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[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

 
 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

                  U.S. GOVERNMENT PRINTING OFFICE
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN KIRKPATRICK, Arizona, Ranking 
DAVID P. ROE, Tennessee              Minority Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
DAN BENISHEK, Michigan               ANN M. KUSTER, New Hampshire
JACKIE WALORSKI, Indiana             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.

                            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

 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 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.
    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 veteran 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.
    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.
    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.
    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.
    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 relationship. 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?
    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 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.
    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.
    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 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.
    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.

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 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.
    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.
    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.
    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 system-wide 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 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 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 
non-Federal 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.
    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.
    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.
    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.]

                            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.
    I appreciate everyone's participation in today's hearing and now 
yield to the Ranking Member for her opening statement.

                                 
               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 veterans.
---------------------------------------------------------------------------
    \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 look forward to working with my colleagues and our panelists on 
this legislation before us.
    Thank you.

                                 
                 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

    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.

                                 
           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. 
Sec. 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 facilities 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. Sec. 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. Sec. 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. Sec. 5701 and Sec. 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 facility-associated 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.
    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.

                                 
              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 enhance 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\
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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.
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    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\
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    \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.
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    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\
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    \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.
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    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 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.
    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.
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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.
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    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 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, well-meaning 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 [email protected] or (615) 
532-1408. You may also contact CSTE's Executive Director, Dr. Jeffrey 
Engel, at [email protected] 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
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         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 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.

                                 
              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.
    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 [email protected] or (202) 507-4260.

                                 
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