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



 
  ELECTRONIC HEALTH RECORD U-TURN: ARE VA AND DOD HEADED IN THE WRONG 
                               DIRECTION? 

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      WEDNESDAY, FEBRUARY 27, 2013

                               __________

                            Serial No. 113-6

                               __________

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

            Helen W. Tolar, Staff Director and Chief Counsel

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 
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                            C O N T E N T S

                               __________

                           February 27, 2013

                                                                   Page

Electronic Health Record U-Turn: Are VA and DoD Headed In The 
  Wrong Direction?...............................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman, Full Committee.......................     1
    Prepared Statement of Chairman Miller........................    34
Hon. Michael Michaud, Ranking Minority Member, Full Committee....     2
    Prepared Statement of Hon. Michaud...........................    35

                               WITNESSES

Hon. Roger W. Baker, Assistant Secretary for Information and 
  Technology and Chief Information Officer, U.S. Department of 
  Veterans Affairs...............................................     4
    Prepared Statement of Mr. Baker and Dr. Petzel...............    36
    Accompanied by:

      Hon. Robert A. Petzel, M.D., Under Secretary for Health, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs
Hon. Jonathan A. Woodson, Assistant Secretary of Defense for 
  Health Affairs, Director, TRICARE Management Activity, U.S. 
  Department of Defense..........................................     6
    Prepared Statement of Mr. Woodson and Hon. Elizabeth McGrath.    38
    Accompanied by:

      Hon. Elizabeth A. McGrath, Deputy Chief Management Officer, 
          U.S. Department of Defense
Valerie C. Melvin, Director, Information Management and 
  Technology Resources Issues, U.S. Government Accountability 
  Office.........................................................     7
    Prepared Statement of Ms. Melvin.............................    40
Jacob Gadd, Deputy Director for Health Care, The American Legion.     9
    Prepared Statement of Mr. Gadd...............................    49
    Executive Summary of Mr. Gadd................................    51

                        QUESTIONS FOR THE RECORD

Letter and Questions From: Hon. Jeff Miller, Chairman, To: Hon. 
  Eric K. Shinseki, Secretary, U.S. Department of Veterans 
  Affairs........................................................    51
Responses From: Department of Veterans Affairs, To: Hon. Jeff 
  Miller, Chairman...............................................    53
Letter and Questions From: Hon. Michael Michaud, Ranking Minority 
  Member, To: Hon. Chuck Hagel, Secretary of Defense.............    57
Question #1 From: Hon. Michael Michaud, Ranking Minority Member, 
  To: DCMO McGrath...............................................    58
Question #2 From: Hon. Michael Michaud, Ranking Minority Member, 
  To: DCMO McGrath...............................................    58
Question #3 From: Hon. Michael Michaud, Ranking Minority Member, 
  To: DCMO McGrath...............................................    59
Question #4 From: Hon. Michael Michaud, Ranking Minority Member, 
  To: DCMO McGrath...............................................    62
Question #5 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    62
Question #6 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    63
Question #7 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    63
Question #8 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    64
Question #9 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    64
Question #10 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. 
  Woodson........................................................    65
Letter From: Hon. Michael Michaud, Ranking Minority Member, To: 
  Hon. Gene L. Dodaro, Comptroller General of the United States, 
  Government Accountability Office...............................    65
Question From: Hon. Beto O'Rourke, To: Ms. Valerie C. Melvin, 
  Director, Information Management and Technology Resources 
  Issues, U.S. Government Accountability Office..................    65
Letter and Response From: Ms. Valerie C. Melvin, Director, 
  Information Management and Technology Resources Issues, U.S. 
  Government Accountability Office, To: Hon. Michael Michaud, 
  Ranking Minority Member........................................    65


  ELECTRONIC HEALTH RECORD U-TURN: ARE VA AND DOD HEADED IN THE WRONG 
                               DIRECTION?

                      Wednesday, February 27, 2013

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 9:15 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Lamborn, Roe, Denham, 
Runyan, Huelskamp, Coffman, Wenstrup, Cook, Walorski, Michaud, 
Takano, Brownley, Kirkpatrick, McLeod, Kuster, O'Rourke, Walz.

              OPENING STATEMENT OF CHAIRMAN MILLER

    The Chairman. The Committee will come to order.
    I want to thank everybody for being with us this morning to 
our hearing entitled Electronic Health Record U-Turn: Are VA 
and DoD Headed in the Wrong Direction?
    Today's hearing is prompted by the recent announcement by 
the Departments of Defense and Veterans Affairs that they would 
no longer be developing a single integrated electronic health 
record or IEHR.
    The announcement earlier this month was surprising to this 
Committee and Congress given the number of previous statements 
that the health record was coming along as planned even on an 
accelerated timeline.
    And the other surprise about VA and DoD's announcement was 
that this Committee heard about this the very first time by 
published news reports.
    While it is not the first time this has happened, it is 
equally disappointing given the number of times that this 
Committee has pledged to work with both departments in support 
of making the electronic record a reality.
    Now, in late 2010, both departments co-announced an 
integrated electronic health record as a single solution to our 
common requirements.
    In June 2012, the two departments set an expected timeline 
of a 2017 rollout for that record.
    In July of 2012, both secretaries testified before this 
Committee and the Armed Services Committee that reinforcing a 
single integrated record was the way forward and that their 
respective departments would achieve that goal together.
    This past December, it was stated that VA and DoD could 
roll out the health record even faster without much supporting 
detail.
    The latest news, a mere two months later, has us asking 
again whether even the original 2017 timeline is a realistic 
timeline.
    The end project, will it deliver the same level of 
integration for transitioning servicemembers? Interoperable is 
not the same as integrated.
    While I understand that information can still be shared, VA 
and DoD have to explain to this Committee, to this Congress, 
and, most importantly, to the servicemembers how this new way 
forward is going to deliver what has been mandated, something 
that is badly needed and has been talked about for over a 
decade.
    I am concerned that this new approach is a step backwards 
towards the model that had been previously tried and failed, 
namely maintaining two different systems between two different 
departments and wishfully thinking that the two systems will 
eventually talk to one another.
    I am further concerned about the stewardship of taxpayer 
dollars over the last several years. I find it hard to think of 
another description than down the drain funding that may have 
produced little results, the same funding that could have gone 
toward taking care of active and former servicemembers.
    Assistant Secretary Baker, I understand that you are 
leaving very soon and you won't be directly overseeing the 
joint electronic health record's development very much longer.
    While I wish more progress had been made during your 
tenure, I can only hope that your successor doubles down on his 
or her efforts to make this a reality. The need for a seamless 
record has now been discussed for over a decade with the mere 
expectation that we will just continue to discuss it.
    The time for action is long passed. Each time the objective 
changes or the goal posts move, it is servicemembers and 
veterans who lose the most. It is unacceptable to this 
Committee and should be to VA and to the Department of Defense 
as well.
    I truly look forward to hearing more today about how, when, 
and in what form VA and DoD will finally bring about a joint 
electronic health record.
    And with that, I yield to my good friend from Maine, the 
Ranking Member, Mr. Michaud.

