[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
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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
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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
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Bill # Bill Name Sponsor Position
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H.R. 1490 Veteran's Privacy Act Miller Support
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H.R. 1792 Infectious Disease Reporting Act Coffman Support
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H.R. 1804 Foreign Travel Accountability Act Huelskamp Support
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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.