26766 Federal Register / Vol. 74, No. 105 / Wednesday, June 3, 2009 / Notices 

DEPARTMENT OF VETERANS 

AFFAIRS 

Privacy Act of 1974; System of 

Records 

AGENCY: Department of Veterans Affairs 

(VA). 

ACTION: Notice of amendment to system 

of records. 

SUMMARY: As required by the Privacy 

Act of 1974, 5 U.S.C. 552a(e), notice is 

hereby given that the Department of 

Veterans Affairs (VA) is amending the 

system of records currently entitled 

‘‘Patient Representation Program 

Records—VA’’ (100VA10NS10) as set 

forth in the Federal Register 67 FR 211 

dated October 31, 2002. VA is amending 

the system by changing the system name 

to Patient Advocate Tracking System 

(PATS); Supplementary Information, 

Routine Uses of Records Maintained in 

the System, Including Categories of 

Users and the Purposes of Such Uses, 

the System Location; Categories of 

Records in the System; Safeguards; 

System Manager and Address. VA is 

republishing the system notice in its 

entirety. 

DATES: Comments on the amendment of 

this system of records must be received 

no later than July 6, 2009. If no public 

comment is received, the amended 

system will become effective July 6, 

2009. 

ADDRESSES: Written comments may be 

submitted through http:// 

www.Regulations.gov; by mail or handdelivery to Director, Regulations 

Management (02REG), Department of 

Veterans Affairs, 810 Vermont Avenue, 

NW., Room 1068, Washington, DC 

20420; or by fax to (202) 273–9026. 

Comments received will be available for 

public inspection in the Office of 

Regulation Policy and Management, 

Room 1063B, between the hours of 

8 a.m. and 4:30 p.m., Monday through 

Friday (except holidays). Please call 

(202) 461–4902 (this is not a toll-free 

number) for an appointment. In 

addition, during the comment period, 

comments may be viewed online 

through the Federal Docket Management 

System (FDMS) at http:// 

www.Regulations.gov. 

FOR FURTHER INFORMATION CONTACT: 

Veterans Health Administration (VHA) 

Privacy Officer, Department of Veterans 

Affairs, 810 Vermont Avenue, NW., 

Washington, DC 20420; telephone (704) 

245–2492. 

SUPPLEMENTARY INFORMATION: 

I. Description of Proposed System of 

Records 

Amendments to this System of 

Records are the result of the 

improvement of the tracking system 

from the Veterans Health Information 

Systems and Technology Architecture 

(VistA) to the utilization of a centralized 

Web based system, Patient Advocate 

Tracking System (PATS). 

The primary function of the Patient 

Advocate Program is to serve as a direct 

channel of communication and 

mediation between VA healthcare 

facility management and individual 

patients, veterans who have applied for 

care, their friends, their families, VA 

healthcare providers and members of 

the community. A VA healthcare 

provider is anyone hired by VA and 

working at a VA facility be it a VA 

medical center (VAMC), Outpatient 

Clinic or Community-Based Outpatient 

Clinic. An employee may be full-time, 

part-time, or intermittent and includes 

temporary workers. Members of the 

community include congressional 

liaisons, veteran’s service organizations 

and attorneys. The program functions as 

the liaison between the patient and the 

healthcare system, ensures that patients 

receive entitled healthcare benefits and 

services in a dignified and 

compassionate manner, and ensures that 

healthcare facility policies and practices 

are in conformance with the VA 

Patients’ Rights and Responsibilities. 

The program is the primary source for 

response when veteran patients’ 

expectations are not met within the VA 

healthcare system. The Patient 

Advocates’ activities cross all 

organizational lines of authority at the 

healthcare facilities for the purpose of 

expressing patient concerns and 

resolution of patient complaints. 

Information collected from the program 

is integrated into the overall quality 

improvement plans and activities of the 

healthcare facility. The purpose of the 

system of records is to establish a 

repository for the information that is 

collected to accomplish the purposes 

described. Records are maintained at the 

local VA level on behalf of the veteran 

making the complaint or compliment so 

improvements may be made at the VA 

healthcare facility. 