    [The prepared statement of Chairman Miller appears in the 
Appendix]

               OPENING STATEMENT OF HON. MICHAUD

    Mr. Michaud. Thank you very much, Mr. Chairman.
    We as a Nation have a ``sacred trust'' to care for those 
who have served and sacrificed. To do this, we rely on a 
community of support. DoD and VA are the pinnacles of that 
community. Together you are the front end and back end of 
veterans' safety net. You come together seamlessly or veterans 
fall through the space between DoD and VA.
    You have no greater mutual responsibility to those who have 
served and to those who serve than to ensure a complete and 
smooth transition from military back to civilian life. Key to 
that smooth transition is the transfer of the health records 
that document the physical and mental sacrifices of our 
Nation's heroes.
    The Integrated Electronic Health Records initiative is 
critical to ushering in a more fluid process for our servicemen 
and women who transition into the veteran world. Ideally, 
instead of servicemembers hand carrying paper records with them 
to medical appointments, access to their records would be 
readily available electronically to providers and health care 
personnel who care for them when they take the uniform off and 
continue their lives as civilians.
    In transforming the VA into the 21st century agency, we 
envision a seamless record that could benefit the men and women 
who have served this Nation honorably. The idea behind VA and 
DoD being capable of electronic communicating was not a new 
one. We believe that VA and DoD could accomplish this task.
    For at least a decade, the two largest agencies in the 
government have worked this issue, often taking two steps 
forward and one step back. I was under the impression and, in 
fact, reassured as late as September of 2012 that the 
development of the IEHR, while challenging, was still on track 
of becoming the reality we intended.
    So in early February when we read in the news of the 
decision of VA and DoD were ``modifying its strategy'' from the 
planned IEHR approach and focus, I was disappointed and 
disheartened.
    It seems to me that we have regressed back to 2004 when the 
Bidirectional Health Information Exchange was the way 
electronic information was exchanged. I am hoping this is not 
the case.
    There are questions that must be answered as to the future 
of the IEHR and plans to move forward. The original strategy, 
the intent of IEHR was to design, build, and implement a new 
single system ``from scratch.''
    In revising your life cycle cost estimates, you have 
determined that approach is too expensive. So you ``modified 
your strategy'' to use core sets of capabilities from existing 
EHR technologies.
    But rather than selecting one system for those currently 
available, you modified it for each department and separately 
select a core system of choice.
    VistA, the VA's current system is old and by all accounts 
replacing VistA with an existing Commercial Off-The-Shelf 
package is estimated to be $16 billion dollars, according to 
the September 6, 2011 letter.
    VA believes that leveraging open source methodologies will 
increase the rate of improvement within VistA and will be much 
cheaper.
    DoD is looking to explore commercial options for its core 
systems and won't have a selection decided until March. How 
does this modified strategy live up to the initial intent of 
IEHR to be a single integrated system?
    I am currently not comfortable with the direction which we 
seems to be heading for both agencies. I am sure everyone in 
here would agree that we cannot afford to continue to move 
forward and back on this issue.
    VA was once a leader in electronic health records. Today it 
is one that is simply trying to keep up. This must change. You 
and we owe more to the Nation's servicemembers and veterans.
    I look forward to hearing the panel's testimonies today and 
having an open and frank discussion as how we move forward.
    So with that, Mr. Chairman, I want to thank you very much 
for having this hearing today. It is a very important hearing. 
I want to thank you once again for your leadership in this 
regard, and I yield back the balance of my time.

    [The prepared statement of Hon. Michaud appears in the 
Appendix]

    The Chairman. Thank you very much.
    And as we welcome the first panel to the table this 
morning, we are going to hear from the Honorable Roger Baker, 
Assistant Secretary for Information and Technology, and the 
Chief Information Officer at the Department of Veterans 
Affairs.
    Assistant Secretary Baker is accompanied by the Honorable 
Robert Petzel, Under Secretary for Health at the Department of 
Veterans Affairs.
    We will also hear on this panel from the Honorable Jonathan 
Woodson, Assistant Secretary of Defense for Health Affairs, and 
Director of TRICARE Management Activity at the Department of 
Defense.
    He is accompanied by the Honorable Elizabeth McGrath, 
Deputy Chief Management Officer at the Department of Defense.
    And then we are going to hear from Valerie Melvin, Director 
of Information Management and Technology Resources at the 
Government Accountability Office.
    Finally, we will hear from Jacob Gadd, Deputy Director for 
Healthcare at The American Legion.
    All of your complete written statements will be made a part 
of the record this morning.
    Mr. Baker, you are now recognized for five minutes.

     STATEMENTS OF ROGER W. BAKER, ASSISTANT SECRETARY FOR 
INFORMATION AND TECHNOLOGY AND CHIEF INFORMATION OFFICER, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY ROBERT A. 
      PETZEL, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH 
    ADMINISTRATION, U.S. DEPARTMENT OF AFFAIRS; JONATHAN A. 
  WOODSON, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, 
   DIRECTOR, TRICARE MANAGEMENT ACTIVITY, U.S. DEPARTMENT OF 
  DEFENSE, ACCOMPANIED BY ELIZABETH A. MCGRATH, DEPUTY CHIEF 
  MANAGEMENT OFFICER, U.S. DEPARTMENT OF DEFENSE; VALERIE C. 
    MELVIN, DIRECTOR, INFORMATION MANAGEMENT AND TECHNOLOGY 
RESOURCES ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; JACOB 
  B. GADD, DEPUTY DIRECTOR FOR HEALTH CARE, NATIONAL VETERANS 
    AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION

