can see who flew where, what the cost of the flights were. 

It is in there. I do not think it captures hotels. Well, it captures 

it in terms of cost because when the travelers submit their travel 

reimbursements, all the receipts get in, get photocopied, get forwarded and sent somewhere. They are sent in. 

So you actually have a line-by-line accounting of the cost of the 

trip and you have in there at the higher order of where the trip 

was to and for what purpose and who was the traveler. 

Mr. BENISHEK. And is that filled out by the traveler then or the 

supervisor or—— 

Dr. JESSE. So it has to be approved by a supervisor. Somebody 

has the approving authority for each person who travels who is the 

supervisory function. And then the reports are filed on return of 

the trip. And they then get reviewed. 

So if I travel and then that gets submitted, it comes back and 

says it is under review. When it gets signed off, it will then close 

it out. And then any out-of-pocket expenses that I had would then 

get reimbursed. So until that is signed off, it does not get reimbursed. 

So, you know, we have worked very hard in VHA to ensure that 

fed traveler is used on a consistent basis for both domestic and foreign travel. And that way the information is captured as part of 

the transaction, as part of doing the work, and does not require 

somebody to go back, pull paperwork, review things, and, frankly, 

have the opportunity to miss a lot. 

So having it done through this way we think is important. One 

way or the other, it is important. 

Mr. BENISHEK. All right. Thank you. My time is up. 

Mr. COFFMAN. Mr. O’Rourke, do you have any further questions 

for this panel? 

Mr. O’ROURKE. No questions. 

Mr. COFFMAN. Very well. Thank you all for your testimony. And 

then the panel is dismissed. 

And we are going to have to recess for votes. Thank you. 

[Recess.] 

Mr. COFFMAN. I now welcome our third panel and final panel to 

the witness table. On this panel, we will hear from Dr. Timothy 

Jones, Epidemiologist for the State of Tennessee and President of 

the Council of State and Territorial Epidemiologists; Mr. Nick 

McCormick, Legislative Associate for the Iraq and Afghanistan Veterans of America; and Dr. Paul Etkind, if I am saying that right, 

Etkind, Senior Director of Infectious Diseases, National Association 

of County and City Health Officials. 

All of your complete written statements will be made part of the 

hearing record. 

Dr. Jones, you are now recognized for five minutes. 

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STATEMENTS OF TIMOTHY F. JONES, TENNESSEE STATE EPIDEMIOLOGIST, PRESIDENT, COUNCIL OF STATE AND TERRITORIAL EPIDEMIOLOGISTS; NICK MCCORMICK, LEGISLATIVE ASSOCIATE, IRAQ AND AFGHANISTAN VETERANS OF 

AMERICA; PAUL ETKIND, SENIOR DIRECTOR OF INFECTIOUS 

DISEASES, NATIONAL ASSOCIATION OF COUNTY AND CITY 

HEALTH OFFICIALS 

STATEMENT OF TIMOTHY F. JONES 

Dr. JONES. Good afternoon, Mr. Chairman, Ms. Kirkpatrick, and 

Members of the Subcommittee. 

As you have heard, I am Tim Jones, the State Epidemiologist in 

Tennessee and I represent the Council for State and Territorial 

Epidemiologists for CSTE. 

CSTE represents more than 1,100 members of the epidemiology 

and surveillance workforce and health departments who work on 

the front lines of public health to investigate and control communicable diseases. 

I am pleased to offer this testimony on your legislation to 

strengthen infectious disease reporting by the U.S. Department of 

Veterans Affairs. 

A hundred and thirty-five years of infectious disease reporting in 

the U.S. has culminated in the national diseases surveillance system that we use today. This surveillance system gives public health 

officials powerful capabilities to monitor the spread of diseases 

across the United States. 

As the voice of our Nation’s epidemiologists, CSTE is responsible 

for defining which diseases and conditions are reportable in states 

and which will be voluntarily reported to CDC. 

Effective public health surveillance begins with the local and 

state health departments. Mandatory disease reporting of individual patients is thus governed by state and local laws. 

A critical step in the ability to respond appropriately to outbreaks and other threats is the prompt notification of public health 

authorities on diseases posing a potential risk to our communities. 

Virtually all health care providers in all states are required to 

report communicable diseases to their local health authorities for 

additional investigation. 

Unfortunately, VA health care facilities do not always follow 

these rules which has led to some substantial problems that have 

been averted were this not the case. 

The outbreak of Legionnaires’ Disease associated with a VA hospital in Pennsylvania highlighted the importance of a prompt and 

thorough response to disease control. Unfortunately, it was not an 

isolated incident. 

I have personal experience with other examples of sub-optimal 

coordination of disease reporting with VA institutions. I have been 

involved in investigations of known outbreaks in which the state 

health department’s participation in a foodborne outbreak in a VA 

hospital was abruptly curtailed because of concerns about jurisdictional authorities. 

Lack of tuberculosis reporting has hampered control efforts outside a VA hospital. Failure to report an infection control lapse in 

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a VA hospital made it very challenging for us to respond to inquiries from the community. 

We have learned indirectly and unofficially through personal acquaintances of a dramatic cluster of illnesses associated with preparation of medications in a health care institution and it unfortunately resulted in several cases of blindness that may have been 

prevented with mandated reporting to public health authorities. 

To be clear, I do not mean to imply that I think that any of these 

examples reflect purposeful avoidance of responsibilities. To the 

contrary, I know that in many of these situations, well-meaning VA 

staff were as frustrated as we were about the effective variable interpretations of the applicability of state health laws in these Federal institutions. 

CSTE has reviewed the current versions of the VA reporting bills 

and we are heartily supportive of your efforts. Federal legislation 

will enhance VA reporting to the national surveillance system and, 

thus, is in the best interest of public health. 

We feel strongly that it is best to craft legislation in such a way 

that mandates VA hospitals comply with state laws which will ensure that they remain on equal footing with all health care facilities as these rules evolve over time. 

We believe that if VA facilities comply, many outbreaks will be 

detected, investigated, and stopped earlier than they may be otherwise. 

In addition, no patient of any health care institutions is a resident of an encapsulated universe. Patients, staff, and families are 

active members of the communities surrounding those facilities and 

their inevitable interactions have important public health implications both inside and outside of those facilities. 

It is impossible to separate a health care facility from its community. Public health law must acknowledge this and facilitate and 

require VA health care facilities to follow the same laws that govern all other institutions in our states and which protect the health 

of us all. 

Thank you for the opportunity to testify today, and I am happy 

to address your questions. 

[THE PREPARED STATEMENT OF TIMOTHY F. JONES APPEARS IN THE

APPENDIX]

Mr. COFFMAN. Mr. McCormick, you have five minutes to deliver 

your remarks. 

STATEMENT OF NICK MCCORMICK 

Mr. MCCORMICK. Thank you. Mr. Chairman, Ranking Member 

Kirkpatrick, thank you for holding this important meeting this 

afternoon. 

On behalf of Iraq and Afghanistan Veterans of America, I would 

extend our gratitude for being given the opportunity to share with 

you our views and recommendations regarding these important 

pieces of legislation. 

IAVA is the Nation’s first and largest non-profit, nonpartisan organization for veterans of the wars of Iraq and Afghanistan and 

their supporters. Founded in 2004, our mission is important, but 

simple, to improve the lives of veterans and their families. 

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With a steadily growing base of over 200,000 members and supporters, we strive to help create a society that honors and supports 

veterans of all generations. 

IAVA believes that effective oversight of veteran issues is integral to the successful implementation of policy and to delivery of 

services that affect the lives of America’s veteran population. 

The men and women who volunteered to serve in our Nation’s 

military enter into a unique agreement of trust with their government. This trust mandates persistent oversight of and when necessary deliberate investigation into the agencies and mechanisms 

charged with delivery of services to this unique population. 

IAVA is, therefore, pleased to lend its support and endorsement 

of these three pieces of legislation pending before the Committee. 

Regarding H.R. 1490, IAVA supports the Veterans’ Privacy Act 

which would ensure that any visual recording made of a patient 

during the course of care through VA is conducted only with the 

consent of that patient or in appropriate cases a representative of 

the patient. 

There are undoubtedly certain circumstances that may warrant 

the installation of monitoring devices in patient rooms for the safety of both patients and staff or to monitor patients’ behavioral activity just as heart and respiration monitors are often needed to 

monitor a patient’s physiological activity. 

However, IAVA believes that veterans and/or their family members who are receiving medical treatment at VA facilities or their 

representatives should be notified of the facility administration’s 

intent in consultation with the medical professionals directly involved in delivering care to place cameras and/or other monitoring 

equipment in a patient’s room and no such action should be undertaken without the express consent of the patient or their representative. 

Regarding H.R. 1792, IAVA also supports the Infectious Disease 

Reporting Act which would direct the secretary of Veterans Affairs 

to report each case of reportable infectious disease that occurs at 

a medical facility of the VA to the appropriate state entity as well 

as the accrediting organization of such facility. 

