Defense Privacy and Civil Liberties Office

U.S. Department of Defense

System of Record Notices (SORNs)

DOD Component Notice

Defense Health Agency

EDHA 09

SYSTEM NAME:

Medical Credentials/Risk Management Analysis System (CCQAS)  (November 18, 2013,  78 FR 69076)

SYSTEM LOCATION:

Armed Forces Institute of Pathology, Department of Legal Medicine, 8403 Colesville Road, Suite 860, Silver Spring, MD 20910-9813.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

The credentials and privileges component of the Centralized Credentials Quality Assurance System (CCQAS) includes all DoD Medical Treatment Facility (MTF) health care providers. The medical malpractice risk management component includes those health care providers who have been involved with medical malpractice cases. The adverse privilege actions component includes DoD health care providers who have been the subject of adverse privilege actions with the military health system. Health care beneficiaries whose medical treatment is the basis for medical malpractice or adverse privileging action.

CATEGORIES OF RECORDS IN THE SYSTEM:

The credentials and privileges component of CCQAS consists of personal identifier information of all DoD health care providers. Additional provider information includes demographic data, licensure data, education and graduate medical education information, specialty information, certification information and medical readiness data. The malpractice component relates to medical malpractice claims recorded against the Department of Defense. Record fields consist of provider information, allegation-related information, diagnosis and procedure information, dates of incident, filing and closure, injury information, Social Security Numbers of military sponsors of malpractice claimants, and professional review assessments. Adverse privilege action fields include provider information, the type of reasons for actions, and relevant dates. Subject records are `medical quality assurance records' if produced or compiled by the Department of Defense incident to an activity to assess the quality of medical care, including activities conducted by individuals, military medical or dental treatment facility committees, or other review bodies responsible for greatly assurance, credentials, infection control, patient care assessment (including treatment procedures, blood, drugs, and therapeutics), medical records, health resources management review and identification and prevention of medical or dental incidents and risks.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

42 U.S.C. 11131-11152 (Pub.L. 99-660, Health Care Quality Improvement Act of 1986); 10 U.S.C. 1102; DoD Directive 6025.14, DoD Participation in the National Practitioner Data Bank; and E.O. 9397 (SSN).

PURPOSE(S):

The system collects and manages malpractice and adverse privilege actions claims data provided by the military services. Data are also used to manage credentials and privileges of health care providers in the Military Health System, and to conduct trend analysis on provider and malpractice data in keeping with DoD Medical Quality Assurance programs. Data from this system is use to report DoD adverse privileging actions and malpractice data to the National Practitioner Data Bank and to the state licensing boards of the individual provider.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:

  • To the Department of Health and Human Services for inclusion in the National Practitioner Data Bank and to state licensing authorities for the purpose of reporting DoD adverse privileging actions and malpractice data as provided in 42 U.S.C. 11131-11152.
  • If the records are `medical quality assurance records,' they may be disclosed outside the DoD as a routine use only as follows:
  • To a Federal executive agency or private organization, if such medical quality assurance record or testimony is needed by such agency or organization to perform licensing or accreditation functions related to DoD health care facilities or to perform monitoring, required by law, of DoD health care facilities.
  • To an administrative or judicial proceeding commenced by a present or former DoD health care provider, concerning the termination, suspension, or limitation of clinical privileges of such health care provider.
  • To a governmental board or agency or to a professional health care society or organization, if such medical quality assurance record or testimony is needed by such board, agency, society, or organization to perform licensing, credentialing, or the monitoring of professional standards with respect to any health care provider who is or was a member or an employee of the DoD.
  • To a hospital, medical center, or other institution that provides health care services, if such medical quality assurance record or testimony is needed by such institution to assess the professional qualifications of any health care provider who is or was a member or employee of the DoD and who has applied for or been granted authority or employment to provide health care services in or on behalf of such institution.
  • To a criminal or civil law enforcement agency or instrumentality charged under applicable law with the protection of the public health or safety, if a qualified representative of such agency or instrumentality requests that such record or testimony be provided for a purpose authorized by law.
  • To officials of an administrative or judicial proceeding commenced by a criminal or civil law enforcement agency or instrumentality to serve the defined purposes proposed for that proceeding.

The 'Blanket Routine Uses' set forth at the beginning of OSD's compilation of systems of records notices do not apply to medical quality assurance records maintained in this system of records.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:


STORAGE:

Records are maintained on paper and on a microcomputer system.

RETRIEVABILITY:

Hard copy is filed by the sponsor's Social Security Number. Electronic records may be accessed by search of the Social Security Number of the health care provider or in the case of a patient, by the Social Security Number of the military sponsor.

SAFEGUARDS:

Records are accessed by authorized personnel having an official need-to-know who have been trained for handling Privacy Act data. Hard copy records are maintained in locked cabinets in restricted access areas. Access to computer files is restricted to a user IDs and password system managed by the CCQAS system administrator.

RETENTION AND DISPOSAL:

Disposition pending (until NARA disposition is approved, treat as permanent).

SYSTEM MANAGER(S) AND ADDRESS:

TRICARE Management Activity, Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, VA 22041-3206.

NOTIFICATION PROCEDURE:

Individuals seeking to determine whether information about themselves is contained in this system should address written inquiries to the TRICARE Management Activity, Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, VA 22041-3206.

Requests for information should contain the full name of the health care provider or military sponsor, the requesting individual's Social Security Number (or Social Security Number of a military sponsor, if inquiry is by a claimant), military department and medical facility and signature of the requester, and the time frame in which the case record was developed.

RECORD ACCESS PROCEDURES:

Individuals seeking access to information about themselves contained in this system should address written inquiries to the TRICARE Management Activity, Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, VA 22041-3206.

Requests for access should contain the full name of the health care provider or military sponsor, the requesting individual's Social Security Number (or Social Security number of a military sponsor, if inquiry is by a claimant), military department and medical facility and signature of the requester, and the time frame in which the case record was developed.

CONTESTING RECORD PROCEDURES:

The OSD rules for accessing records, for contesting contents and appealing initial agency determinations are published in OSD Administrative Instruction 81; 32 CFR part 311; or may be obtained from the system manager.

RECORD SOURCE CATEGORIES:

Medical facilities of the military departments, the National Practitioner Data Bank, and other health care practitioners.

EXEMPTIONS CLAIMED FOR THE SYSTEM:

None.

FEDERAL REGISTER HISTORY:

February 2, 2000, 65 FR 4947; November 18, 2013, 78 FR 69076