II. Proposed Routine Use Disclosures of 

Data in the System 

A new Routine Use 15 is added. VA 

may disclose information from this 

system to the Equal Employment 

Opportunity Commission (EEOC) when 

requested in connection with 

investigations of alleged or possible 

discriminatory practices, examination of 

Federal affirmative employment 

programs, or other functions of the 

Commission as authorized by law or 

regulation. This routine use enables VA 

to provide information to EEOC to assist 

it in fulfilling its duties to protect 

employees’ rights, as required by statute 

and regulation. 

A new Routine Use 16 is added. VA 

may disclose information from this 

system to the Merit Systems Protection 

Board (MSPB), or the Office of the 

Special Counsel, when requested in 

connection with appeals, special studies 

of the civil service and other merit 

systems, review of rules and regulations, 

investigation of alleged or possible 

prohibited personnel practices, and 

such other functions promulgated in 5 

U.S.C. 1205 and 1206, or as authorized 

by law. This routine use enables VA to 

provide information to MSPB to assist it 

in fulfilling its duties as required by 

statute and regulation. 

A new Routine Use 17 is added. 

Disclosure to other Federal agencies 

may be made to assist such agencies in 

preventing and detecting possible fraud 

or abuse by individuals in their 

operations and programs. 

This routine use permits disclosures 

by the Department to report a suspected 

incident of identity theft and provide 

information and/or documentation 

related to or in support of the reported 

incident. 

A new Routine Use 18 is added. VA 

may, on its own initiative, disclose any 

information or records to appropriate 

agencies, entities, and persons when (1) 

VA suspects or has confirmed that the 

integrity or confidentiality of 

information in the system of records has 

been compromised; (2) the Department 

has determined that as a result of the 

suspected or confirmed compromise, 

there is a risk of embarrassment or harm 

to the reputations of the record subjects, 

harm to economic or property interests, 

identity theft or fraud, or harm to the 

security, confidentiality, or integrity of 

this system or other systems or 

programs (whether maintained by the 

Department or another agency or entity) 

that rely upon the potentially 

compromised information; and (3) the 

disclosure is to agencies, entities, or 

persons whom VA determines are 

reasonably necessary to assist or carry 

out the Department’s efforts to respond 

to the suspected or confirmed 

compromise and prevent, minimize, or 

remedy such harm. This routine use 

permits disclosures by the Department 

to respond to a suspected or confirmed 

data breach, including the conduct of 

any risk analysis or provision of credit 

protection services as provided in 38 


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Federal Register / Vol. 74, No. 105 / Wednesday, June 3, 2009 / Notices 26767 

U.S.C. 5724, as the terms are defined in 

38 U.S.C. 5727. 

III. Compatibility of the Proposed 

Routine Uses 

The Privacy Act permits VA to 

disclose information about individuals 

without their consent for a routine use 

when the information will be used for 

a purpose that is compatible with the 

purpose for which VA collected the 

information. In all of the routine use 

disclosures described above, the 

recipient of the information will use the 

information in connection with a matter 

relating to one of VA’s programs, will 

use the information to provide a benefit 

to VA, or disclosure is required by law. 

The notice of intent to publish and an 

advance copy of the system notice have 

been sent to the appropriate 

Congressional committees and to the 

Director of the Office of Management 

and Budget (OMB) as required by 5 

U.S.C. 552a(r) (Privacy Act) and 

guidelines issued by OMB (65 FR 

77677), December 12, 2000. 

Approved: May 18, 2009. 

John R. Gingrich, 

Chief of Staff, Department of Veterans Affairs. 

100VA10NS10 

SYSTEM NAME: 

Patient Advocate Tracking System 

(PATS)–VA. 

SYSTEM LOCATION: 

PATS application is installed on a 

centrally located system at Falling 

Waters. The backup system in case of 

disaster recovery scenario is located at 

Hines. The data entered into the 

application also resides on this central 

system. A limited set of information is 

transferred from this central system in 

Falling Waters to Austin Automation 

Center. This limited set of information 

transferred to Austin Automation Center 

is utilized to run specific reports for 

central business office. 