Had this bill been law at the time of the outbreak of Legionnaires’ Disease at the O’Hare and Oakland campuses of the VA 

Pittsburgh Healthcare System in 2011 and 2012, the number of infected people could potentially have been far lower. 

Indeed, the CDC’s after action report on this incident indicated 

that poor communication and procedural missteps in the VA Pittsburgh system were just as much to blame for the outbreak as the 

bacteria itself. 

Our veterans have been taught the ability to communicate effectively as one of the most essential characteristics of good leadership 

and is necessary to mission success. 

IAVA fully supports the Infectious Disease Reporting Act because 

it represents the kind of common sense communication policy that 

American veterans deserve with regard to their health care. 

And, finally, regarding H.R. 1804, IAVA also supports the Foreign Travel Accountability Act which would direct the secretary of 

Veterans Affairs to report semi-annually to the Congressional Veterans’ Committees on official foreign travel made by VA employees. 

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These individuals are on the front lines of assisting American 

veterans and their family members with health care issues, educational benefits, and disability claims, and IAVA commends these 

employees for their work. 

However, according to VA reports produced to this Committee, 

VA employees have taken over 1,300 trips for unspecified or unacceptably vague purposes. 

From the Internal Revenue Service to the General Services Administration, government spending scandals have become much too 

common in occurrence. 

The responsibility of the VA to support the Nation’s veterans necessitates the VA be held to the highest ethical standards with regard to the management of public funds. Many of America’s veterans and their families are experiencing great financial hardship 

while waiting for the disability claim to be processed and many of 

them are waiting while they struggle to cope with the physical, 

emotional, and mental scars of war. 

IAVA supports the Foreign Travel Accountability Act because our 

veteran members understand better than most that every penny 

counts and every penny should be accounted for. 

Mr. Chairman, we at IAVA again appreciate the opportunity to 

offer our views on these important pieces of legislation and we look 

forward to continuing to work with each of you, your staff, and the 

Subcommittee to improve the lives of veterans and their families. 

Thank you again for your time and consideration. 

[THE PREPARED STATEMENT OF NICK MCCORMICK APPEARS IN THE

APPENDIX]

Mr. COFFMAN. Thank you, Mr. McCormick. 

Now, did you serve in Iraq or Afghanistan or—— 

Mr. MCCORMICK. I served in Iraq, Mr. Chairman, in 2008. 

Mr. COFFMAN. With what branch of service? 

Mr. MCCORMICK. The U.S. Army, sir. 

Mr. COFFMAN. Thank you for your service. 

Dr. Etkind, you have five minutes. Thank you. 

STATEMENT OF PAUL ETKIND 

Dr. ETKIND. Thank you for this opportunity to speak with you 

today. 

My name is Paul Etkind. I am Senior Director of Infectious Diseases at the National Association of County and City Health Officials or NACCHO and a former epidemiologist for the Massachusetts Health Department as well as for the City of Nashua, New 

Hampshire. 

NACCHO is a membership organization comprised of the Nation’s 2,800 local health departments. The city, county, metropolitan district, and tribal departments work every day to ensure the 

safety of the water we drink, the food we eat, the air we breathe, 

and to protect every resident from disease and disaster. 

Chairman Coffman, NACCHO and local health departments 

across the country recognize and appreciate your leadership on this 

issue of disease reporting to Federal, state, and local health authorities. 

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NACCHO is pleased that the Subcommittee is considering the 

Infectious Disease Reporting Act or H.R. 1792. The bill directs the 

secretary of Veterans Affairs to report each case of reportable infectious diseases that occurs at a medical facility of the Department 

of Veterans Affairs or the VA to the appropriate state entity as 

well as to the accrediting organization of such facility. 

The bill is an important step to ensuring coordination between 

state and local health departments and the VA health care facilities located within their jurisdictions. 

NACCHO believes it is critical for disease surveillance, identifying disease outbreaks, and recognizing disease trends in a community that reportable disease notices go to the health department 

of the county or the community where the person with this diagnosed disease or condition resides. 

Each state has its own legal mandates for what is reported and 

to whom, but there is a robust system of notification and referral 

between the states and between the states and their local health 

departments. 

Even if a VA facility is a regional reference institution that 

draws patients from different states and locales, this notification 

and referral system will assure that the right locale will be rapidly 

informed and prevention follow-up will be instituted. 

Although there are variances in the reporting conventions between some states, often the first responders to a notice of a reportable disease is at the local health department. 

The impact of prevention and control activities which are the result of case investigations are enhanced when cases are reported 

earlier. 

The VA is one of the largest medical care systems in our Nation. 

Their facilities are an important part of the health care provider 

network in our Nation’s communities and are, therefore, important 

to public health surveillance as well as to disease prevention activities. 

In December 2012, NACCHO wrote the VA urging they reaffirm 

the importance of achieving timely and complete reporting of reportable diseases and conditions from all its health care facilities. 

Local health departments around the country have varying relationships with these facilities. Whether a VA reports notifiable disease to the health department should not be dependent upon individual relationships. Rather, it should be established as a systemwide expectation. 

Unfortunately, health care associated infections such as those 

that occurred at the Pittsburgh VA are far too common. Since 2001, 

more than 150,000 patients have been potentially exposed to hepatitis B, hepatitis C, and HIV due to unsafe medical practices in 

American health care facilities. 

We believe this legislation is an important step to ensuring that 

possible health care associated infections are reported and investigated as early as possible. 

The bill calls for penalties for non-reporting. In practice, penalties are rarely assessed for cases that are not reported. This puts 

the health department and the physician or medical facility into an 

adversarial position which most health departments prefer not to 

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do since it may negatively affect future dealings between those entities. 

NACCHO recommends the VA health facility be subject to the 

same penalties as a medical facility not owned by the Federal Government. It keeps the option of a financial penalty open, but opens 

the institution up for other penalties which or remediation strategies which some states may have on their books. 

The bill has the added importance of facilitating the formal entrance of a large medical care facility or system into the Nation’s 

public health surveillance and care system. NACCHO has no doubt 

that this will be positive for disease prevention and will provide a 

formal mechanism for developing relationships between the VA at 

all levels and public health authorities at all levels. 

This will not only help with disease prevention and control, but 

these relationships are the bedrock of responding to and mitigating 

the effects of any kind of emergency that a community, a state, or 

our Nation might encounter. 

Chairman Coffman and Ranking Member Kirkpatrick, thank you 

again for your attention to this important public health issue. 

NACCHO looks forward to continuing to work with you to address 

this issue as the legislation moves forward. 

If you have questions about this statement, please do not hesitate to contact me whether it is here or you have my email as well 

as my phone number. Thank you so much. 

[THE PREPARED STATEMENT OF PAUL ETKIND APPEARS IN THE APPENDIX]

Mr. COFFMAN. Thank you all for your testimony. 

Dr. Etkind, your organization, NACCHO, I just want to clarify 

this, it recommends amending the bill to require reporting diagnosed cases of infection rather than merely those occurring at a VA 

medical facility? 

Dr. ETKIND. That is right. We believe that the cases should be 

reported as they are diagnosed. If they are occurring at a medical 

center, it could be somebody who comes in with that or it may not 

be a new infection. I think the clarity is greater if it is when the 

diagnosis is made. Then it is considered to be a new case. 

Mr. COFFMAN. Is this because of the time sensitive nature in 

terms of public health of being able to respond as a—— 

Dr. ETKIND. The sooner we know post diagnosis, then the more 

effective we can be in terms of preventing other cases whether they 

are community-based or helping the institution to prevent further 

cases. 

Mr. COFFMAN. Okay. Dr. Jones, in your testimony, you mentioned your involvement in outbreaks at VA hospitals in which a 

state’s health department participation was abruptly curtailed due 

to concerns about jurisdictional authorities. 

Can you elaborate on this a little further? 

Dr. JONES. Yeah. That was an unfortunate example. We knew 

that there was a gastroenteritis foodborne outbreak in a VA hospital. It was reported to us. We had developed a questionnaire. We 

had a team there that had had their briefing sitting around the 

table in the facility and were just starting to go down the hall to 

interview patients when someone came in, whispered into the ear 

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of the infection control nurse, and he said I am sorry, you are going 

to have to leave. 

And it was some invisible person’s interpretation that all of a 

sudden the state did not have jurisdiction there. 

Mr. COFFMAN. Okay. Do you think under current law, were they 

right, though? Did the state have jurisdiction? 

Dr. JONES. No. I mean, the VA’s testimony—— 

Mr. COFFMAN. Okay. 

Dr. JONES. —says that VA does not have to comply. 

Mr. COFFMAN. Right. 

Dr. JONES. I think there is a lot of crossed wires in terms of interpreting whether or not facilities have to comply depending on 

the institution. 

Mr. COFFMAN. Okay. Mr. McCormick, what are your thoughts on 

VA’s recommendation that employee foreign travel paid for by nonFederal sources be excluded from the foreign travel accountability 

ban? 

Mr. MCCORMICK. I am sorry. Can you clarify that again, Mr. 

Chairman? 