                  STATEMENT OF ROGER W. BAKER

    Mr. Baker. Thank you, Chairman Miller, Ranking Member 
Michaud, and Members of the Committee.
    I appreciate the opportunity to appear before you today to 
discuss the VA efforts to develop a single joint electronic 
health record system with the Department of Defense.
    And as you mentioned, accompanying me today is under 
secretary for Health, Dr. Robert Petzel.
    I would like to assure the Members of this Committee that 
press reports notwithstanding, the DoD and VA remain committed 
to achieving the goals of the IEHR program, that is common 
data, common applications, and a common user interface.
    We have done a poor job in communicating the changes that 
we are making to the program. We are looking to achieve those 
goals through a lower risk and lower cost path than we were on.
    As my written testimony details, over the past 18 months, 
the IEHR program has had difficulty in making the milestones it 
established.
    In September of 2012, the Interagency Program Office 
produced an updated budget estimate that doubled the estimated 
cost to develop the IEHR.
    As a result, we, and I would say we VA and DoD together, 
are pursuing a different strategy to achieve the same goals by 
starting from an existing base of technology, what we have 
called a core of an EHR to build our integrated EHR upon.
    The purpose of this change is to reduce risk, reduce cost, 
and accelerate the availability of needed functionality.
    I would stress that while the IEHR program has had 
challenges, it has also had some successes. VA and DoD have 
agreed on a single data standard, the open health data 
dictionary, and we are moving down the path to implement it 
over the next year.
    VA medical systems, the VistA systems that Congressman 
Michaud mentioned, are being moved into DISA data centers, DoD 
data centers so that we are collocated with DoD medical 
systems.
    We have acquired a single enterprise services bus that will 
connect all the various parts of the system together. We have 
deployed a common graphical user interface to three locations 
and are expanding it to all facilities involved with polytrauma 
support. And we have established joint clinical requirements 
for the first seven of the many shared applications we plan to 
integrate into the IEHR.
    Over the last three years, VA in our systems development 
area has greatly improved the results of our investments, 
achieving over 80 percent of the milestones we set. We do this 
by watching our committed dates very closely, recognizing the 
signs of failure early, and changing direction or even stopping 
a program when that is indicated.
    Using those principles, VA and DoD have acted to change our 
approach with the IEHR to deliver on our shared goals with less 
cost and less risk.
    Mr. Chairman, the IEHR is a complex, large, and difficult 
program. While we wish that we could report only successes to 
you and the two secretaries, as a leadership team our job is to 
see the problems and find solutions.
    We believe we have done that in this case and we look 
forward to your questions. Thank you.

    [The prepared statement of Roger W. Baker appears in the 
Appendix]

    The Chairman. Thank you very much.
    Mr. Woodson.

                STATEMENT OF JONATHAN A. WOODSON

    Mr. Woodson. Good morning.
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee, thank you for providing me this opportunity to 
discuss our progress in the future of the Department of Defense 
and Veterans Administration integrated electronic health 
record.
    In April 2009, the President charged our two departments to 
create a seamless system of integration. The direction was 
clear. When a member of the armed forces separates from the 
military, their electronic records, medical, personnel, and 
benefits will transition and remain with them forever.
    Over the last three years, our departments have been 
working closely to deliver two functional and fundamental--on 
two fundamental tasks in the health care arena, one to 
integrate health data for an individual into a single 
electronic health record and, two, simultaneously modernize the 
department's legacy health information systems.
    We have made tangible progress on a number of critical 
elements necessary to achieve our vision on the integrated 
record. The most notable efforts include the following:
    The beginning to create the joint health data dictionary, 
ensuring that we are using the same precise language to 
describe health data elements and fields in our combined health 
record system.
    Moving VA data centers to the Defense Information System 
Agency or DISA, an important step for efficiency in operations 
and creating a single repository of data.
    Selecting a single DoD/VA joint single sign-on and contacts 
management solution that accurately identifies clients in both 
systems.
    And implemented a joint graphical user interface or GUI 
that displayed information from both the Department of Defense 
and VA systems at the same time.
    Initially rolled out in North Chicago, San Antonio, and the 
Hawaii health systems, this is an important interim step to 
make it easier for our staffs to view patient information no 
matter which health system the patient uses.
    These are important achievements that are necessary for the 
seamless sharing of information regardless of other decisions 
we make regarding the final configuration of the integrated 
health record. The work that has already been accomplished is 
money well spent.
    Now, despite these successes, we also completed an initial 
life cycle cost estimate for the integrated electronic health 
record. The cost estimate was significant. And given the 
increasingly constrained Federal budget environment, our 
secretaries directed us to reevaluate the planned approach and 
consider alternatives that could accelerate timelines for 
interoperability, reduce costs, and reduce risk.
    The two departments identified specific actions we could 
take and on February 5th, Secretaries Panetta and Shinseki 
approved our recommendations that included, one, expanding our 
existing Blue Button capability so that VA and DoD patients can 
securely download their medical record using industry standard 
formats by May 2013, two, ensuring clinicians can see 
consolidated patient data through a common viewer at nine key 
sites by July 2013, three, completing the mapping of VA health 
data to the health data dictionary by September 2013, and, 
four, accelerating the realtime availability of VA data by 
December 2013.
    While our vision of an integrated electronic system remains 
intact, we have, however, changed the pathway to get there. 
Instead of building a new system from scratch, the departments 
will use existing core capabilities that would get us 
functionality to users more quickly and still allow the 
flexibility to add additional modules or applications that we 
will jointly acquire to create the modern system.
    The Department of Defense's approach is to take advantage 
of advances in the marketplace and select existing clinical 
capabilities from the public and private sectors to serve as 
our core to build the electronic health record.
    The VA has decided to use their existing system, VistA, as 
their core.
    Circumstances require decisive action. Delaying these 
decisions would have only increased cost and risk. We believe 
the path we have chosen best serves the departments, the 
special populations whom we jointly are responsible for, and 
the American taxpayer.
    I appreciate the opportunity to come before you today to 
provide a more comprehensive review of the future of the 
integrated electronic record and I look forward to your 
questions.
    Thank you.

    [The prepared statement of Jonathan A. Woodson appears in 
the Appendix]

    The Chairman. Thank you very much, Mr. Woodson.
    Ms. Melvin, you are recognized for five minutes.

                 STATEMENT OF VALERIE C. MELVIN

    Ms. Melvin. Good morning.
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee, thank you for the opportunity to participate in 
today's hearing on VA's and DoD's efforts to share electronic 
health records.
    As you know, the departments operate two of the Nation's 
largest health care systems which during this fiscal year are 
projected to provide coverage to about 9.6 million 
servicemembers and their beneficiaries and to 6.3 million 
veterans.
    VA's and DoD's systems have many common business needs for 
providing health care coverage to these individuals and toward 
this end, the two departments have an extensive history of 
working to achieve shared health care resources.
    Our work has examined the departments' efforts over the 
last 15 years to share data between their individual systems 
and to develop interoperable electronic health record 
capabilities.
    We have noted varying degrees of progress, but also 
pervasive and persistent management challenges related to their 
efforts.
    At your request, my testimony today summarizes our work 
that has examined the departments' activities in this regard.
    Overall, VA and DoD have relied on a patchwork of 
initiatives involving their separate health information systems 
to achieve varying degrees of electronic health record 
interoperability.
    For example, the departments' early efforts included 
developing capabilities to electronically transfer separating 
servicemembers' health information from DoD to VA and building 
an interface to enable the sharing of computable data between 
the departments' modernized health data repositories.
    Further, in response to the 2008 National Defense 
Authorization Act, they established objectives for meeting 
specific data sharing needs and an interagency program office 
that was to be accountable for implementing an electronic 
health record system.
    More recently, the departments have engaged in developing a 
virtual lifetime electronic health record as well as 
information technology capabilities for the first joint Federal 
health care center.
    While collectively these initiatives have increased data 
sharing in various capacities, the departments have recognized 
that more is needed.
    However, their efforts to achieve fully interoperable 
electronic health record capabilities have been limited by 
long-standing project management and planning weaknesses, 
inadequate accountability, and poor oversight which often has 
led to changes in the departments' priorities, focus, and 
timeframes for completing the initiatives.
    As a factor contributing to these weaknesses, the 
departments' interagency program office which was to be the 
single point of accountability for electronic health data 
sharing has not been positioned to fulfill its key management 
responsibility.
    Accordingly, we have made numerous recommendations to VA 
and DoD aimed at addressing such challenges as the persistent 
absence of clearly defined and measurable goals and metrics, as 
well as the associated plans and timeframes for gauging 
progress toward achieving full interoperability.
    The 2011 initiative to develop a single integrated 
electronic health record system had the potential to mitigate 
some of the challenges that have served as impediments to 
exchanging data in the departments' separate systems.
    However, the recent decision to reverse course and continue 
to operate and exchange health data among these separate 
systems raised concerns in light of the historical challenges 
we have noted.
    Further, while the departments have said their new approach 
to developing an integrated electronic health record will 
deliver capabilities sooner and at lower cost, long-standing 
institutional deficiencies in key IT management areas of 
strategic planning, enterprise architecture, and investment 
management could prevent them from jointly addressing their 
common health care system needs in the most efficient and 
effective manner.
    We have ongoing work, undertaken at the request of the 
Senate Committee on Veterans' Affairs, to examine VA's and 
DoD's decisions and activities related to this latest endeavor.
    Mr. Chairman, this concludes my prepared statement. I would 
be pleased to respond to any questions that you or other 
Members of the Committee may have.