Patient contacts are coded in order to 

facilitate tracking of these contacts to 

show where system improvements 

might be made. Aggregate data are 

maintained at the Network and 

Headquarters levels for the development 

of reports to make system wide changes. 

Records are collected and stored 

electronically for ease of retrieval by 

individual patient names and ease in 

compiling aggregate data. 

CATEGORIES OF INDIVIDUALS COVERED BY THE

SYSTEM: 

The records include information 

concerning individual patients, veterans 

who have applied for care, their friends, 

their families, VA healthcare providers 

and members of the community. 

Members of the community include 

congressional liaisons, veterans service 

organizations and attorneys. 

CATEGORIES OF RECORDS IN THE SYSTEM: 

The records may include information 

maintained in paper records, and 

entered into a centralized Web based 

system, Patient Advocate Tracking 

System (PATS) related to concerns and 

complaints regarding an individual’s 

medical care, VA benefits, and/or 

encounters with healthcare facility 

personnel. The records include 

information that is compiled to review, 

investigate, and resolve these issues. 

AUTHORITY FOR MAINTENANCE OF THE SYSTEM: 

Title 38, United States Code, chapter 

73, section 7301 (b). 

PURPOSE(S): 

The records may be used for such 

purposes as producing various 

management and patient follow-up 

reports; responding to patient and other 

inquiries; conducting healthcare-related 

studies, statistical analysis, and resource 

allocation planning; providing clinical 

and administrative support to patient 

medical care; audits, reviews and 

investigations conducted by the staff of 

the healthcare facility, VISN, VHA 

Headquarters, and VA’s Office of 

Inspector General (OIG); law 

enforcement investigations; quality 

improvement reviews and 

investigations; personnel management 

and evaluation; employee ratings and 

performance evaluations; employee 

disciplinary or other adverse action, 

including discharge; advising healthcare 

professional licensing or monitoring 

bodies or similar entities or activities of 

VA and former VA healthcare 

personnel; accreditation of a facility by 

an entity such as the Joint Commission; 

and, notifying medical schools of 

medical students’ performance. The 

information is integrated into the overall 

quality improvement plans and 

activities of the facility and used to 

improve services and communications, 

as well as, to track categories of 

complaints and the locations of 

complaints in order to improve the 

delivery of healthcare. 

ROUTINE USES OF RECORDS MAINTAINED IN THE

SYSTEM, INCLUDING CATEGORIES OF USERS AND

THE PURPOSES OF SUCH USES: 

To the extent that records contained 

in the system include information 

protected by 45 CFR Parts 160 and 164, 

i.e., individually identifiable health 

information, and 38 U.S.C. 7332, i.e., 

medical treatment information related to 

drug abuse, alcoholism or alcohol abuse, 

sickle cell anemia or infection with the 

human immunodeficiency virus, that 

information cannot be disclosed under a 

routine use unless there is also specific 

statutory authority in 38 U.S.C. 7332 

and regulatory authority in 45 CFR Parts 

160 and 164 permitting disclosure. 

1. The record of an individual who is 

covered by a system of records may be 

disclosed to a Member of Congress, or 

a staff person acting for the Member, 

when the Member or staff person 

requests the record on behalf of and at 

the written request of the individual. 

2. Disclosure may be made to the 

National Archives and Record 

Administration and the General 

Services Administration for records 

management inspections conducted 

under authority of Title 44, Chapter 29, 

of the United States Code (U.S.C.). 

3. VA may disclose information from 

this system of records to the Department 

of Justice (DoJ), either on VA’s initiative 

or in response to DoJ’s request for the 

Information, after either VA or DoJ 

determines that such information is 

relevant to DoJ’s representation of the 

United States or any of its components 

in legal proceedings before a court or 

adjudicative body, provided that, in 

each case, the agency also determines 

prior to disclosure that release of the 

records to the DoJ is a use of the 

information contained in the records 

that is compatible with the purpose for 

which VA collected the records. VA, on 

its own initiative, may disclose records 

in this system of records in legal 

proceedings before a court or 

administrative body after determining 

that the disclosure of the records to the 

court or administrative body is a use of 

the information contained in the records 

that is compatible with the purpose for 

which VA collected the records. 