Mr. COFFMAN. I am assuming that by non, let’s see, by non-Federal sources, so I suspect that that would be, say, a non-profit organization, I would assume that was involved in promoting something that the VA had an interest on internationally. And so they 

attended a conference that was underwritten by another entity that 

was not taxpayer funded. 

Would you feel that that should fall under the accountability requirements as well? 

Mr. MCCORMICK. I think, you know, full accountability is a good 

thing, Mr. Chairman. You know, in the military, 100 percent accountability is expected of every servicemember, and I think to hold 

those same standards and apply them to members of the VA is 

something that, you know, we would be supportive of. 

Mr. COFFMAN. Okay. Ranking Member Kirkpatrick. 

Mrs. KIRKPATRICK. Thank you, Mr. Chairman. 

Dr. Etkind, how many VA facilities currently report infectious 

diseases? 

Dr. ETKIND. I could not tell you that. I am sorry. Again, there 

is no systematic collection of that information. It is all based on 

the, frankly, the personal relationships between the health authorities in those communities and the authorities within the VA. 

Mrs. KIRKPATRICK. Is there a standardized policy or system for 

reporting infectious diseases within the VA? 

Dr. ETKIND. My understanding is that there is an urging that reporting be done, but there is no mandate. 

Mrs. KIRKPATRICK. Here is my concern. You said that where 

there is mandatory reporting, it is rarely enforced. And so if we are 

requiring mandatory reporting by the VA and it is not enforced, 

then we really have not made any progress here. 

Dr. ETKIND. No, I would respectfully disagree. I think that we try 

to stay away from the mandate. If there is a problem, the typical 

response from local health departments and, frankly, in my own 

history has been to go and you discuss it. You find out where the 

disconnect is and you try to remediate it. 

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Just is there a misunderstanding about some law? Is there a 

misunderstanding about regulations or procedures? And most often 

a professional conversation between authorities is sufficient for 

making sure that everybody is on the same page. 

Mrs. KIRKPATRICK. I represent a large rural district in Arizona 

and a lot of the veterans go to a private practice physician or a 

community health center or maybe a regional hospital that is not 

part of the VA system. 

Do you think this bill adequately covers those veterans who get 

treatment outside of the VA system? 

Mr. MCCORMICK. I think that the private sector is clearly subject 

to the reporting laws of those states, Arizona in particular. So I do 

not fear that they are missed somehow. 

If there are cases that occur and it is discovered that they had 

not been reported and perhaps we would have known about them 

much sooner where we could have interrupted possibly secondary 

transmission, at that point that is when you visit the doctor and 

you talk about what happened and figure out where the disconnect 

is. 

Mrs. KIRKPATRICK. Dr. Jones, moving to you, one of our first 

hearings was about the Legionnaire outbreak. And you said in your 

testimony that you thought better coordination could have prevented some of the deaths and some of the cases that broke out. 

Can you describe for me in a little more detail what kind of coordination you see could have been in place at the VA to prevent 

those deaths? 

Dr. JONES. I think in general, I mean, we in public health are 

used to investigating outbreaks quickly and thoroughly. And it is 

really important that that be done promptly. I mean, the whole 

point is to stop it before it spreads. 

I was not in that particular VA, but we had an instance where, 

you know, a VA called us and said we have had four patients with 

TB in the last two months. We think we have had a problem. And, 

oh, by the way, three of them are dead. 

You know, how many people did they expose in the previous two 

months while we did not know about them? And that is the kind 

of thing where I think in cooperation with the VA, you know, they 

are taking good care of patients, but we can help them do that tracing outside the VA in the community and prevent those kind of exposures if we hear about them promptly. 

Mrs. KIRKPATRICK. How quickly should they have been reported? 

Dr. JONES. It depends on the disease, but basically for most 

things by the next business day. There are some things like meningitis where we want to get called at three a.m. on a Sunday because we have got to go to the school and find the other kids that 

were exposed and give them antibiotics. But in general, within a 

day or so. 

Mrs. KIRKPATRICK. Is it your opinion that the VA has a system 

in place right now for reporting infectious diseases that is adequate? 

Dr. JONES. I think the system is not the problem at all. It is just 

following the law. But, you know, the VA has an incredibly advanced sophisticated medical record system and I think it would be 

resource free for them. 

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I mean, my understanding is someone could sit in Washington 

and hit a button at eight p.m. every night and report to states. So 

I think it would be a very easy thing to implement. 

Mrs. KIRKPATRICK. Wouldn’t it also be easy to implement that reporting to the CDC? 

Dr. JONES. Yes. In general, the CDC does not like to collect personal identifiers. And they are really not the ones that contact patients individually and do the ground work. So, you know, collecting national data, yes, that would be easy. But I think it should 

not go through CDC and down to states because we do not have 

time to wait for that. 

Mrs. KIRKPATRICK. Okay. Thank you, Doctor. 

I yield back. 

Mr. COFFMAN. Dr. Jones, can you talk a little about how different 

parts of the country face different challenges when it comes to infectious diseases? 

Dr. JONES. Yes. We heard a little bit earlier about the fact that 

different states require different diseases to be reported. In essence, you know, 99 percent of those lists are identical across the 

country. There are very rare exceptions. 

I mean, valley fever in central California, vibrio in coastal states 

where they have oysters. But those are small exceptions. Never 

have I heard a complaint from a private or non-profit hospital 

about administrative burden in terms of different rules in different 

places. I mean, it is essentially a nonissue because the states are 

so similar. 

Mr. COFFMAN. Okay. Dr. Etkind, in your testimony, you state, 

quote, whether a VA reports notifiable diseases to the health department should not be dependent upon individual relationships. 

Can you talk about instances where the lack of personal relationships negatively impacted patients? 

Dr. ETKIND. I think whenever there is a delay in reporting and 

ultimately when the problem gets to be so great that you say, hey, 

we need to bring in other people, at that point you are kind of far 

down the process and you have lost opportunities to reduce the risk 

of people for further transmission. 

Mr. COFFMAN. And, Mr. McCormick, have VA’s actions of placing 

a covert camera in a veteran’s room without consent and the Legionnaires’ Disease outbreak in Pittsburgh had any effect on veterans’ trust in VA? 

Mr. MCCORMICK. Mr. Chairman, I would certainly say it does obviously given the number of issues that my organization has raised 

over the last few months and few years with respect to the VA. 

Instances like these lead us to think that the VA’s head-in not 

in the game, so to speak, or their efforts at rectifying the problems 

that veterans face are misguided or, you know, present us with a 

lot of problems that remain to be solved. And the path they choose 

on these issues is very troubling. 

So I would say, yes, the credibility definitely takes a hit when 

these sorts of things are in the news and so forth. 

Mr. COFFMAN. Thank you. 

Ranking Member Kirkpatrick. 

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Mrs. KIRKPATRICK. Mr. McCormick, you were testifying about the 

Foreign Travel Accountability Act. In the act, we require a report 

to Congress semi-annually. 

Do you think that it would be better to have it just once a year 

rather than twice a year? I would just like your opinion about that. 

Mr. MCCORMICK. Simply in terms of numbers, Ranking Member 

Kirkpatrick, basically I think semi-annually is better. Just it, you 

know, cultivates sharper recordkeeping. And given the tight budgets here in D.C. today and so forth, I think it keeps individuals on 

their toes as far as the money that they are charged with handling, 

administering, and so forth. So I think semi-annually is far better. 

Mrs. KIRKPATRICK. My last question is for anybody on the panel 

who can answer it. Doesn’t HIPAA prevent the surveillance of a patient in a hospital including the VA system? 

Dr. JONES. Not at all. There is an exception for public health to 

receive personally identifiable information and that is really the 

whole point. You know, if someone has got TB, got HIV, whatever 

it happens to be, we need to know who they are, what their address is to be able to go and find them, find their community members and their families and do something about it. 

Public health has an impeccable record in terms of confidentiality, particularly in communicable diseases. I am not aware of 

any breaches. And then any time that we share that information 

when it is not needed, we eliminate any personal identifiers. None 

go to CDC. None are ever public. 

Mrs. KIRKPATRICK. Okay. So you are satisfied that is not happening? 

Dr. JONES. Absolutely. 

Mrs. KIRKPATRICK. Okay. Thank you, panel. Thank you very 

much. 

And thank you, Mr. Chairman. I yield back. 

Mr. COFFMAN. Thank you, Ranking Member Kirkpatrick. 

And I just want to say how important I think that this reporting 

is down at the state and local level from a public health standpoint 

because you are the ones that are on the front lines of dealing with 

infectious diseases. 

And I think it would be highly inappropriate, I think it is highly 

inappropriate for the VA not to report to you because your communities are impacted, could be impacted or are impacted by the 

spread of infectious diseases when they go beyond the boundaries 

of the VA system which is likely in infectious diseases. 

And, Mr. McCormick, I think you addressed the issue of non-Federal travel. And I just want to state how important that is because 

I think that they should have to disclose if they are not traveling 

on the taxpayers’ dime who, in fact, is funding that and is there 

a conflict of interest involved in that. 

And so I think it is just important to have a full accounting of 

that. 

And with that, the meeting is adjourned. Thank you very much. 