    [The prepared statement of Valerie C. Melvin appears in the 
Appendix]

    The Chairman. Thank you very much, Ms. Melvin.
    Mr. Gadd, you are recognized for five minutes.

                   STATEMENT OF JACOB B. GADD

    Mr. Gadd. Good morning.
    I want to begin with a short story. I was personally on an 
American Legion site visit to Anchorage, Alaska to examine 
transition of care. While there, I met a veteran who was 
frustrated and I asked him to talk about his frustrations with 
transition.
    And he said it was simple. It was his records. When he went 
to VA, they told him that they could not access his records 
even though it was a joint venture site. And then he had to go 
back over to DoD to get his records. When he went back over to 
DoD, the base told him to come back in two weeks because the 
base had run out of paper.
    The fact that our government cannot handle this basic task 
for a veteran in transition is inexcusable.
    On behalf of our national commander, James Koutz, and the 
2.4 million members of The American Legion, I would like to 
thank you, Chairman Miller, Ranking Member Michaud, and Members 
of the Committee, for the chance to talk to you this morning 
because while all these distinguished members of the panel can 
tell you the impact of the electronic record for VA or DoD, we 
are here to tell you the impact this failure is going to have 
on the veteran. And, unfortunately, it will not be good.
    VA and DoD have come before you today to say they are still 
pursuing the same goal as before. They have told us that they 
will get the same results and are still moving towards an 
integrated record.
    But as we have heard on February 5th, the secretaries of 
DoD and VA changed their plans. They said that they are going 
to keep their same platforms and instead connect each other's 
platforms through a graphical user interface.
    The American Legion finds this announcement and direction 
forward both troubling and unacceptable. Veterans are not 
getting the single system they were promised. As long as VA and 
DoD remain in separate camps pursuing their own individual 
systems, it is the veterans that will be short changed.
    The American Legion supported the creation of a virtual 
lifetime electronic record because we have seen firsthand the 
difference having all of the records in front of you makes when 
a veteran is seeking treatment or filing a claim for a 
disability.
    Drawing on decades of experience from veterans and service 
officers of our organization, we saw the need for a truly 
seamless record between VA and DoD.
    In a resolution passed at our convention in 2011, not only 
did we call for this to be implemented this year, 2013, we 
supported the concept strongly enough to note features that 
should be included to make the system function better for the 
people that it was actually meant to serve, the veterans.
    We recommended VSOs and other key stakeholders be included 
in the planning process so we could share our experience and 
speak to the benefits and the drawbacks of a joint health care 
record system.
    However, VSOs have been left out of the majority of the 
planning for this record and we were not consulted about the 
wisdom of abandoning a single unified record for veterans. We 
had to find out through a newspaper article like the rest of 
America.
    We recommended that a unified system integrate all the 
branches of the VA in addition to the DoD records so that VHA, 
VBA, and NCA could all speak the same language and clearly to 
each other. Such a system should also fully integrate 
electronic scheduling and make appointments within the health 
care system easier for veterans, but this is not what we are 
getting.
    We recommended that a unified system help a servicemember 
injured on active duty so their records could be flagged, so 
years later when they left the service, that information would 
be readily available.
    We all know about the claims backlog. A single unified 
record was something that could have actually made a dent in 
the process and deliver benefits to deserving veterans faster. 
The majority of the delay in claims, as we all know, is the 
collection of medical evidence that a single unified record 
could solve.
    For example, The American Legion has seen when we present 
fully developed claims the importance of having all of the 
information in place and easily accessible by VA.
    It takes an average claim 257 days to get a decision. Fully 
developed claims, when all the information is in place, are 
averaging just 120 days, finally reaching the number under 
Secretary Shinseki's goal of 125 days to complete a claim. We 
have even seen claims coming out of the Pittsburgh office at a 
little over 30 days.
    Getting all of the information into one place can be the 
key to finally breaking the back of the backlog, but we won't 
have it if we do not get what veterans were promised back in 
2009, a single unified record, a true seamless record between 
VA and DoD.
    The American Legion has had a great deal of experience 
dealing with VA's electronic health care records over the 
years.
    Through people like former legislative director, Warren 
McDonald, The American Legion was involved in the creation of 
VistA, picking up the work pioneered by the Public Health 
Service and the National Bureau of Standards in the early 
1980s.
    Later, Sonny Montgomery and Charles Hagel who worked for 
the VA helped implement it nationwide. Thirty years later, we 
are faced with some of the same challenges.
    Do we continue to invest in paper files, patches, and stop 
gap measures or do we invest our efforts in building a new and 
world-class health care system for the future?
    VA and DoD have spent four years and close to a billion 
dollars to develop this and we are in the same place that we 
were four years ago.
    The American Legion understands VA and DoD are both 
committed to improving the transition process, but until they 
fulfill the promise made to veterans of a single seamless, 
unified record, the veterans of this country will remain 
skeptical of their government's ability to deliver on all of 
the promises made to them.
    I thank you for this opportunity to bring the voice of 
veterans to this Committee and I am happy to answer any 
questions that you may have.