4. Disclosure may be made to any 

facility regarding the hiring, 

performance, or other personnel-related 

information with which there is, or 

there is proposed to be, an affiliation, 

sharing agreement, contract, or similar 

arrangement for purposes of 

establishing, maintaining, or expanding 

any such relationship. 

5. Disclosure may be made to a 

Federal agency or to a State or local 

government licensing board and/or to 

the Federation of State Medical Boards 

or a similar non-government entity 

which maintains records concerning 

individual employment histories or 

concerning the issuance, retention or 

revocation of licenses, certifications, or 

registration necessary to practice an 

occupation, profession or specialty, in 

order for the Department to obtain 

information relevant to a Department 

decision concerning the hiring, 

retention or termination of an employee 


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26768 Federal Register / Vol. 74, No. 105 / Wednesday, June 3, 2009 / Notices 

or to inform Federal agencies, licensing 

boards or the appropriate nongovernment entities about the 

healthcare practices of employees who 

resigned, were terminated, or retired 

and whose professional healthcare 

activity so significantly failed to 

conform to generally accepted standards 

of professional medical practice as to 

raise reasonable concern for the health 

and safety of patients receiving medical 

care in the private sector or from 

another Federal agency. These records 

may also be disclosed as part of an 

ongoing computer-matching program to 

accomplish these purposes. 

6. For program review purposes and 

the seeking of accreditation and/or 

certification, disclosure may be made to 

survey teams of the Joint Commission, 

College of American Pathologists, 

American Association of Blood Banks, 

and similar national accreditation 

agencies or boards with whom VA has 

a contract or agreement to conduct such 

reviews, but only to the extent that the 

information is necessary and relevant to 

the review. 

7. Disclosure may be made to a State 

or local government entity or national 

certifying body which has the authority 

to make decisions concerning the 

issuance, retention or revocation of 

licenses, certifications or registrations 

required to practice a healthcare 

profession, when requested in writing 

by an investigator or supervisory official 

of the licensing entity or national 

certifying body for the purpose of 

making a decision concerning the 

issuance, retention or revocation of the 

license, certification or registration of a 

named healthcare professional. 

8. Disclosure of information to the 

Federal Labor Relations Authority 

(including its General Counsel) when 

requested in connection with the 

investigation and resolution of 

allegations of unfair labor practices, in 

connection with the resolution of 

exceptions to arbitration awards when a 

question of material fact is raised, in 

connection with matters before the 

Federal Service Impasses Panel, and to 

investigate representation petitions and 

conduct or supervise representation 

elections. 

9. Disclosure of relevant information 

may be made to individuals, 

organizations, private or public 

agencies, or other entities with whom 

VA has a contract or agreement or where 

there is a subcontract to perform such 

services as VA may deem practicable for 

the purposes of laws administered by 

VA, in order for the contractor or 

subcontractor to perform the services of 

the contract or agreement. 

10. Disclosure may be made to a 

Federal agency, in response to its 

request, in connection with the hiring or 

retention of an employee, the issuance 

of a security clearance, the reporting of 

an investigation of an employee, the 

letting of a contract, or the issuance of 

a license, grant, or other benefit by the 

requesting agency, to the extent that the 

information is relevant and necessary to 

the requesting agency’s decision on the 

matter. 

11. Disclosure may be made to a 

Federal, State or local agency 

maintaining civil, criminal or other 

relevant information such as current 

licenses, if necessary to obtain 

information relevant to any agency 

decision concerning the hiring or 

retention of an employee, the issuance 

of a security clearance, the letting of a 

contract, or the issuance of a license, 

grant or other health, educational or 

welfare benefit. 

12. Disclosure of information may be 

made to the next-of-kin and/or the 

person(s) with whom the patient has a 

meaningful relationship to the extent 

necessary and on a need-to-know basis 

consistent with good medical-ethical 

practices. 