[Whereupon, at 3:31 p.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Hon. Mike Coffman, Chairman 

Good afternoon. This hearing will come to order. 

I want to welcome everyone to today’s legislative hearing on: 

• H.R. 1490, The Veterans’ Privacy Act; • H.R. 1792, The Infectious Disease Reporting Act; and • H.R. 1804, The Foreign Travel Accountability Act. 

The three bills we will consider today are the result of investigations conducted 

by this Subcommittee in the course of its oversight duties that have revealed poor 

judgment and mismanagement by the Department of Veterans Affairs. 

These bills are intended to heighten the protections for our veterans at VA medical centers and prevent the recurrence of problems identified in the investigations. 

H.R. 1490, the Veterans’ Privacy Act, was introduced by the Chairman of the Full 

Committee, Representative Jeff Miller. The bill directs the Secretary of Veterans Affairs to prescribe regulations to ensure that, in the absence of informed consent by 

the patient or their legal representative, any visual recording can only be conducted 

under limited circumstances such as under court order. 

In April, I introduced H.R. 1792, the Infectious Disease Reporting Act. Based on 

investigations conducted by this Subcommittee, as well as a hearing in February it 

is clear that VA needs to be held to the same standard for infectious disease reporting as its health care counterparts in each state. 

The Infectious Disease Reporting Act will require VA facilities nationwide to comply with state infectious disease reporting requirements. Once reported to the state, 

this data will be reported to the Centers for Disease Control and Prevention and 

used to monitor public health. Each state faces its own unique challenges regarding 

infectious diseases and the Infectious Disease Reporting Act takes this into account. 

It is baffling to me that the University of Pittsburgh Medical Center Hospital, which 

sits just a few hundred feet from the Pittsburgh VA medical center, is required to 

report infectious diseases while the VA hospital is not. 

The news reports from Pittsburgh this past weekend detailing the extent of the 

Legionella problem and that it dates as far back as 2007 underscore the need for 

this legislation. The fact that VA provided information to reporters that this Subcommittee has been requesting since January is unacceptable. This lack of transparency looks like an attempt to evade legislative oversight and makes me wonder 

whether there is more to this story than what VA has chosen to reveal. 

The need for the infectious disease reporting act is reflected not just in the Legionnaires’ Disease outbreak in Pittsburgh. Just last month almost twenty veterans 

tested positive for hepatitis A or B after a VA hospital in Buffalo admitted to 

reusing insulin pens on patients. 

Time and again we have heard from VA that they are industry leaders in various 

areas, but in infectious disease reporting, VA doesn’t even compete. 

Our final bill today is H.R. 1804, the Foreign Travel Accountability Act, which 

was introduced by Congressman Tim Huelskamp, a Member of this Subcommittee. 

This bill directs the Secretary to submit to Congress semi-annual reports on foreign 

travel. The reports will include, among other things, the purpose each trip, the destination, the total cost to the Department. 

In January, after VA told him the State Department may have records on VA foreign travel, Chairman Miller sent a request to the State Department for more information. Just last week he received the State Department’s two sentence reply which 

referred him back to VA. This ridiculous finger pointing clearly exhibits the need 

for this legislation. 

It is important that taxpayer dollars appropriated to VA are properly spent on 

providing the care and benefits our veterans have earned. Not sending VA employees abroad on taxpayer subsidized vacations that do little to improve the care veterans receive. 

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1 U.S. Department of Veterans Affairs, ‘‘The Origina of the VA Motto: Lincoln’s Second Inaugural Address.’’ http://www.va.gov/opa/publications/celebrate/vamotto.pdf. 

I appreciate everyone’s participation in today’s hearing and now yield to the 

Ranking Member for her opening statement. 

f 

Prepared Statement of Hon. Jackie Walorski 

Mr. Chairman and Ranking Member, it’s an honor to serve on this Committee. 

I thank you for holding this legislative hearing to advance pending legislation 

which will improve oversight of certain VA programs and practices. This will ultimately result in strengthening the quality of care for our veterans. 

I also want to thank the veteran service organizations testifying today and those 

in attendance. Your resolve to bring attention to inefficiencies and significant shortcomings within the VA has not gone unnoticed. Because of you, this Committee has 

committed itself to ensuring the VA continually improves the services you have 

earned. 

Through hearings this Committee has held and through the work of countless individuals seeking to better the VA, a number of critical issues have arisen which 

must be addressed. The legislation my colleagues have brought before us today addresses many of the concerns raised by veterans and the oversight work of this 

Committee. 

Outside of the headquarters of the VA, there exist the words of President Abraham Lincoln, ‘‘To care for him who shall have borne the battle and for his widow, 

and his orphan.’’ 1 The VA must not waiver in its obligation to our Nation’s vet- erans. I look forward to working with my colleagues and our panelists on this legislation 

before us. 

Thank you. 

f 

Prepared Statement of Hon. Jeff Miller 

Thank you, Chairman Coffman. 

It is a pleasure to be here today with you, to discuss my bill, the Veterans’ Privacy 

Act. 

Last June, a video camera disguised as a smoke detector was installed in the 

room of a brain damaged veteran at the James A. Haley VA Medical Center in 

Tampa, Florida. When the veteran’s family discovered the camera, they were understandably upset. 

When asked about the camera, VA officials first denied the existence of the camera, then later admitted that the ‘‘smoke detector’’ was actually a video camera. 

When further asked if the camera was recording, VA told the family that the camera was not recording, but only monitoring the patient. 

Only after inquiries by the media and this Committee did VA come clean and 

admit that the camera was recording. Ultimately, VA yielded to the pressure and 

removed the camera from the patient’s room. When I learned about these events, 

I was shocked at VA’s disregard for the privacy rights of its veteran patients. 

VA failed to provide any justification for covertly recording this patient in his 

room. In light of this incident, I asked VA for what it believed was its legal authority to place a camera in a patient’s room without consent. VA’s legal opinion was 

that the hidden camera did not violate the law, and further represented that it was 

developing a national policy to address the issue of video surveillance of patients. 

I have recently been told that VA did not expect to have the policy finalized before 

September 2013, more than a year after these events occurred, and a year after I 

was first told that a policy was forthcoming. 

Therefore, in order to protect the privacy rights of veterans who receive medical 

care from VA hospitals, I have introduced the Veterans’ Privacy Act. My bill directs 

VA to prescribe regulations to ensure that any visual recording made of a patient 

during the course of care by VA is carried out only with the full and informed consent of that patient or, in appropriate cases, their representative. 

The bill contains important exceptions. The Secretary would be authorized to 

waive notice and consent where: 

1) Upon determination by a physician or psychologist that the recording is medically necessary, or 

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2) Pursuant to a court order, or 

3) When the recording would occur in a public setting where a person would not 

have a reasonable expectation of privacy, such as a waiting room or hallway. 

I look forward to working with Committee Members, our VSO partners, VA, and 

other stakeholders on this bill, because protecting the privacy of patients while receiving care in VA must be among our constant priorities. 

Thank you once again, Chairman Coffman, for holding this hearing today and for 

your hard work and leadership of the Subcommittee on Oversight & Investigations. 

I appreciate the opportunity to be with you all today. With that, I yield back. 

f 

Prepared Statement of Robert L. Jesse, M.D., Ph.D. 

Good afternoon Chairman Coffman, Ranking Member Kirkpatrick, and Members 

of the Subcommittee. Thank you for inviting me here today to present our views 

on several bills that would affect Department of Veterans Affairs (VA) health programs and services. Joining me today is Jane Clare Joyner, Deputy Assistant General Counsel. Because of the time afforded for preparation of testimony, we do not 

yet have cleared costs for these bills. 

H.R. 1490 Veterans Privacy Act. 

H.R. 1490 would amend VA’s informed consent statute to establish a new subsection concerning visual recording of Veterans made when VA is providing care 

under title 38, United States Code. The bill would require the Secretary to promulgate regulations establishing procedures to ensure that a visual recording of a patient receiving such care is made only with the full and informed consent of the patient or, in appropriate cases, the patient’s representative. The bill would allow the 

VA to waive the informed consent requirement under three circumstances: pursuant 

to a determination by a physician or psychologist that such recording is medically 

necessary; pursuant to a warrant or order of a court of competent jurisdiction; or 

in a public setting where a person would not have a reasonable expectation to privacy. The term ‘‘visual recording’’ would be defined to mean the recording or transmission of images or video. 

VA supports the intent of the bill but we recommend some clarification to ensure 

the best interests of patients are supported. We are concerned that the definition 

of ‘‘visual recording’’ is ambiguous and open to interpretation, which could adversely 

impact patient care. For example, the ‘‘transmission of images’’ could encompass 

still photographs or images, such as x-rays that are then digitized or scanned, as 

well as cine images that are now routine in catheterization laboratories and Magnetic Resonance Imaging (MRI). In VA, such images are commonly sent to a physician via secured email for reading. These concerns could be corrected by revising 

subsection (b)(3) to state that the term ‘‘visual recording’’ means the recording or 

transmission of images or video, excluding medical imaging such as those images 

produced by radiographic procedures, nuclear medicine, endoscopy, ultrasound, etc., 

and images, video and other clinical materials transmitted for the purposes of telehealth. For example, in FY2012, 9 percent of Veterans received elements of their 

care via telehealth. 

