Announcement of Competition Under the America COMPETES Reauthorization Act of 2011: Veterans Medical Appointment Scheduling System

AGENCY:

Department of Veterans Affairs.

Action:

Notice.

SUMMARY:

To encourage development of systems that help Veterans schedule appointments to receive care from the Veterans Health Administration and to reduce risks in the future procurement and deployment of those systems, the Secretary of Veterans Affairs (VA) announces a prize contest under Section 105 of the America COMPETES Reauthorization Act of 2011, Public Law 111-358 (2011), 15 USC 3719 (the “Act”).

DATES:

Entries will be accepted until 10:59 p.m. EDT on March 1, 2013. Winners will be announced on or about 90 days after the entry deadline.

ADDRESSES:

The official contest Web site is http://vascheduling.challenge.gov. Contestants must register via the official contest Web site as provided in Section 4 of the Rules set forth in this notice. Entries must be submitted electronically as specified in Section 5 of the Rules.

FOR INFORMATION CONTACT:

Michael A. Moore, Special Assistant to Chief Technology Officer, Office of the Secretary, Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420; (202) 461-5764. (This is not a toll-free number.) Also, see Section 11, below.

SUPPLEMENTARY INFORMATION:

Introduction

VA uses the Medical Scheduling Package (MSP), a component in its VistA electronic health record (EHR) system, to perform multiple interrelated functions to bring patients, clinicians and other resources together so care can be delivered. The MSP also captures data which allows VA to measure, manage and improve access to care, quality of care, operating efficiency and operating and capital resources.

VA's current MSP is more than 25 years old. It does not meet current requirements and does not provide the flexibility to support new and emerging models of care. VA will be replacing the MSP.

Using the authority of the Act and this contest, VA will obtain information that will allow it to understand various risks and thus reduce risks inherent in the procurement and deployment of highly complex mission critical software which integrates with VA's VistA system.

VA's Health Delivery System

VA's Veterans Health Administration (VHA) operates one of the largest integrated health delivery systems in the United States, delivering comprehensive care to approximately six million Veterans through a network of health care facilities owned and staffed by VA, academic medical affiliates and other contracted providers, contracted networks, and episodic fee-for-service purchases. Veterans scheduled approximately 80 million outpatient clinical visits—more than 300,000 each working day in FY 2011.

VA delivers care through 21 Veterans Integrated Services Networks (VISNs) which administer:

• 152 hospitals, sometimes known as VA Medical Centers or VAMCs,
• 971 outpatient clinics—most of which are extensions of a parent hospital, and
• 133 community living centers which deliver skilled nursing and extended care.

VHA sites of care are distributed across the United States and Puerto Rico with additional clinics in Guam and the Philippines. Veterans are administratively aligned with the hospital of their choice but may receive care through any hospital.

VA's care delivery model is centered in the Patient Aligned Care Team (PACT), VA's implementation of the Patient Centered Medical Home.

• PACTs consist of multidisciplinary clinical and support staff that deliver all primary care and coordinate the remainder of patients' needs, including specialty care.
• Veterans assigned to a PACT may schedule appointments with any member of the team.
• Routine appointments with specialists are often scheduled based on a PACT referral; specialty care referrals can also come from clinicians providing inpatient care, the Emergency Department, community providers, or patients themselves.
• Veterans generally schedule their own follow-up appointments with specialists or specialty care services without the intervention of the PACT.

Appointment scheduling is currently performed primarily via telephone, in person, or mail. The intervention of a VA employee is currently required to make appointments. VA needs to enable Veterans to schedule their own appointments electronically via online and mobile devices.

VA also needs to schedule and coordinate care across internal and external administrative, or system, boundaries. As examples:

• Veterans may choose to live in different states at different times of the year and need to make appointments to receive care where they live when they need it.
• A clinician who can provide needed care for a Veteran may be located at a different hospital, in different VISN or at an external academic affiliate or contract medical group.
• A physician who will be examining a Veteran to determine nature and extent of a service-related disability may also be located at a different hospital, VISN, or be delivering examination services under contract.
• Telemedicine technologies can support care delivery by a clinician who is physically located at a different hospital or even in a different VISN than the physical location where the Veteran will receive the care.
• PACTS need to coordinate care with non-VA community providers when Veterans choose to receive care both inside and outside the VA system.
• Support services such as non-VA transportation services must be coordinated.