13. A record containing the name(s) 

and address(es) of present or former 

members of the armed services and/or 

their dependents may be disclosed 

under certain circumstances to any 

criminal or civil law enforcement 

governmental agency or instrumentality 

charged under applicable law with the 

protection of the public’s health or 

safety, if a qualified representative of 

such organization, agency or 

instrumentality has made a standing 

written request that such name(s) or 

address(es) be provided for a purpose 

authorized by law; provided that the 

record(s) will not be used for any 

purpose other than that stated in the 

request and that organization, agency or 

instrumentality is aware of the penalty 

provision of 38 U.S.C. 5701(f). 

14. VA may disclose on its own 

initiative any information in this 

system, except the names and home 

addresses of veterans and their 

dependents, which is relevant to a 

suspected or reasonably imminent 

violation of law, whether civil, criminal 

or regulatory in nature and whether 

arising by general or program statute or 

by regulation, rule or order issued 

pursuant thereto, to a Federal, State, 

local, Tribal, or foreign agency charged 

with the responsibility of investigating 

or prosecuting such violation, or 

charged with enforcing or implementing 

the statute, regulation, rule or order. On 

its own initiative, VA may also disclose 

the names and addresses of veterans and 

their dependents to a Federal agency 

charged with the responsibility of 

investigating or prosecuting civil, 

criminal or regulatory violations of law, 

or charged with enforcing or 

implementing the statute, regulation, 

rule or order issued pursuant thereto. 

15. VA may disclose information from 

this system to the Equal Employment 

Opportunity Commission (EEOC) when 

requested in connection with 

investigations of alleged or possible 

discriminatory practices, examination of 

Federal affirmative employment 

programs, or other functions of the 

Commission as authorized by law or 

regulation. 

16. VA may disclose information from 

this system to the Merit Systems 

Protection Board (MSPB), or the Office 

of the Special Counsel, when requested 

in connection with appeals, special 

studies of the civil service and other 

merit systems, review of rules and 

regulations, investigation of alleged or 

possible prohibited personnel practices, 

and such other functions promulgated 

in 5 U.S.C. 1205 and 1206, or as 

authorized by law. 

17. Disclosure to other Federal 

agencies may be made to assist such 

agencies in preventing and detecting 

possible fraud or abuse by individuals 

in their operations and programs. 

18. VA may, on its own initiative, 

disclose any information or records to 

appropriate agencies, entities, and 

persons when (1) VA suspects or has 

confirmed that the integrity or 

confidentiality of information in the 

system of records has been 

compromised; (2) the Department has 

determined that as a result of the 

suspected or confirmed compromise, 

there is a risk of embarrassment or harm 

to the reputations of the record subjects, 

harm to economic or property interests, 

identity theft or fraud, or harm to the 

security, confidentiality, or integrity of 

this system or other systems or 

programs (whether maintained by the 

Department or another agency or entity) 

that rely upon the potentially 

compromised information; and (3) the 

disclosure is to agencies, entities, or 

persons whom VA determines are 

reasonably necessary to assist or carry 

out the Department’s efforts to respond 

to the suspected or confirmed 

compromise and prevent, minimize, or 

remedy such harm. This routine use 

permits disclosures by the Department 

to respond to a suspected or confirmed 

data breach, including the conduct of 

any risk analysis or provision of credit 

protection services as provided in 38 

U.S.C. 5724, as the terms are defined in 

38 U.S.C. 5727. 


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Federal Register / Vol. 74, No. 105 / Wednesday, June 3, 2009 / Notices 26769 

POLICIES AND PRACTICES FOR STORING, 

RETRIEVING, ACCESSING, RETAINING, AND

DISPOSING OF RECORDS IN THE SYSTEM: 

STORAGE: 

Records are maintained on paper, 

microfilm, magnetic tape, disk, or laser 

optical media. In most cases, copies of 

back-up computer files are maintained 

at off-site locations. 

RETRIEVABILITY: 

Records are retrieved by name, social 

security number or other assigned 

identifiers of the individuals on whom 

they are maintained. 