We recommend this change to the definition, in part, because as written, H.R. 

1490 would allow a physician or psychologist to conduct a medical imaging procedure, such as an X-ray, Computed Tomography (CT) scan, MRI scan, or ultrasound 

on a patient without the patient’s consent if the physician or psychologist deemed 

the procedure to be medically necessary. This exception is not consistent with ethical standards for informed consent for treatments and procedures. Competent patients have the right to make autonomous decisions about the medical interventions 

that clinicians propose to perform on them. H.R. 1490 would, as currently written, 

lower the standard for patient consent and autonomous decision- making. We assume this is not the intent of the drafters. 

H.R. 1792 Infectious Disease Reporting Act. 

H.R. 1792 would amend VA’s quality assurance statute, 38 U.S.C. §7311, to require VA to report certain infectious diseases that occur in VA medical facilities. 

The bill would define a ‘‘reportable infectious disease’’ as a disease that the State, 

in which the facility is located, requires to be reported. VA would be required to report such diseases to an appropriate entity in accordance with State law. Similarly, 

the bill would require reporting to the accrediting organization of the facility. The 

bill states that if VA fails to make a required report in accordance with State law, 

VA must pay the State an amount equal to the penalty paid by non-Federal faciliVACREP180 with DISTILLER

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ties that fail to make such reports. The bill would waive sovereign immunity and 

authorize States to file civil actions against VA to recover any amounts due for failure to make required reports in accordance with State law. Such suits would be filed 

in U.S. district court for the district in which the medical facility is located. The 

reporting requirement would take effect 60 days after the date of enactment. 

VA supports, in general, the provision of information to outside entities on infectious diseases. The Centers for Disease Control and Prevention (CDC) depends on 

communicable disease surveillance to carry out analysis and form national recommendations. Reporting of selected infectious diseases has been widely accepted as 

mutually advantageous to both health care providers and the recipients of the information. CDC advises States and Territories as they formulate their individual requirements for health reporting. While no VA entity is currently required to participate in these State-mandated reporting processes, VA Medical Centers have been 

encouraged to participate in the process; over the years VA and VHA have provided 

guidance through Handbooks and Directives on how to achieve this participation 

while assuring compliance with existing Federal laws that protect privacy and confidentiality. 

VA would like to discuss with the Committee ideas to provide more standardization and consistency in its practices to fulfill the aims of the bill, which we believe 

can be achieved without new mandates in legislation that raise legal complications, 

as well as create administrative burdens by requiring compliance with many different State laws. 

Most States do espouse a general framework of ‘‘accepted’’ reportable disease as 

agreed to by the Council on State and Territorial Epidemiologists; many of these 

are similar to, if not identical to, those recommended by CDC. However, while CDC 

has some basic elements of data which it evaluates relative to communicable diseases, many States have reporting requirements that included numerous data elements beyond those which contributes to the disparity in reporting requirements 

from State to State. 

We look forward to discussing with the Committee VA’s current practices and 

ideas to expand on what VA is now doing. 

While we submit that a voluntary approach is our preferred course of action, we 

also offer below suggested changes to the bill should Congress choose to move forward with a mandated approach. 

First, the bill would amend VA’s quality assurance statute, 38 U.S.C. §7311. This 

type of reporting requirement is not appropriate as part of VA’s Quality Assurance 

(QA) program because names and personal identifiers cannot generally be disclosed 

from QA records. Thus, we recommend the legislation not be drafted as an amendment to 38 U.S.C. §7311. We are available to provide technical assistance to the 

Subcommittee to address this concern. 

Second, in light of the reporting requirements, it may be necessary to amend two 

VA statutes protecting the confidentiality of Veterans records: 38 U.S.C. §5701 and 

§7332. Unless amended, these provisions may hinder, or even prohibit, disclosure 

of necessary information. 

Third, the bill requires reporting of ‘‘a reportable infectious disease that occurs 

at a medical facility of the Department of Veterans Affairs in accordance with the 

laws of the State in which the facility is located.’’ Each State defines reportable infectious diseases for its purposes. However, precisely which infectious diseases 

should be reported by VA is not clear. Specifically, the phrase ‘‘occurs at a medical 

facility’’ in section 2 is ambiguous. It is not clear whether this means that VA 

should report all State-defined reportable infectious diseases, all health care facilityassociated infectious diseases (such as central line-associated bloodstream infections, 

catheter-associated urinary tract infections, and ventilator–associated pneumonia), 

or only those health care facility-associated infectious diseases that are part of the 

State-defined reportable infectious diseases. Further, it is not clear what would be 

required if, for example, a patient who resides in Nevada, develops a reportable infection while being cared for at a VA hospital in California, where State law may 

differ. 

Fourth, we believe that requiring the reporting of each case of a reportable infectious disease to the accrediting organization of each facility would be inappropriate, 

unnecessary, and burdensome. The Joint Commission, which is currently the accrediting organization for all Veterans Health Administration facilities, does not typically receive systematically-collected health outcomes data on infectious conditions, 

and it is not clear how such data would inform the accreditation process. In the normal course of their reviews of VA health care facilities, The Joint Commission, as 

well as other oversight entities, would be able to verify reporting to States once the 

legislation is enacted. 

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Finally, we are also concerned about the administrative burden associated with 

waiving sovereign immunity to allow States to fine VA for failure to report in accordance with State law and to file civil action against VA to recover such fines. 

We are opposed to this provision of the statute, and believe these features are not 

necessary to achieve the intent of the bill. We are glad to make ourselves available 

to provide technical assistance to the Subcommittee to address these concerns. 

H.R. 1804 Foreign Travel Accountability Act. 

H.R. 1804 would amend title 38, United States Code by adding a new section 518 

to establish a requirement for semiannual reporting of ‘‘covered foreign travel’’ made 

during the 180 days preceding the report. The bill would require VA to report the 

details of each instance of covered foreign travel, including the purpose, destination, 

name, and title of each traveling employee, as well as the final costs of all covered 

foreign travel made during the period covered by the report. The bill would provide 

that reports required by section 518 include all of the above information regardless 

of whether the information duplicates the quarterly report to Congress on conference expenses under section 517 of title 38, United States Code. The bill would 

define ‘‘covered foreign travel’’ to include any official travel made by a VA employee, 

including one stationed in a foreign country, to a location outside of the United 

States or Washington, D.C., any U.S. territory, commonwealth or possession, Indian 

lands, or U.S. territorial waters. 

VA has no objection to providing Congress with useful information for its oversight responsibilities, but we recommend the bill be amended so the data required 

by the semiannual reports is consistent with the data available from the E–Gov 

Travel Service (ETS) system, which is currently FedTraveler.com. We believe these 

data will meet the general purpose of this legislation. Using ETS data will ensure 

an efficient and accurate report. As currently outlined in the bill, the report would 

require data that are not available in ETS. For example, expenses or reimbursements related to operating and maintaining a car, including the cost of fuel and 

mileage are generally not available in ETS. Rather, privately-owned vehicle costs 

would only be reimbursed based on mileage. Operating and maintenance costs 

would not be reimbursed. Costs for rental vehicles, if authorized, would be identified 

on the travel report, but operating and maintenance costs would not be reimbursed 

or known. Operating and maintenance costs for Government vehicles would be difficult to separate out for each travel episode. Similarly, computer rental fees, rental 

of hall auditoriums or meeting spaces, and entertainment appear to fall under the 

category of acquisition expenses associated with a conference. As such they would 

not be associated with a particular traveler, nor would such costs be reflected in the 

ETS. 

VA recommends the bill be amended to exclude any employee foreign travel where 

a non-Federal source reimburses the Government for all costs. Section 1353 of title 

31, United States Code, authorizes agencies to accept gifts of travel in support of 

official travel from non-Federal sources. Agencies are required to report the acceptance of such travel gifts on a semi-annual basis to the Office of Government Ethics 

(OGE). Because the bill appears to be concerned with reporting the costs of VA employee foreign travel, such purpose would not be served by including no-cost travel 

which VA already reports on a semi-annual basis to OGE. 

Finally, VA requests clarification as to the timeframe covered by each report. Our 

understanding is that the initial report due June 30, 2014, would cover the first half 

of Fiscal Year (FY) 2014, October 1, 2013 through March 31, 2014, and that the report due December 31, 2014, would cover the second half of FY 2014, April 1, 2014 

through September 30, 2014. Similarly, we understand that the required reports 

would be based on approved and completed expense vouchers, so that travel for 

which an expense voucher is pending but not approved at the end of the reporting 

period would be included in the subsequent period. VA would be glad to meet with 

the Committee to provide technical assistance on this legislation. 

Mr. Chairman, this concludes my statement. Thank you for the opportunity to appear before you today. I would be pleased to respond to questions you or the other 

Members may have. 

f 

Prepared Statement of Timothy F. Jones, M.D. 