VA currently relies on the MSP to perform non-scheduling functions including workload data capture and a broad range of workload and other management reports.

VA's Technical Infrastructure

VA's current medical MSP is a component (application) of its VistA electronic health record (EHR) system.

The MSP is tightly integrated with VistA; it reads data from more than 130 other VistA applications and has read/write functionality with more than 30 additional applications.

VistA systems are localized at the hospital level and will remain so for at least the near-term future. Each hospital operates a separate instance of VistA. Portions of the VistA code are identical in each instance; different instances of VistA may have different interfaces between the MSP and other VistA applications.

Any replacement product must not negatively impact any current applications that interface with the MSP or its data.

Replacing VA's Medical Scheduling Software

VA intends to replace the current MSP with a scheduling product which is a standards-based, modular, extensible and scalable, certified as compliant and fully interoperable with the production version of VistA now held by the Open Source Electronic Health Record Agent (OSEHRA), http://www.osehra.org/.

The replacement product must effectively perform VA's scheduling-centric and scheduling-related legacy business functions. It must also demonstrate it can meet non-functional requirements including integration with multiple instances of VistA.

Role of This Contest in Replacement of VA's Medical Scheduling Software

This contest will achieve two significant goals in replacement of VA's MSP.

• First, it will mitigate risks which VA has identified as contributing to the failure of previous attempts to replace the MSP.
• Second, it will encourage commercial software vendors to actively engage in development of solutions, by providing a basis on which VA can rate proposals in any subsequent procurement of a replacement for the MSP.

Risk Mitigation. VA's previous attempts to replace the MSP module in VistA were not successful. Assessments of the reasons for these failures identified three critical risks that VA will mitigate via this contest:

• Market Research: One of the reasons VA was not successful was lack of sufficient knowledge about the actual capabilities of vendors to meet VA's business needs. Via this contest, VA will obtain valuable information about industry's current ability to meet VA's business needs via actual demonstration of product capabilities in a VA-defined test environment. Additionally, VA will be able to assess industry's ability to perform not just scheduling-centric functions offered by most robust scheduling products, but also scheduling-related workload-capture and data-reporting functions that are unique to VA. This contest will also provide VA with valuable information about changes in business workflows that will be needed when a replacement product is deployed.
• Integration issues: Another reason why earlier attempts were not successful was VA's inability to effectively integrate replacement software with the VistA system. Since then, VA has elected to place VistA in the open source community and to prefer software products which are openly architected to integrate with VistA. Via this contest, VA will be able to assess industry's ability to technically integrate its products with Open Source VistA.
• Test environment: Analyses for the previous lack of success also found that VA was unable to effectively test replacement software to assure it met functional and technical requirements. To support this contest VA will develop and deploy a test environment, judge contest entries using that test environment, assess the effectiveness of the test environment, then use the results of that assessment to adjust the test environment as needed to support testing in a procurement of a deployable scheduling replacement product.

Via this contest, VA will obtain the needed information in a lower-risk-of-failure context than if directly procuring a deployable replacement product. VA believes the information it obtains via direct evaluation of entries in this contest will be superior in quality and can be obtained in significantly less time via this contest route than by custom development. VA also believes the aggregate cost of the contest is highly competitive with the cost of acquiring the same types of information via other arrangements. If industry is not able to demonstrate it can meet VA's needs then no prize will be awarded.

Effect on Subsequent Procurement. VA anticipates that compatibility with Open Source VistA will be among the requirements in any subsequent procurement of a replacement for the MSP. Demonstration of open source compatibility in this contest may be taken into consideration in the rating of proposals in any subsequent procurement.

Contest Requirements and Rules

1. Subject of the Contest. The goal of this contest is to encourage creation of systems that help Veterans make appointments to receive outpatient and ambulatory care from the Veterans Health Administration. VA also seeks to obtain information which will allow it to reduce the risks inherent in procurement and deployment of a replacement medical scheduling product.

2. Numbers and Amounts of Prizes.

a. VA will award monetary prizes of as much as $3 Million to as many as three entrants that deliver demonstration software or service which the judges determine delivers the required functionality and is compatible with Open Source VistA, as described in this notice.

b. Judges will determine the number and amount of monetary prizes. Judges may determine that no prize will be awarded.

c. VA may consider compatibility with Open Source VistA as demonstrated in this contest when considering proposals in any subsequent procurement of MSP-related product(s).