    [The prepared statement of Jacob B. Gadd appears in the 
Appendix]

    The Chairman. Thank you very much for everybody's testimony 
this morning.
    And as we start out, I think it would be a good idea to get 
some definitions down so the Committee understands the language 
in which you spoke this morning. We have heard several 
individuals talk about a common user interface.
    Mr. Woodson, I think you had said something about a bus 
that connects them all together.
    And I guess if somebody would define what that means and 
then which is this closer to, interoperable or integrated.
    Mr. Woodson.
    Mr. Woodson. Thank you, Mr. Chairman.
    Let me see if I can address very specifically your 
question. The electronic health record has many components to 
it that includes a common data store, so the information in a 
place where it can be verified, and then a series of 
applications in which it is organized and then a screen, if you 
will, where providers can, in fact, look at the information, 
interact with the information to utilize it for care or do 
arrangement of information, so-called computable information to 
improve the quality of care.
    Our intent is to have clearly a common single electronic 
record which includes the common data stores, a single 
authoritative base where VA information, DoD information on 
patients are in the same place.
    The common data centers make sure that all of the 
interfaces for the applications, and there will be different 
applications depending on whether you are a pulmonologist or an 
endocrinologist or you need to work with business systems, 
billing, et cetera, but common interfaces, this enterprise 
service bus which allows us to organize and transfer 
information and plug applications in, we have agreed to acquire 
common applications going forward.
    The difference is that in order to accelerate time to 
delivery, because there are so many components, we felt it was 
important to see if we could use existing cores which are sets 
of applications that need to be tightly integrated, otherwise 
you produce hazards in patient safety, and this is the subtle 
difference in what we are talking about, but it is going to be 
the same graphic user interface, same data centers, same 
infrastructure for the electronic health record.
    And then finally, I would note is that understanding that 
the Department of Defense and the Department of VA do have 
different missions. It is important to note that as part of the 
business process, there needs to be some fine tuning because 
there are other applications and other technology that they 
need to touch as part of their business and so it is really one 
single electronic health record.
    Mr. Baker. If I could just add to that a little bit, Mr. 
Chairman.
    I think the most important thing that VA and DoD have 
agreed to, and there have been a lot of agreements, is that 
health data dictionary that says that the data produced by VA 
and the data produced by DoD will be represented exactly the 
same way in exactly the same database so that it is accessible 
from any facility in the VA or DoD.
    Adherence to that and focusing on achieving that will 
provide the largest benefit of all the things that we are 
working on if you were to break those pieces down. So the 
representation of the data, the structure of the data, 
adherence to that representation is probably the key piece of 
what we are doing.
    The Chairman. Anybody want to add anything?
    Ms. McGrath. I would just reiterate the importance of the 
data that Mr. Baker mentioned. Without standardized the data, 
then you cannot achieve the interoperability that we are all 
after. And so that is an extremely important point.
    In this particular business case DoD has established 
standard data across the Defense Department. Given the mobility 
of our active duty servicemembers, we must have the 
standardized data in order for us to then transition 
seamlessly. When the member transitions from DoD care to VA 
care, the data really is the key. And so I would just put a 
very fine point on that.
    The Chairman. And I understand that the data is the key, 
but we are talking about two core technologies still.
    Why in the world can't we get to one core technology?
    Ms. McGrath. So, again, I will be happy to start. The path 
the departments were on, and you have heard multiple times, 
indicated that the cost estimate was just not affordable. And 
so the decision was made to start from some thing, again to 
reduce risk----
    The Chairman. Can I interrupt just for a second?
    Ms. McGrath. Oh, yes, please.
    The Chairman. I appreciate the department's concern about 
affordability, but what is going to serve the servicemember and 
the veteran the best, the cheap one or the one that may cost a 
little more?
    Ms. McGrath. Well, I appreciate the question, and can say 
that our approach is to provide service to our veterans while 
remaining mindful of cost.
    The Chairman. That is what you just said.
    Ms. McGrath. Well, yes, cost absolutely is a factor. Risk 
is also a factor. The integration that is required from 
building every module from scratch also increases risk to a 
program because more connections must be made. And so, the more 
things you need to connect, the higher the risk, higher the 
cost, higher the integration.
    We asked is there an opportunity to reduce risk that would 
still yield the business outcome that we want to achieve, 
maintain schedule, and produce the integrated record at a lower 
cost. The determination was that if you started from some 
thing, some set of core capabilities focused on patient safety, 
as Dr. Woodson mentioned, then you had the ability to deliver 
the integrated record from a core set of capabilities. And so 
you build out from some thing as opposed to building the entire 
system brick by brick.
    The Chairman. And I appreciate the effort, but it sounds to 
me like we are doing a u-turn and going back to the exact same 
thing again, just maybe going on a different road to get there.
    And my time is expired, but, Mr. Baker, I just want to know 
one thing. You had met with some of the Committee staff about a 
week before the announcement hit the paper that you were not 
going to be doing the process in the way everybody thought you 
were going to be moving. You did not say anything to the staff 
at that point. And four, five, six days later, it hits the 
press that you are going to go in a different direction.
    Is there a reason or did somebody make that decision after 
you talked to staff?
    Mr. Baker. Congressman, as you know, I talk to your staff 
quite a bit. I have tried to be very communicative.
    The Chairman. But this----
    Mr. Baker. Understand.
    The Chairman. --was one specific meeting about this issue.
    Mr. Baker. At that meeting, I felt that we had not yet 
briefed the secretaries on the recommendation that we were 
making. It was pre-decisional information. It would be 
inappropriate for me to get ahead of the secretaries and their 
ability to make the decision that we were going to recommend to 
them.
    And so at that meeting, I did not feel it would be 
appropriate for me to have that discussion before it had been 
had with the secretaries.
    The Chairman. So I am to believe that in a week's time, two 
secretaries of the largest agencies in the Federal Government 
were able to come to a consensus of an entire change of 
direction? I find that really hard to believe.
    Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Concerning the cost estimates, in 2011, the initial 
estimates of the cost to develop the integrated electronic 
health records was projected to be between four and six billion 
dollars. However, in September of 2012, the interagency program 
office produced a new estimate of the cost that doubled the 
cost of the development of the system.
    My first question is, what incident or surrounding 
circumstances prompted a re-look at the initial projection of 
four to six billion dollars?
    My second question would be is the driving factors of the 
cost increase and, thirdly, why couldn't VA and DoD settle on 
one system to use?
    I will start with Mr. Baker and I will ask DoD to also 
respond.
    Mr. Baker. Thank you, Congressman.
    I believe the re-look at the cost was driven by the DoD 
processes, the milestone A and milestone B, kind of a typical 
thing that a program would do operating under those processes. 
But I would let Ms. McGrath or Mr. Woodson address that a bit 
more.