Mr. Chairman and Members of the Subcommittee—— 

The Council of State and Territorial Epidemiologists (CSTE) welcomes the opportunity to provide the House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations this written statement for the record on legislation to enVACREP180 with DISTILLER

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1 Epidemiologists are best known for detecting, monitoring, controlling, and preventing infectious disease outbreaks. Perhaps less known, but equally important, is epidemiologists’ work to 

monitor chronic disease, injuries, and environmental health threats; identify factors that put individuals at greater health risk; implement prevention strategies; and prepare for and respond 

to natural disasters. 2 ‘‘A Brief History of the National Notifiable Disease Surveillance System,’’ Centers for Disease 

Control and Prevention. Available at http://wwwn.cdc.gov/nndss/script/history.aspx, accessed 

May 30, 2013. 3 Based on weekly reports to CDC by state health departments, the MMWR series is CDC’s 

primary vehicle for scientific publication of timely, reliable, authoritative, accurate, objective, 

and useful public health information and recommendations. MMWR readership predominantly 

consists of physicians, nurses, public health practitioners, epidemiologists and other scientists, 

researchers, educators, and laboratorians. 

hance infectious disease reporting by the U.S. Department of Veterans Affairs (VA) 

including, H.R. 1490, H.R. 1792, and H.R. 1804. CSTE represents more than 1,100 

members comprised of the epidemiology and surveillance workforce in federal, state, 

and local health departments. We work on the front lines of public health, investigating and controlling communicable diseases nationwide. 1

A critical step in the ability to respond appropriately to outbreaks and other 

threats is the prompt notification of public health authorities on diseases posing a 

potential risk to our communities. Virtually all health care providers, in all states, 

are required to report communicable diseases to their local health authorities for additional investigation. Unfortunately, VA health care facilities are exceptions to this 

rule, which has led to some substantial problems that may have been averted were 

this not the case. The legislation introduced to hold VA health care facilities to the 

same standards as other health care providers will help address this problem, and 

CSTE heartily supports these efforts. 

Disease Surveillance Rooted in Effective Federalism 2

The long-standing history of infectious disease reporting in the United States 

serves as an example of effective federalism that has been refined over 135 years. 

Beginning in 1878, Congress authorized the U.S. Marine Hospital Service (forerunner of the Public Health Service or PHS) to collect reports from U.S. consuls 

overseas about local occurrences of diseases such as cholera, smallpox, plague, and 

yellow fever. This information was used to institute quarantine measures to prevent 

introducing or spreading these diseases in the United States. In 1879, Congress 

funded the collection and publishing of reports of these notifiable diseases and in 

1893 expanded the authority for weekly reporting and publishing of these cases to 

include data from states and municipal authorities. 

To improve the uniformity of the data, Congress in 1902 directed the Surgeon 

General to provide specific forms to be used for collecting and compiling these data 

and for publishing reports at the national level. In 1903, the PHS convened the first 

annual conference of state and territorial health officers to begin implementation of 

the congressional act, thus marking the dawn of national surveillance for communicable, infectious diseases of public health importance. By 1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participants in the national reporting of 29 specified diseases. 

In 1950, a new federal agency, then named the Centers for Disease Control (now 

the Centers for Disease Control and Prevention or CDC), recognized the importance 

of state input in reporting communicable diseases, and asked the Association of 

State and Territorial Health Officials (ASTHO)—the national nonprofit organization 

representing U.S. public health agencies and their employees—to convene state epidemiologists and charge them with the responsibility of deciding which diseases 

should be reported nationally. A conference of state and territorial epidemiologists 

generated a fully documented list of nationally notifiable diseases. Ten years later, 

CDC assumed responsibility for collecting data on these nationally notifiable diseases and began publishing the Morbidity and Mortality Weekly Report (MMWR) 

with data reported by state health departments. 3

Today, these data are the foundation of the National Notifiable Diseases Surveillance System (NNDSS), a multifaceted public health disease surveillance system 

that gives public health officials powerful capabilities to monitor the occurrence and 

spread of diseases. Fifty-seven jurisdictions contribute to the NNDSS: the 50 states, 

New York City, the District of Columbia, and 5 territories including Guam, Commonwealth of Northern Mariana Islands, American Samoa, U.S. Virgin Islands and 

Puerto Rico. As the voice of these state, territorial, and local epidemiologists, CSTE 

maintains responsibility for defining and recommending which diseases and conditions are reportable within states and localities, and which of these diseases and 

conditions will be voluntarily reported to CDC. In collaboration with CDC, CSTE 

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works to determine changes to the list of nationally notifiable conditions and to enhance processes and procedures of the NNDSS. 

Disease Reporting Governed by State, Local Laws and Rules 

Effective public health surveillance begins with the local- and state-health departments. Mandatory disease reporting of individual patients and corresponding health 

records with personal identifying information is thus governed by state and local 

laws and rules, which vary by jurisdiction. These data provide the direction and 

scope of many state and local health department activities, from detecting individual 

cases and controlling outbreaks to implementing prevention and intervention activities. Because of the Health Information Portability and Accountability Act (HIPAA) 

exemptions for public health reporting, health department staff is able to identify 

persons affected by the diseases of concern to investigate and institute control measures to prevent further spread of disease. State health departments support national 

public health surveillance by voluntarily sharing their notifiable disease reports 

using de-identified data with CDC. 

Health Care Providers Are Critical Partners in Surveillance 

State and local public health departments are reliant on their partners in the 

health care community—those who interact directly with patients—to obtain case 

reports on many infectious and non-infectious diseases. While public health reporting laws and rules differ by locale, they are similar in that these health care providers—including physicians, laboratories, and other providers of care—are required 

to report legally notifiable diseases to their jurisdiction’s public health authorities 

when they reasonably suspect a patient of having a disease or condition of concern. 

Once reported, assigning residence (by state, county, etc.), de-duplicating reports, 

and other reconciliations are responsibilities of the public health agency. 

Health care facilities, including acute care hospitals, long-term care facilities, and 

outpatient facilities generally also fall under mandated reporting requirements. In 

practice, physicians often assume that the acute care hospital infection control staff 

will initiate a report to the public health agency on a patient for whom the physician is caring. Notably, for health care facility reporting mandates, a specific individual responsible for reporting is not named in the law or rule, but rather it is expected that the facility shall report. Other individuals or entities may also be mandated to report events of potential public health concern. For example, in many 

places school principals or restaurant owners must report when outbreaks occur 

that may be associated with their establishments (e.g. influenza-like illness, 

foodborne disease). 

Failure of an individual or entity to report is frequently a crime and potentially 

punishable as a misdemeanor offense with imprisonment, de-licensing, or fines. In 

practice, however, criminal penalties are exceedingly rarely used; compliance is encouraged by continuing education and public health relationships with health care 

providers. 

Public Health Agencies Collect, Investigate Disease Reports 

The public health agency to which disease reports are sent depends on the jurisdiction, but is generally the state or local health department where the disease is 

diagnosed. In most cases, medical providers and health care facilities report directly 

to the local or county health department where they are located, or in the absence 

of local health departments, directly to the state. Large, multistate laboratories usually send electronic lab reports to the state health department where the patient 

or ordering facility is located. All states have mechanisms to share reports with 

other jurisdictions as appropriate, depending on where a disease was contracted or 

treated, and where and how measures to investigate and control them must be implemented. 

Generally, state and local health departments are responsible for investigating 

these communicable diseases reports, and responding appropriately. Depending on 

the situation, such responsibilities may involve compiling of data for routine reporting, or investigating outbreaks or emergent events which require an immediate and 

vigorous response to protect the public’s health. Rapid access to information is critical to accurately and promptly investigating such reports. 

Consistent and Complete Disease Reporting Necessary to Protect Public 

Health 

State and local laws and rules require reporting of a list of diseases and conditions designated as notifiable by CSTE and CDC. Jurisdictions may make minor 

changes to the list of reportable diseases to fit local or regional needs, such as the 

addition of ‘‘Valley Fever,’’ which is caused by a fungus (Coccidioidomycosis) that 

is endemic only to the Southwest region of the United States. 

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4 Healthcare Inspection: Legionnaire’s Disease at the VA Pittsburg Healthcare System, Pittsburg, PA. Department of Veterans Affairs Office of Inspector General, Office of Healthcare Inspections. April 23, 2013. 

The goal of public health reporting is to detect, investigate and prevent diseases 

and conditions that pose a potential threat to others in the local, state, regional, national or even international communities. Many examples of this are well-known. A 

report of a case of tuberculosis leads to provision of treatment for the patient to 

render them no longer infectious, identification and notification of close contacts for 

evaluation and treatment, and occasionally quarantine or other public health measures as necessary to prevent additional spread of disease. Persons with sexually 

transmitted diseases are promptly treated, and their close contacts are identified 

and treated to prevent further spread. Persons who have had close contact with a 

patient with meningococcal meningitis are traced and urgently treated to prevent 

them from contracting disease. Clusters of illness associated with restaurants are 

investigated immediately in order to ensure that conditions at the implicated establishment are corrected immediately or it is closed until that is accomplished. 