3. Basis on which a winner will be selected. (See section 6 for judging procedures and point system.) Winners will be selected from entries that demonstrate to the satisfaction of the judges that they:

a. Perform as required by these rules while interfaced with VA-provided VistA instances running on VA-provided virtual machines. Performance with other versions or instances of VistA will not be considered.

b. Perform each of the scheduling-centric business functions defined by VA on Attachment A to this notice, including particularly:

1. Automated scheduling of an appointment at any VA site from any location by a Veteran using online or mobile devices or by a VA employee acting as a scheduler, and

2. Where semi-automated scheduling is performed, use of a calendar-view format presentation of available resource(s), with support for point-and-click scheduling when the calendar view shows needed resources to be available.

c. Perform all or some of the designated Scheduling-Related/VA-Specific business functions set forth on Attachment B to this notice, including functions related to workload capture, data analysis and reporting, operational and capital planning and travel reimbursement.

d. Perform each of the non-functional requirements set forth on Attachment C to this notice.

e. Do so using open APIs, including open source code for the interfaces between the product and VistA, and at the option of the entrant, using open source modules to support some or all of the product's additional functions. Note: Entries that consist of proprietary code are not precluded, so long as interfaces with VistA use open APIs and the software implementing the interfaces is made available as open source code.

4. Registration for this Contest.

a. Not later than 10:59 p.m. EST February 1, 2013, potential entrants must request registration for the contest by submitting a letter via the “Submissions” section of the official contest Web site, http://vascheduling.challenge.gov. The letter must be signed by the entrant if an individual or by a corporate officer if the entrant is a corporation. The letter must:

1. Attest that the potential entrant is eligible to participate in this contest per the requirements of this notice and the Act,

2. Attest that disqualifying factors for participation in the contest, as defined in this notice and the Act, do not exist,

3. Contain a listing (which may be an attachment) of all owners of all intellectual property (IP) which the potential entrant will incorporate or use in its entry,

4. Contain a listing (which may be an attachment) of all components of the entry that the potential entrant will designate as open source,

5. Attest that the potential entrant is the owner or licensee of any and all intellectual property (IP) to be incorporated in the entry, and by virtue of such ownership or license has full right and authority to authorize, and does authorize VA (and any of VA's consultants, contractors or collaborating federal agencies) to reproduce, test, demonstrate and use such IP for any purpose related to this contest, including judging,

6. Attest that the potential entrant:

a. Is the owner or licensee of any and all IP in open source modules designated by the entrant to be incorporated in the entry;

b. Has full right and authority to convey all rights set forth in an Apache 2.0 license in the designated open source modules; and

c. Will, if selected as a winner in this contest, apply the Apache 2.0 license to the designated source modules and contribute the software to OSEHRA.

7. Attest that the potential entrant agrees it is bound by all rules, assumes all risks, and has acquired or will acquire any insurance required by this notice.

8. State whether the potential entry will be an installable software, software as a service (SaaS) or contain components of both, and whether the contestant intends to supply resources external to the virtual machines to be provided by VA to support or execute the contestant's entry (e.g., servers that support SaaS), and identifying those resources.

9. State the name, business and email address and telephone number of the individual who is the designated contact for and who will receive all communications related to this contest.

a. The letter, attachments, and any additional written materials must be submitted electronically in a format fully compatible with both Microsoft Word 2007 and Adobe Acrobat Pro 9.

b. Letters which do not include each of the items stated in paragraph 4(a) and in the required formats will not be effective to register the potential entrant.

c. At the option of the potential entrant, letters may be accompanied by additional written materials describing the potential entrant or the entry not exceeding ten 81/2 by 11 inch pages in length. These materials will be in a format fully compatible with Microsoft Word 2007 or Adobe Acrobat Pro 9.

d. Letters and all attachments are subject to file size limits of the official contest Web site.

5. Procedures for Submitting Entries; Confidentiality of Entries.

a. Potential entrants that submit a letter meeting the requirements set forth in Section 4, above, will be registered for this contest.