    The second question was what drove that. And I think the 
frank answer is experience. We have had 18 months to see what 
it was going to take to look at the requirements for some of 
the packages that needed to be acquired and the path forward on 
those.
    And when the IPO looked at what they had seen and used that 
then to build a new estimate, that the estimate was 
significantly larger.
    And the third piece relative to why not one core, I think 
the VA is quite happy with and convinced that the VistA system 
is the place to start. It is a good system and we own it. The 
DoD is not yet there from their perspective. They are going 
down a path and will consider VistA along with other 
alternatives for their selection of the core.
    I think that is probably where we are at this point. I will 
just leave it there.
    Mr. Michaud. Mr. Woodson, would you like to respond?
    Ms. McGrath. The timing of the life cycle cost estimate was 
exactly as Mr. Baker indicated as part of the acquisition 
process within the Department of Defense. We do a full-blown 
engineering life cycle cost estimate before, what we refer to 
as a milestone--early in the program, early enough in the 
program that we can, assess cost and use it to ensure that we 
are on the right path.
    Some of the drivers for that cost estimate were those 
things that I mentioned about the high level of integration, 
cost, and procurement required to achieve the path that we were 
on.
    I would also just reiterate the Department of Defense is 
looking at VistA along with other commercial capabilities to 
serve as its core. And, again, when we say the core, it is a 
jointly defined core between the two organizations focused on 
delivering the standard data and creating the integrated 
electronic health record.
    Mr. Michaud. Dr. Petzel, do you and the physicians in VHA 
believe VistA is a modern system that is effective?
    Dr. Petzel. Well, Congressman Michaud, we have had now 25 
years of experience with VistA and our clinicians would say 
that it is the best clinical management platform that they have 
ever used.
    You have to remember that 70 percent of our docs come from 
the VA system, but they rotate through hospitals all over the 
country and have experience with a wide variety of medical 
information systems.
    And I am quite confident that if you were to interview 
them, they would say this is the best, again, clinical 
management platform that exists in this country right now.
    Mr. Michaud. What's so amazing is that it is, and I have 
heard the same thing from not only VA employees but also the 
private sector, that it is the best system. So I cannot fathom 
why Department of Defense will not move to that particular 
system.
    Ms. McGrath. We certainly are considering VistA along with 
commercial capabilities as we evaluate the opportunities to 
serve as our core.
    Mr. Woodson. So your question is excellent and certainly I 
have no doubt as to what Dr. Petzel's assessment is of VistA. 
In fact, I have used it in previous years.
    There are a couple of issues for the Department of Defense 
is that no matter how you slice this program for the Department 
of Defense, this is a new acquisition. And the issue we need to 
understand is that as good as VistA is, it is not one system. 
It is a number of different systems, so we would have to choose 
one of those hundred plus systems to try and transfer over.
    For us, because it is an acquisition program, if you buy, 
let's say, a commercial off-the-shelf product from a vendor, 
you get with that implementation support. You get people who 
come in and configure it. There is no infrastructure really 
right now for us to bring VistA into 56 hospitals and 700 
clinics and be able to configure it.
    The good news about VistA is that, again, it was ahead of 
its time and it is a good electronic health record. But the way 
it was developed, it does not have all of the manuals that 
would allow us to bring it over easily, understand master 
files, and so there is some risk for the Department of Defense 
in trying to acquire it.
    Now, having said that, the Department of Veterans Affairs 
is helping us analyze how we might do that and that is part of 
our evaluation going on right now. We have asked very specific 
questions relative to how, in fact, VistA can be modernized and 
segmented to bring over what we need as even we acquire in the 
future applications together.
    But the issue is that it clearly is of a lower risk for the 
Department of Veterans Affairs because it is already 
functioning in their systems and reflects their business 
processes and their clinical processes. For the Department of 
Defense, it represents a new acquisition.
    And then the final thing I will say is that I think it is 
important for this program in some sense to skate to where the 
puck will be. And what I mean by that is the current VistA 
system is a generation one plus two in terms of how we look at 
electronic health records.
    Industry is already at a generation three and moving to a 
generation four. And just to give you an example of what I am 
talking about, as medicine has advanced and become more 
complicated, imbedded in the medical record is a lot more 
decision support.
    We would need to assess what it would require for us to 
bring VistA over, modernize it, and what the total cost of 
ownership would be over time because we would have to develop 
an infrastructure to maintain it, to modernize it, innovate on 
it so that we stay at a pace with the commercial market.
    So there are several factors that we need to consider in 
our decision.
    The Chairman. Mr. Runyan.
    Mr. Runyan. Dr. Petzel, did you have something to add to 
that?
    Dr. Petzel. Well, I think we just wanted to clarify the 
fact that there is a core VistA that is one in the same and 
that is the VistA that we would use and what DoD would be 
using. There aren't a hundred plus different kinds of the core 
of VistA. So that is a moot point for us.
    Mr. Runyan. Thank you.
    Mr. Baker, just kind of going back to what the Chairman was 
asking, if you kind of knew you were going to make the decision 
and you were meeting with Committee staff on this exact issue, 
why wouldn't you have had the brief with the secretaries to 
inform us so we do not have to see it come up in the paper?
    Mr. Baker. Congressman, let me first apologize for the fact 
that you read it in the paper. That certainly was not by my 
design. But I work for the secretary of Veterans Affairs and I 
felt that the information we were working on at that point was 
pre-decisional.
    The two secretaries get together on a scheduled basis. We 
knew that meeting was coming. They had not yet been presented 
the recommendation or made a decision on that front.
    To my view, it would have been presumptuous of me to get 
out in front of my boss on that topic in any briefing with any 
organization. And so while I apologize in the way that you 
learned about it, that was not certainly the way that I would 
have defined it.
    In my view, I needed to make certain that I handled this 
appropriately with the secretary, with the two secretaries.
    Mr. Runyan. Now, doing obviously one of the biggest things 
no matter what system at the end of the day we decide to go 
with, you have talked about the joint dictionary obviously 
being the first step.
    And I know Dr. Roe probably has had some experience in 
medical coding, if you will, which I believe is at the gist of 
this.
    Where are you in that process in making sure everybody is 
speaking the same language?
    Mr. Baker. Congressman, that is the purpose of the five 
quick whims that we recommended to the secretaries and that 
they agreed on and that is to bring the large-scale data that 
we hold into conformance with that health data dictionary by 
the end of 2013 so that the DoD database known as the CDR and 
the VA database known as the CDW represent data in the same--
exactly the same dictionary, exactly the same fashion so that 
when we exchange information about medicines or lab results 
that we are not translating. We are specifying. It looks 
exactly the same. And that is what those quick whims that we 
announced in February relative to interoperability are.
    The secretaries believed, and this specifically came from a 
request from Secretary Panetta, is can you give us some quick 
whims in the interoperability area. And the answer is yes. If 
we focus on making those databases conform to the HTD, we can 
get to that part of the system faster.