Foodborne disease outbreaks often lead to traceback of foods, with recalls of many 

thousands of pounds of product, preventing potential illness over very large areas 

of distribution. Other prominent recent examples include a nationwide outbreak of 

fungal meningitis, in which identification and recall of a contaminated pharmaceutical product prevented potentially hundreds of additional deaths. 

It is not at all uncommon for public health agencies to receive several reports of 

illness from various sources, which to an individual clinician or institution may appear isolated or sporadic, but which in aggregate signify an important cluster or outbreak. This is an example of the critical importance of all health care providers and 

facilities consistently and promptly reporting diseases to their local authorities. 

While many cases of reportable diseases are ‘‘sporadic,’’ or unrelated to others and 

require little additional follow-up, some extent of public health investigation is necessary to ensure that they are not a sign of a potentially more widespread situation 

requiring interventions to mitigate additional spread. Unfortunately, it is not uncommon for public health investigations to identify causes of disease involving such 

things as widely disseminated food products, contaminated medications, malfunctioning equipment, unsafe food-handling or manufacturing processes, intentionally 

perpetrated acts, or unsafe environmental conditions to which the public may be exposed (sometimes including, unfortunately, health care facilities). In the large majority of cases, persons or establishments potentially involved in an outbreak are extremely cooperative with public health authorities in working toward identifying 

and eliminating the sources of health threats. Rarely, however, concerns such as 

legal culpability, economic sequelae, or adverse publicity can hinder investigations 

and response. Uniform adherence to legal reporting requirements is essential to ensure that there are no such barriers to protecting the public’s health and safety. 

Public health authorities work closely with private and institutional health care 

providers in this capacity. Confidentiality is rigorously protected by public health 

laws at all times. Authorities make every effort not to interfere with personal physician-patient relationships and individual treatment decisions, but rather work to 

provide additional services and resources which a physician or institution would not 

otherwise have available. This can include performing investigations in the broader 

community, coordination with other public health and regulatory agencies, provision 

of services otherwise inaccessible to high-risk populations, public information management, and occasionally use of public health legal authorities to overcome barriers 

to appropriate disease control. 

Breakdowns in VA Reporting Necessitate New Legislation 

A recent VA Office of the Inspector General report regarding an outbreak of Legionnaire’s Disease associated with a VA hospital in Pennsylvania highlighted the 

importance of a prompt and thorough response to disease control. 4 In that instance, 

improved coordination with state and local public health authorities might have 

helped prevent infections and deaths associated with the outbreak. But unfortunately, the Pennsylvania Legionnaire’s case is not an isolated incident. There are 

other examples of suboptimal coordination of disease reporting with VA institutions 

and state and local public health agencies. 

I have been involved in investigations of known outbreaks in VA hospitals in 

which the state health department’s participation was rather abruptly curtailed due 

to concerns about jurisdictional authorities. Lack of prompt notification of cases of 

tuberculosis has hampered control efforts outside the institution in which the person 

was housed. Lack of information regarding communication with large numbers of 

persons potentially exposed to infection control lapses within a health care facility 

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have made it challenging to respond to public inquiries from many of those persons 

once they were back out in our communities. We once learned of a dramatic cluster 

of illnesses (one resulting in several cases of blindness) associated with preparation 

of medications in a health care institution, only indirectly when notified unofficially 

by personal acquaintances. 

These examples do not reflect malintent, dereliction of duties, or purposeful avoidance of responsibilities, per se. To the contrary, in many of these situations, wellmeaning VA staff were equally frustrated about the effect of variable interpretations 

of the applicability of state public health requirements in these federal institutions. 

Over many years, efforts to address such barriers have been quite variable, often 

appearing to depend highly on particular individual interpretations of regulations 

and policies. 

CSTE subject matter experts have reviewed the current versions of the VA reporting bills and in principle, are very supportive of these efforts. CSTE believes that 

federal legislation will enhance VA reporting to the NNDSS, and thus is in the best 

interest of public health. CSTE feels strongly that the best way to craft legislation 

that will ensure that VA health care facilities will be on a level playing field with 

other reporting health care facilities is to mandate that VA facilities comply with 

jurisdictional, i.e., state and local reporting laws, rules, and procedures. Referring 

federal requirements to these laws, rules, and procedures will ensure VA facilities 

remain on equal footing with private health care facilities as these rules evolve over 

time. Similarly, requiring that VA adhere to existing standards will enhance, rather 

than reinvent, the already effective NNDSS; requiring the VA to diverge from existing standards could place an unnecessary administrative burden on the system. 

CSTE experts have reviewed many scenarios, including the Pennsylvania VA Legionnaires outbreak, and believe that if VA facilities comply with jurisdictional reporting laws, many facility-based outbreaks will be detected, investigated, and 

stopped earlier than they may be otherwise. In addition, no patient of any health 

care institution is a resident of an encapsulated universe. Patients, staff, and families are active members of the communities surrounding those facilities, and their 

inevitable interactions have important public health implications both inside and 

outside those buildings. It is impossible to separate a health care facility from its 

community, and vice versa. Public health law must acknowledge this, and facilitate 

and require VA health care facilities to follow the same laws that govern all other 

institutions in our states, which protect the health of us all. 

CSTE appreciates the opportunity to submit this statement for the record and 

looks forward to working with the Subcommittee as it seeks to strengthen public 

health law in the interest of our nation’s veterans and citizens. If you have questions about this statement, please do not hesitate to contact me at 

Tim.F.Jones@tn.gov or (615) 532–1408. You may also contact CSTE’s Executive Director, Dr. Jeffrey Engel, at JEngel@cste.org 

f 

or (770) 458–3811. 

Prepared Statement of Nick McCormick 

Bill # Bill Name Sponsor Position 

H.R. 1490 Veteran’s Privacy Act Miller Support.

H.R. 1792 Infectious Disease Reporting Act Coffman Support.

H.R. 1804 Foreign Travel Accountability Act Huelskamp Support.

Chairman Coffman, Ranking Member Kirkpatrick, and Distinguished Members of 

the Subcommittee: 

On behalf of Iraq and Afghanistan Veterans of America (IAVA), I would like to 

extend our gratitude for beinggiven the opportunity to share with you our views and 

recommendations regarding these important pieces of legislation. 

IAVA is the nation’s first and largest nonprofit, nonpartisan organization for veterans of the wars in Iraq and Afghanistan and their supporters. Founded in 2004, 

our mission is important but simple – to improve the lives of Iraq and Afghanistan 

veterans and their families. With a steadily growing base of over 200,000 members 

and supporters, we strive to help create a society that honors and supports veterans 

of all generations. 

IAVA believes that effective oversight of veteran issues is integral to the successful implementation of policy and to the delivery of services that affect the lives of 

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America’s veteran population. The men and women who volunteer to serve in our 

nation’s military enter into a unique agreement of trust with their government. This 

trust mandates persistent oversight of and, when necessary, deliberate investigation 

into the agencies and mechanisms charged with delivery of services to this unique 

population. 

H.R. 1490 

IAVA supports H.R. 1490, the Veterans’ Privacy Act, which would ensure that any 

visual recording made of a patient during the course of care through the Department of Veterans Affairs (VA) is conducted only with the consent of that patient or, 

in appropriate cases, a representative of the patient.There are, undoubtedly, certain 

circumstances that may warrant the installation of monitoring devices in patient 

rooms for the safety of both patients and staff or to monitor a patient’s behavioral 

activity, just as heart and respiration monitors are often needed to monitor a patient’s physiological activity. However, IAVA believes that veterans and/or their 

family members who are receiving medical treatment at VA facilities, or their representatives, should be notified of the facility administration’s intent – in consultation with the medical professionals directly involved in delivering care – to place 

cameras and other monitoring equipment in a patient’s room, and no such action 

should be undertaken without the expressed consent of the patient or their representative. 

H.R. 1792 

IAVA supports H.R. 1792, the Infectious Disease Reporting Act, which would direct the Secretary of Veterans Affairs to report each case of reportable infectious 

disease (a disease that a state requires to be reported) that occurs at a medical facility of the VA to the appropriate state entity, as well as to the accrediting organization of such facility. 

In 2011–12, 32 people were infected with Legionnaires’ disease in the Pittsburgh 

area. It was later determined that the source of at least 5, and potentially up to 

21 of these infections was contaminated water at the O’Hara and Oakland campuses 

of the VA Pittsburgh Healthcare System. Had this bill been law at the time of this 

outbreak, the number of infected people could potentially have been far lower. Indeed, the CDC’s after-action-report on this incident indicated that poor communication and procedural missteps in the VA Pittsburgh system were just as much to 

blame for the outbreak as the Legionella bacteria itself. 

Our veterans have been taught that the ability to communicate effectively is one 

of the most essential characteristics of good leadership and is integral to mission 

success. IAVA fully supports the Infectious Disease Reporting Act because it represents the kind of common-sense communication policy that American veterans deserve with regard to their healthcare. 