1. Registered contestants will be sent an email at the address provided by the contestant. The email will contain instructions on how to access VA-supplied virtual machine space to integrate, configure, and test their solution prior to submission as an entry.

2. Depending on the number of potential entrants that register for this contest and the ready availability of virtual machines, there may be a delay between submission of a letter requesting registration and an email accepting the letter. There may also be delay in actual availability of virtual machines. Potential entrants assume all risk of such delays and the possibility that any delay may leave them insufficient time before the entry deadline to fully integrate, configure and test their solution.

b. Each contestant will be supplied with three virtual machines.

1. Each machine will be loaded with a sample instance of VistA with sample data, each with a different patch level and each set to operate in a different time zone. This will permit configuration and testing of multiple-site scheduling functions.

2. Two of the virtual machines will use the Red Hat Enterprise Linux 6.1 (64 bit) operating system. The third machine will use the Windows Server 2008 (32 bit) operating system.

3. Contestants may begin installation and testing of their product immediately upon receipt of access to the virtual space.

c. Contestants may provide resources in addition to the virtual machines provided by VA, e.g., servers which support SaaS.

1. Integration of all external resources with the virtual machines provided by VA will be the sole responsibility of the contestant.

2. All expenses related to any additional resources will be at the sole cost and expense of the contestant.

d. VA will post Screening Use Cases in the “Updates” section on the contest Web site, http://vascheduling.challenge.gov. These Use Cases will be used in the evaluation of the functional and technical capabilities of entries.

e. Each contestant will integrate their solution with the provided VistA instances, and will provide test plans and automated test scripts that demonstrate performance of the functional requirements on Attachments A, B, and C in the context of the Screening Use Cases.

f. Test scripts must meet the following requirements:

1. Scripts must be submitted as open source software, in accordance with the criteria posted on the contest Web site, including documentation and OSI-approved open source licenses, with the Apache 2.0 license applied to all code. The submittal must include instructions for execution and a copy of results for comparison.

2. Scripts must operate in the OSEHRA CTEST environment.

3. Scripts must be repeatable, that is, they must include separated executable automated code that restores all data values to their previous state, allowing the test to be rerun with consistent results.

4. If any changes are made to the provided VistA instances, those changes must also be submitted as open source code, compliant with the criteria posted on the contest Web site including documentation and OSI-approved open source licenses, with the Apache 2.0 license applied to all code. This includes the VistA-side components of any interface code, such as Applications Program Interfaces (APIs).

5. Contestant must submit repeatable open source test scripts for all specified use cases in accordance with the instructions posted on the contest Web site, with instructions and results from their testing.

g. Each registered contestant that wishes its or their product to be formally entered in the contest shall, not later than 10:59 p.m. EST March 1, 2013, submit a letter via the “Submissions” section of the official contest Web site, http://vascheduling.challenge.gov. The letter must be signed by the entrant if an individual or by a corporate officer if the entrant is a corporation. The letter must state:

1. The registered contestant has completed installation of its or their product, test plans and automated test scripts on the virtual servers provided by VA, has completed testing to its or their satisfaction, and formally submits the contents of the virtual machines as their entry in the contest.

2. The letter submitted by the registered contestant at the time of registration is incorporated by reference and the contents of that letter are in all respects ratified and confirmed. Provided, however, that contestants may at their option amend the contents of the following sections of the registration letter:

a. Section 4(a)(3), relating to a listing of the owners of all IP incorporated into the contestant's entry;

b. Section 4(a)(4), relating to the components of the entry which the contestant will designate as open source;

c. Section 4(a)(8), relating to whether the entry is installable software, SaaS, or contains components of both and whether resources external to the VA-supplied virtual machines is or will be used by the contestant to support or execute contestant's entry.

d. Section 4(a)(9), relating to contact information.

e. Section 4(d), relating to optional descriptive materials.

3. If resources external to the VA-supplied virtual machines is or will be used by a contestant to support or execute contestant's entry, the letter shall also state: “[I/We] certify that from and after the submission of this letter until the announcement of the contest winners, no changes whatsoever will be made to any of the external software or resources [I/we] have designated to support or execute [my/our] entry.”

4. Registered contestants that do not submit a letter as required by this subsection will be deemed to have withdrawn from the contest and the contents of virtual machines assigned to them will not be judged.