SAFEGUARDS: 

1. Access to VA working and storage 

areas is restricted to VA employees on 

a ‘‘need-to-know’’ basis; strict control 

measures are enforced to ensure that 

disclosure to these individuals is also 

based on this same principle. Generally, 

VA file areas are locked after normal 

duty hours and the facilities are 

protected from outside access by the 

Federal Protective Service or other 

security personnel. 

2. Patient Advocate Tracking System 

(PATS) is a Web based application 

installed on central computer systems in 

a data center at Falling Waters, WV. The 

systems are maintained by authorized 

personnel. The end users access the 

application using the Web browser 

installed on their desktops. 

Additionally, access to computer rooms 

at health care facilities is generally 

limited by appropriate locking devices 

and restricted to authorized VA 

employees and vendor personnel. ADP 

peripheral devices are placed in secure 

areas (areas that are locked or have 

limited access) or are otherwise 

protected. Information in VistA may be 

accessed by authorized VA employees. 

Access to PATS application and data in 

the application is controlled at two 

levels; the systems recognize authorized 

employees by series of individually 

unique passwords/codes as a part of 

each data message, and the employees 

are limited to only that information in 

the application which is needed in the 

performance of their official duties. 

Information that is downloaded from 

PATS and maintained on personal 

computers is afforded similar storage 

and access protections as the data that 

is maintained in the original files. 

Access to information stored on 

automated storage media at other VA 

locations is controlled by individually 

unique passwords/codes. 

3. Access to the Austin VA Data 

Processing Center is generally restricted 

to Center employees, custodial 

personnel, Federal Protective Service 

and other security personnel. Access to 

computer rooms is restricted to 

authorized operational personnel 

through electronic locking devices. All 

other persons gaining access to 

computer rooms are escorted. 

Information stored in the computer may 

be accessed by authorized VA 

employees at remote locations including 

VA health care facilities, Information 

Systems Centers, VA Central Office, and 

Veteran Integrated Service Networks. 

Access is controlled by individually 

unique passwords/codes which must be 

changed periodically by the employee. 

RETENTION AND DISPOSAL: 

Paper records and information stored 

on electronic storage media are 

maintained and disposed of in 

accordance with Records Control 

Schedule 10–1, Section XLV, as 

authorized by the National Archives and 

Records Administration of the United 

States. 

SYSTEM MANAGER(S) AND ADDRESS: 

Official responsible for policies and 

procedures; Director, National Veteran 

Service and Advocacy Program, 

Department of Veterans Affairs, 810 

Vermont Avenue, NW., Washington, DC 

20420. Officials maintaining the system 

are the Director at the facility where the 

individual were associated. 

NOTIFICATION PROCEDURE: 

Individuals who wish to determine 

whether this system of records contains 

information about them should contact 

the VA facility location at which they 

are or were employed or made or have 

contact. Inquiries should include the 

person’s full name, social security 

number, dates of employment, date(s) of 

contact, and return address. 

RECORD ACCESS PROCEDURE: 

Individuals seeking information 

regarding access to and contesting of 

records in this system may write, call or 

visit the VA facility location where they 

are or were employed or made contact. 

CONTESTING RECORD PROCEDURES: 

(See Record Access Procedures 

above.) 

RECORD SOURCE CATEGORIES: 

The patient, family members, and 

friends, employers or other third parties 

when otherwise unobtainable from the 

patient or family; Patient Medical 

Records—VA (24VA136); private 

medical facilities and healthcare 

professionals; State and local agencies; 

other Federal agencies; VISNs, Veterans 

Benefits Administration automated 

record systems (including Veterans and 

Beneficiaries Identification and Records 

Location Subsystem—VA (38VA23) and 

the Compensation, Pension, Education 

and Rehabilitation Records—VA 

(58VA21/22); and various automated 

systems providing clinical and 

managerial support at VA healthcare 

facilities. 

[FR Doc. E9–12954 Filed 6–2–09; 8:45 am] 

BILLING CODE 8320–01–P 


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