    Mr. Runyan. And you are not creating your own vocabulary 
within the VA, DoD. It would be standardized to----
    Mr. Baker. Yes. It exists----
    Mr. Runyan. --the private sector, everything else?
    Mr. Baker. It exists today. One of the things that we 
agreed to was that in adopting that standard, it had to be open 
so that anyone could use that standard. And so the vendor of 
the standard put it into the public domain before we made the 
announcement that we had agreed to that standard.
    That standard is also based on the published national 
standards. And I will use the acronyms and then somebody in the 
medical side is going to have to fix them. It is LOINC, RxNorm, 
and SNOMED are three medical standards for data representation 
that are managed by the National Bureau of Standards, I 
believe, the National Bureau of Medical Standards.
    Dr. Petzel. And excuse me, Congressman, but just to add a 
little bit further, the office of the national coordinator is 
anticipating that our efforts to standardize this data are 
going to be a beacon for the rest of the country in terms of 
what they need to do and the standards that they need to adopt 
so that everybody's records will eventually be saying the same 
thing.
    Mr. Runyan. Which would make this whole transition a lot 
easier.
    Dr. Petzel. It certainly would.
    Mr. Runyan. I think everybody would argue that.
    So I yield back, Chairman.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman, and thank all of you for 
coming here.
    I think this last part that was being brought up is 
actually critical. While I am disappointed in how some of this 
rolled out, I also think putting it in the context of where the 
private sector is at on this.
    And we had an opportunity, the Chairman, the Ranking 
Member, myself, to witness the Kaiser Permanente, the VA 
program out there that they are doing. It was an electronic 
medical record that was talking to other electronic medical 
records and to pharmacies and being able to recognize 
handwritten notes and all of the things that are really 
important.
    What is that and is that the vision you are trying to get 
to?
    And the private sector input into this is going to be 
critical because as you said, Dr. Petzel, they want this as 
badly as we do here and they do not have it at this point.
    So is that Kaiser run what we are looking at?
    Mr. Baker. Thank you, Congressman.
    The specific item you are talking about was the original 
pilot of the Nationwide Health Information Network.
    Mr. Walz. Right.
    Mr. Baker. And that is defined by HHS, the office of the 
national coordinator, a set of protocols for exchanging 
information between different medical record systems.
    If you think about what that system does for us, it allows 
us, and we are now in production with that, to exchange 
information with private sector hospitals in Indianapolis, as 
you pointed out, San Diego, and a variety of health information 
exchanges around the country.
    That is something that both DoD and VA have implemented for 
that exchange and we are promulgating it. That deals with all 
of the work that we do where people that we see are also seen 
in the private sector. So that is the strategy we have.
    Mr. Walz. What percentage of people is that? It is 
significant. Am I right?
    Mr. Baker. We let the doctors address that.
    Dr. Petzel. Well, Congressman Walz, from our perspective in 
VA, as many as 40 percent of our patients have some interaction 
with the private sector.
    Mr. Walz. So if you want a truly interoperable system, both 
streamlining data and protecting the patient, that is going to 
be a critical component too. To get the two of you talking 
smoothly on the same platform without the ability to reach 
outside the system is not the way we want to go. Is that fair 
to say?
    Mr. Woodson. Well, I think we have several objectives, but 
your objectives which you are talking to is very important in 
one of our objectives. It is to be able to exchange data with 
the private sector as well as, of course, with our Federal 
partner in a seamless manner.
    And the key thing is just to understand that one part of 
the program is focused on this issue of exchanging data, 
standardizing data, and being able to exchange it wherever it 
needs to go to include blue button and all sorts of things so 
that the patient has control of their information as well.
    And then the second part that I think has caused some of 
the concern is really the information system we have within our 
Federal agencies to just record information and provide 
decision and support.
    What you are talking about is extraordinarily important and 
one of the major aims of our program.
    Dr. Petzel. And, Congressman Walz, just to highlight the 
differences, the National Health Information Network, the NHIN, 
is a black box into which Kaiser puts its data, we put our 
data, DoD puts their data, and then any of us can extract the 
other's information given the proper identities. That is what 
that is about.
    What we are about in between DoD and VA is creating a fully 
integrated medical record so we do not have to do that. We do 
not have to put it into a black box, et cetera. It is just one 
seamless continuous record whether they are being seen in VA or 
DoD. Different concept.
    Mr. Walz. It seemed like the black box worked. That might 
be the difference. It seemed to me that the black box worked.
    Mr. Baker. Congressman, at the level that is happening with 
the Nationwide Health Information Network, VA and DoD have been 
exchanging at that level for years. You know, that is a set of 
information that the clinicians have determined as most 
critical when they first see a patient, allergies, 
prescriptions, you know, those sort of things.
    The whole medical record is a much more comprehensive piece 
of data that is not exchanged by the Nationwide Health 
Information Network.
    Mr. Walz. Okay. Thank you all.
    I yield back.
    The Chairman. Before I recognize Dr. Roe, I would like to 
ask one question because we keep going back to cost and it 
seems that DoD is focusing a lot of their decisional record on 
cost.
    And I just would like to know has sequestration or the 
Defense budget had anything to do with the decision to change 
the direction in which we were traveling?
    Ms. McGrath. I think cost is always a factor in every 
program. Cost, schedule performance, they are standard facets 
of every acquisition program.
    The Chairman. Did sequestration or Defense budget cuts have 
anything to do with the decision that has been made?
    Ms. McGrath. We do not fully understand the impact, the 
full impact that sequestration----
    The Chairman. It is coming Friday.
    Ms. McGrath. Right. Yes, I understand.
    The Chairman. You do not know yet the full impact?
    Ms. McGrath. Some of it will depend on if there are 
additional flexibilities provided to the agencies with regard 
to how the cuts are taken. That will help inform----
    The Chairman. That is hoping against hope.
    Ms. McGrath. Yes.
    The Chairman. We have been at this for 16 months. When I 
say sequestration has been the law of the land since November 
of 2011----
    Ms. McGrath. So for----
    The Chairman. --no agency sitting at the table today took 
it seriously. Now everybody--excuse me?
    Ms. McGrath. I am sorry?
    The Chairman. You kind of acted as though you had taken it 
seriously. Did you take sequestration seriously in January of 
2011 or 2012?
    Ms. McGrath. The department certainly has executed the 
proper plans within the organization to prepare for 
sequestration. Specific to this program, I can tell you, 
though, budget cuts as a result of the agreement to move this 
sequestration timeline from January to March resulted in a 
decrement to the DoD budget on this particular program in 
excess of $50 million.
    We are assessing every program, to include this one, to 
determine the full impact that the sequestration will have. 
Sequestration will have an impact on this program.
    The Chairman. Mr. Woodson, did the $400 billion worth of 
cuts that were taken by DoD over a ten year period and the 
opportunity of sequestration impact DoD have anything to do 
with the decision to change the direction that both agencies 
said they were heading in and then abruptly changed?
    Mr. Woodson. So, I think what it did do is it focused more 
acutely the need to make a more proper and accurate assessment 
of the costs of the program. And so, you have to look at the 