5. Letters formally submitting entries for judging, along with all attachments, are subject to file size limits of the official contest Web site.

h. All virtual machine environments will be frozen as of 10:59 p.m. EST March 1, 2013. If a registered contestant has submitted a letter as provided in section 5(g), then the contestant's entry in this contest will be deemed to be the code and other content installed on the virtual machines at the time the virtual machine environment is frozen, as well as the code and other contest installed on external resources if any, at that time.

i. Submissions or entries will not be readily available to other entrants or to the public. These materials may, however, be disclosable as determined solely by VA pursuant to its obligation to comply with the Freedom of Information Act (FOIA), 5 U.S.C. 552.

6. Judging of Entries.

a. Method. VA may use any technical means it determines suitable to evaluate any entry, award points and determine any winner in this contest. All or any part of the evaluation may be conducted by third parties under VA supervision. VA may use an entrant's submitted testing scripts, routines and software to perform all or part of any evaluation and judging. VA may, at its option, request an entrant to demonstrate its or their entry either in-person or via web-based technologies.

b. Technical Evaluation. VA contemplates it will judge entries as follows.

1. An entry will first be evaluated to determine Open Source VistA Compatibility, i.e.:

a. Whether it is compatible with the three separate VistA instances on the VA-supplied virtual machines, and

b. Whether the interfaces between the product and VistA are based on software code that either is or can become open source.

VA contemplates substantial portions of this evaluation will be conducted by OSEHRA. Any entry that does not demonstrate Open Source VistA Compatibility to the satisfaction of the judges will be disqualified and will not be further considered for a prize.

2. An entry which demonstrates Open Source VistA Compatibility will then be evaluated to determine whether it performs all Non-Functional requirements set forth on Attachment C. Any entry which does not demonstrate to the satisfaction of the judges that it can perform the Non-Functional Requirements on Attachment C will be disqualified and will not be further considered for a prize.

3. Entries which demonstrate Open Source VistA Compatibility and also demonstrate they meet Non-functional Requirements will be deemed to be Technically Compatible.

c. Functional Evaluation. VA will evaluate an entry that has demonstrated Technical Compatibility to determine whether it can perform the Scheduling-centric functions defined on Attachment A. An entry that does not demonstrate to the satisfaction of the judges that it can perform the Scheduling-centric functions defined on Attachment A will be disqualified and will not be further considered for a prize.

d. VA-Specific Functions. An entry that demonstrates Technical Compatibility and also demonstrates it can perform all of the Scheduling-centric functions on Attachment A will then be evaluated to determine whether it can perform any of the Scheduling-related or VA-specific functions defined on Attachment B.

1. Judges will award the designated points for each function defined on Attachment B that they determine is performed by the entry.

2. A maximum of 120 points can be awarded for performance of functions defined on Attachment B.

e. Open Source Content. An entry that demonstrates Technical Compatibility and also demonstrates it can perform all of the Scheduling-centric functions on Attachment A will also be evaluated by the judges to determine the extent to which it uses software modules, as designated by the entrant, which are or will become open source.

1. Interfaces between the product and VistA will not be considered in this phase of the judging, as they are a required component of Open Source Compatibility.

2. Judges will evaluate the significance of the designated open source modules in delivering required functions. For example, judges may determine that modules that provide common platform services or business logic are more significant than modules that deliver the presentation layer.

3. Judges may award a maximum of 30 points for significant open source modules incorporated in an entry.

Points awarded by the judges will determine the winners of this contest.

7. Eligibility. To be eligible to participate in this contest and win a prize:

a. Entrants must register for this contest as set forth in Section 4 and submit a letter formally entering their product in the contest as set forth in Section 5.

b. If an individual, an entrant must be a citizen of or permanent resident of the United States. If an entity, an entrant must be incorporated in and maintain a primary place of business in the United States.

c. An entrant may not be a Federal entity or Federal employee acting in the scope of the employee's employment.

d. Entrants shall be responsible for obtaining insurance they deem necessary to cover claims by any third party for death, bodily injury, or property damage or loss resulting from an activity carried out in connection with or participation in this contest.

e. Entrants must have complied with all requirements of this notice and all requirements established by the Act.

f. By registering for or submitting an entry in this contest, contestants and entrants agree to assume any and all risks and waive any claims against the Federal Government and its related entities (except in the case of willful misconduct) for any injury, death, damage, or loss of property, revenue or profits, whether direct, indirect, or consequential, arising from their participation in this contest, whether the injury, death, damage, or loss arises through negligence of otherwise. Provided, however, that by registering or submitting an entry, contestants and entrants do not waive claims against VA arising out of the unauthorized use or disclosure by the agency of the intellectual property, trade secrets, or confidential information of the entrant.