H.R.1804 

IAVA supports H.R. 1804, the Foreign Travel Accountability Act, which would direct the Secretary of Veterans Affairs to report semiannually to the congressional 

veterans committees on official foreign travel made by VA employees.VA employees 

are at the frontlines of assisting American veterans and their family members with 

healthcare issues, educational benefits, and disability claims, and IAVA commends 

these employees for their work. However, according to VA reports provided to this 

committee, VA employees have taken over 1,300 trips for unspecified or unacceptably vague purposes. From the Internal Revenue Serviceto the General Services Administration, government spending scandals have become much too common an occurrence. 

The responsibility of the VA to support the nation’s veterans necessitates that the 

VA be held to the highest ethical standards with regard to the management of public funds. Many of America’s veterans and their families are experiencing great financial hardship while waiting for their disability claims to be processed, and many 

of them are waiting while they struggle to cope with the physical, emotional, and 

mental scars of war. IAVA supports the Foreign Travel Accountability Act because 

our veteran members understand better than most that every penny counts, and 

every penny should be accounted for. 

Mr. Chairman, we at IAVA again appreciate the opportunity to offer our views 

on these important pieces of legislation, and we look forward to continuing to work 

with each of you, your staff, and the Subcommittee to improve the lives of veterans 

and their families. Thank you for your time and attention. 

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Prepared Statement of Paul Etkind DrPH, MPH 

Chairman Coffman, Ranking Member Kirkpatrick and members of the Subcommittee, the National Association of County and City Health Official (NACCHO) 

appreciates the opportunity to submit testimony for the legislative hearing on H.R. 

1490 ‘‘Veterans’ Privacy Act;’’ H.R. 1792, ‘‘Infectious Disease Reporting Act;’’ and 

H.R. 1804, ‘‘Foreign Travel Accountability Act.’’ NACCHO is a membership organization comprised of the nation’s 2,800 local health departments. These city, county, 

metropolitan, district, and tribal departments work every day to ensure the safety 

of the water we drink, the food we eat, and the air we breathe, and to protect every 

resident from disease and disaster. 

NACCHO and local health departments across the country recognize and appreciate the Chairman Coffman’s leadership on the issue of disease reporting to federal, 

state, and local health authorities. 

NACCHO is pleased that the Subcommittee is considering the Infectious Disease 

Reporting Act (H.R. 1792). The bill directs the Secretary of Veterans Affairs to report each case of reportable infectious disease that occurs at a medical facility of 

the Department of Veterans Affairs (VA) to the appropriate state entity, as well as 

to the accrediting organization of such facility. The bill is an important step to ensuring coordination between state and local health departments and the VA health 

care facilities located in their jurisdictions. 

NACCHO believes it is critical for disease surveillance, identifying disease outbreaks, and recognizing disease trends in a community that reportable disease notices go to the health department of the county or community where the person with 

this diagnosed disease or condition resides. Each state has its own legal mandates 

for what is reported and to whom, but there is a robust system of notification and 

referral between the states and between the states and their local health departments. Even if a VA facility is a regional reference institution drawing patients from 

different states and locales, this notification and referral system assures that the 

right locale will be rapidly informed and prevention follow-up will be instituted. 

Although there may be minor differences between reportable disease lists between 

some of the states, a standard list of reportable diseases and conditions would most 

closely look like the list issued by the Centers for Disease Control and Prevention 

(‘‘CDC’’) through its National Notifiable Disease Surveillance System (NNDSS). The 

list can be accessed at http://wwwn.cdc.gov/nndss/document/nndss—event—code— 

list—July—28—final.pdf. 

Although there may be variances in the reporting conventions between some 

states, often the first responders to a notice of a reportable disease is the local 

health department. The impact of prevention and control activities, which are the 

result of case investigations, is enhanced when cases are reported earlier. The VA 

is one of the largest medical care systems in our nation. Their facilities are an important part of the healthcare provider network in our nation’s communities, and 

are therefore important to public health surveillance activities as well as disease 

prevention activities. 

It is important to note that the legionellosis at the Pittsburgh VA has resulted 

in a VA/Allegheny County Advisory Group reviewing the policies relevant to 

legionella prevention and control. Similarly, the VA in St. Louis and the city health 

department collaborated in notifying 1,800 patients who may have been exposed to 

Hepatitis B, Hepatitis C and HIV because of a breakdown in dental equipment sterilization procedures in 2009–2010. Further, the Danville (IL) VA recently instituted 

a policy of restricting visitors from the community because 6 patients began exhibiting flu-like symptoms. These prevention activities recognize the connections between the institution and the community. Both need to be engaged for their activities to have the desired impact. 

Timely disease surveillance is critical to preventing infectious disease morbidity 

and mortality. Incomplete reporting, lack of consistent national standards, and a 

lack of timely reporting have created significant barriers to appropriate and effective 

disease-specific control measures since delays between the onset of illness and receipt of disease notification can allow for additional transmission to occur and additional people to become ill, thereby facilitating further spread of infection. 

In December 2012, NACCHO wrote the VA urging they reaffirm the importance 

of achieving timely and complete reporting of reportable diseases and conditions 

from all of its health care facilities. Local health departments around the country 

have varying relationships with these facilities. Whether a VA reports notifiable disease to the health department should not be dependent upon individual relationships; rather, it should be established as a system-wide expectation. 

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In addition to reporting communicable diseases, NACCHO urges amending the 

legislation to include timely and complete reporting of other conditions such as cancer, genetic diseases and birth defects, and vital records such as births and deaths. 

Many states also have some chronic diseases and occupational injuries/conditions included in their reportable disease list. 

Unfortunately, healthcare-associated infections (HAIs), such as those that occurred at the Pittsburgh VA facility are far too common. Since 2001, more than 

150,000 patients have been potentially exposed to hepatitis B and C viruses and 

HIV due to unsafe medical practices in American healthcare facilities. One of the 

most recent examples, and one of the highest profile outbreaks, occurred last year 

when the CDC and state and local health departments notified nearly 14,000 patients of their possible exposure during a multistate outbreak of fungal meningitis 

and other infections. 

At any given time, about one in every 20 hospitalized patients has an HAI, while 

over one million HAIs occur across health care every year. Hospital-acquired HAIs 

alone are responsible for $28 billion to $33 billion in potentially preventable health 

care expenditures annually. Scientific evidence has shown that certain types of 

HAIs can be drastically reduced to save lives and avoid excess costs. 

The federal government has made progress in recent years to reduce HAIs and 

has developed a National Action Plan to Prevent Health Care-Associated Infections. 

While the Department of Veterans Administration participates on the federal steering committee, we believe there is more to be done. We believe this legislation is 

an important first step to ensuring possible HAI’s are reported and investigated as 

early as possible. 

Most, if not all, states require that diseases be reported by the diagnosing physician, or the institution in which the diagnosis was made. NACCHO recommends 

that the bill reflect reporting a case diagnosed rather than occurring at a medical 

facility. A case that occurs at a healthcare facility would only capture someone who 

became ill while in the care of the medical facility. 

The bill calls for penalties for non-reporting. In practice, penalties are rarely assessed for cases that are not reported. That puts the health department and the 

physician/medical facility into an adversarial position, which most health departments prefer not to do since it may negatively affect future dealings between the 

entities. NACCHO recommends that the VA health facility be subject to the same 

penalties as a medical facility not owned by the federal government. That keeps the 

option of a financial penalty but opens the institution up for other possible penalties 

which some states may have on their books. 

This bill will have the added importance of being a pilot, or test, of having a large 

federal medical care system formally entering the nation’s public health surveillance 

and care system. NACCHO has no doubt that the results will be positive for disease 

prevention and will provide a formal mechanism for developing relationships between the VA at all levels with public health authorities at all levels. This will not 

only help with disease prevention and control, but these relationships are the bedrock of responding to and mitigating the effects of any kind of emergency that a 

community, state or nation might encounter. 

The relationships built with the help of emergency preparedness funding between 

public health, medical care, emergency response, and public safety officials in the 

first decade of this century played a huge part in the successful response to the 

H1N1 influenza pandemic. How much will our emergency response system, and national security, be improved if other large federal medical care systems were to be 

formally joined to the public health and private medical care sectors? The National 

Institutes of Health has several large care facilities, one of which only recently had 

an outbreak of a resistant bacterium that was difficult to control. The same threat 

exists in the Department of Defense, with its hospitals and clinics on bases across 

the nation. Armed forces personnel are not restricted to these bases: they live, shop 

and enjoy the recreational facilities of the surrounding communities. There are a 

myriad of opportunities for infectious diseases to pass between the bases and their 

surrounding communities. Another setting at risk is the federal prison system, with 

its numerous clinics and hospitals. Employees do not live on prison grounds. They 

move back and forth between the prisons and their respective neighboring communities, creating the same opportunities for pathogens to similarly move between institutions and communities. I would ask that you consider the even broader, and 

positive, implications of this bill. 

NACCHO appreciates the opportunity to submit testimony and thanks the Subcommittee for their attention to this important public health issue. NACCHO looks 

forward to continuing to work with the Subcommittee as the legislation moves forward. If there are questions about this statement, please contact me at 

petkind@naccho.org or (202) 507–4260. 

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