8. Intellectual Property (IP).

a. VA is not responsible for a registered contestant's or entrant's lack of compliance with copyright, trademark, patent or other Federal law. Contestants and entrants will hold harmless, defend, and indemnify the Federal Government and any agency or component thereof from and against any suit, claim, demand, liability, damages, costs and expenses (including attorneys' fees and costs of defense), of whatever nature, whether groundless, false or fraudulent, arising out of any use, licensing or relicensing of any IP that is incorporated in the entrant's entry.

b. Without limiting the generality of the foregoing and in explanation but not limitation of sections 4(a)(5) and 4(a)(6), contestants and entrants are responsible for obtaining all third-party licenses required to allow the VA and its contractors to receive any and all IP installed on any virtual machine, to run any and all testing software or scripts, and to demonstrate an entrant's product. Windows and Linux operating systems will be accepted; however contestants and entrants will need to obtain proper licenses for running any Windows in any resource external to the VA-supplied virtual machines that is or will be used by the contestant to support or execute contestant's entry.

c. The winner(s) of this contest will, in consideration of the prize to be awarded, apply the Apache 2.0 license to the designated open source modules (including the interfaces between winner's product and VistA) and contribute the modules to OSEHRA.

d. VA may in its sole and absolute discretion choose to negotiate with any entrant to acquire, license, use or convey any other intellectual property developed in connection with this contest.

9. Judges and Judging Procedures.

a. Subject to the requirements of 15 U.S.C. 3719(k), the VA Assistant Secretary for Information Technology, acting on behalf and with the authority of the Secretary of VA, will appoint one or more qualified individuals to act as judges of this contest and may appoint himself as a judge. Judges may include individuals from outside VA, including from the private sector. Judges will operate in a transparent manner.

b. A judge may not have a personal or financial interest in, or be an employee, officer, director, or agent of any entity that is a registered entrant in this contest, and may not have a familial or financial relationship with an individual who is a registered entrant.

c. Specific tasks related to the judging process may be delegated to VA employees or employees of a collaborating Federal agency. Third parties may perform judging tasks subject to supervision by VA or by a collaborating Federal agency.

d. Judges shall have the authority to disregard any minor error in any entry that does not create any substantial benefit or detriment to any entrant.

e. Judges shall have the authority to obtain from any entrant additional information, clarification of information, or assistance in resolving any technical issues relating to the installation, use, testing or evaluation of any entry, so long as no substantial benefit or detriment to any entrant occurs thereby.

f. Decisions of the judges are final.

10. Payment of Prizes.

a. Prior to payment of any prize, an apparent winner must execute (at VA's option, under oath or affirmation) such documents as VA may reasonably require, including but not limited to:

1. Declarations and certifications that relate to the apparent winner's eligibility to participate in this contest, the absence of any disqualifying factor, the assumption of risks and acquisition of any insurance required by the rules,

2. The conveyance of any intellectual property required by the rules, and

3. Any other matter that VA may reasonably require, including but not limited to information reasonably necessary for VA to make payment via electronic funds transfer and issue IRS Forms 1099 according to VA's fiscal policy.

11. Procedures for obtaining additional information.

a. During the period of the contest, potential contestants or entrants may submit questions or comments to VA using the “Discussions” section on the official contest Web site, http://vascheduling.challenge.gov.

b. VA may choose not to respond to any question or comment or to delete questions or comments that it determines are not relevant to the competition or which seek technical guidance. VA's responses on the “Discussion” section of the contest Web site are not official guidance.

c. VA may also provide information and official guidance related to this contest on the “Updates” section of the official contest Web site, http://vascheduling.challenge.gov. An entrant is bound by official guidance on the “Updates” section that is posted prior to formal submission of their entry.

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. John R. Gingrich, Chief of Staff, Department of Veterans Affairs, approved this document on October 11, 2012, for publication.