timelines of how things were, in fact, sort of evolving.
    Yes, I mean, if you're looking down the barrel of 
significant budget cuts you look at all your programs and say, 
how can we make them more efficient? And how can you achieve 
the same end at reduced cost and reduced risk?
    But, to be fair the issue is, the department has done 
planning but these are unchartered waters. We have the 
combination of issue of sequestration and CR, which has 
produced enormous budgetary pressure. So, if you are asking me, 
could we accurately predict how things would unfold and how we 
take into account every possible situation that might occur? I 
don't think we have because I don't know that we know what the 
universe of possibilities are.
    The Chairman. And I appreciate the concern for 
sequestration and what I was driving at is, every time on the 
Armed Services Committee we would ask service secretaries 
SECDEF, you know, what were you doing to prepare? I would ask 
commanders in the field, have you been given any direction? The 
answer was, no.
    And that is what is concerning those of us who are sitting 
here today. All of the sudden everybody is running around with 
their hair on fire over the last 90 days when this is not 
something new.
    I mean, and we should have been focusing on how much this 
was costing back in the very beginning not just at the end 
either. But, it bothers me that nobody at the table is willing 
to fight for the best outcome. You are now fighting for the 
most cost-effective outcome. Mr. Woodson?
    Mr. Woodson. Yeah, I appreciate your question and your 
sentiment. I think we have always fought for the best outcome 
and to be good stewards of the taxpayer dollar, we always have 
to do these reassessment of costs, which is the value of what 
we spend the dollars on. And that is a function of good program 
management.
    I don't think we are just going for the cheapest variety. 
We want full functionality. And as I said before, we want a 
system that will serve us into the future. We want to skate to 
where the puck will be, not to where it is or has been.
    And the issue that I think everyone needs to appreciate is 
that over--we have talked about issues about what we have done 
over ten years. The change in technology over ten years is just 
dramatic. I mean, everyone in this audience probably has a cell 
phone. The kind of cell phone you had in the year 2000 or 1998 
is radically different from the one you have today and so, we 
have to take into account appreciation, the change in 
technology and making sure we are positioned to move ahead with 
the pack in the future.
    The Chairman. And I can appreciate that. And let me use 
this analogy. An X-box and a Playstation can play the same game 
on the same TV screen, but they don't talk together. And that 
is the concern that I have about the direction that we are 
heading. Dr. Roe?
    Dr. Roe. Thank you, Chairman. And for full disclosure, an 
electronic medical record made me a Congressman. We instituted 
that in our medical practice, one of the most difficult things 
I did. So, I appreciate your pain of trying to make this work.
    But, having said that, I know Ms. Melvin said that she and 
you all were committed to a vertical electronic health record. 
Well, I was always committed to dunking a basketball, but I 
could never do it. Commitment didn't mean I would actually get 
there.
    And I think that is what concerns me now, is here we are 
starting in 1999--I have been on the Veterans Affairs Committee 
four years, this is my fifth year on here. We started having 
this discussion and Mr. Walz was there and the Chairman was 
here, the Ranking Member was here.
    I asked this question about three or four years ago, I 
said, in ten years are we going to be still sitting here 
talking about something we talked about for the last ten years 
and spent billions of dollars and didn't do? And remember, when 
you are looking at this right here, you are looking at a doctor 
that has to sit--data is information about a patient that needs 
to be accessible so that that patient gets the best care.
    And I think the point that was made by Mr. Gadd, this is 
about people, this is about patients, this is about veterans 
and taking care of these folks. And I think the first question 
I was--change is tough and I realize, I have been through the 
DoD, I have been to Great Lakes twice to look at that, 
obviously, with Mr. Baker accompanying me there and it is not 
easy.
    Dr. Wenstrup had to leave. He had to go just a minute ago, 
but he has served in the military in Iraq and he stated that, 
yeah, you have a single sign-in, but two different entry 
templates, two pathways, it is difficult, it slows them down.
    I have said this all along. If it takes you--when you enter 
your record, if it takes a doctor three minutes for the thing 
to ramp up and get in and you are seeing 25 people that day, 
you have just delayed your day two, three hours just because of 
technology.
    First thing I would ask, if these systems can't talk to 
each other--and look, there are smart people sitting down 
there. A lot smarter than I am about electronics. I am fairly 
ignorant about it. But if the VistA system was just 25 years 
old, is the best technology we have, this is what I am hearing, 
then that shouldn't be real expensive. And the first thing I 
would have asked is, if that is the system that quotes the 
best, I would argue maybe it is, maybe it isn't, but if it is, 
how much would it cost to put it in?
    Just say, okay DoD, we are going to scrap ours. We are 
going to go to one system so that when he goes into the 
military or I go back in and I sign up, I have my virtual 
records, so that you don't have to worry about all that 
integration and all that, with one system.
    And I think Mr. Michaud asked that question; how much does 
it cost to do it? I know it wouldn't be easy to do, but what is 
the cost? That is the first thing I would have asked. Because 
we are going to be sitting here ten years from now saying it 
doesn't work.
    Ms. McGrath. Part of the analysis we are conducting with 
regard to the opportunity to use VistA or a commercial 
capability includes both cost and schedule, so right now, I 
don't have a cost estimate for you to say how much would it 
cost to implement this for the Department of Defense.
    Dr. Roe. My times getting short, but I think that would be 
the first thing I want to know is, look, we have got to pick 
one or the other and we have said this on the Committee now for 
four years.
    It looks like this integration when it happens and talking 
to Brad, I mean, to Congressman Wenstrup, I mean, Dr. Wenstrup, 
is that it is difficult and I have seen it when we were up at 
Great Lakes a year and a half or so ago.
    I mean, just pulling up a CBC and a urinalysis report is 
not an integrated health care system. That is pretty simple 
stuff. And what you need is you need one; when that soldier 
goes in--when I went in 40 years ago this month, I had the same 
electronic record that Thomas Jefferson had, a piece of paper. 
And it looks like that we are having--we are almost back to 
that now where these two systems are not going to be able to 
talk--at least they can say simple sentences together, but not 
get all that information they need.
    And it looks to me like--and Mr. Chairman, I believe we are 
going to be sitting here ten years from now saying the same 
thing. I honestly believe that.
    Can anybody sit here and tell me if I am fortunate enough 
to get re-elected for a few more terms that I am not going to 
have this same conversation when I have no hair on my head.
    Dr. Woodson. I don't think we will.
    Dr. Roe. Well, reassure me why, Dr. Woodson. Why won't we? 
Because we have been since 1999.
    Dr. Woodson. Right. And I think since--the point I was 
trying to make before about the advancement in technology is 
that we have reordered our thinking about what an electronic 
health record is. In fact, standards for electronic health 
records are being published as we speak and what the 
expectations of what it means to have an electronic health 
record has changed dramatically.
    And remember most of the private sector is just getting 
into electronic health records. So, the good news for the 
Federal government is that we were in it early. The problem is 
we developed our own home grown systems and now we are at the 
place where we need to make them talk to each other effectively 
and serve the men and women of the military and the veterans 
appropriately.
    Dr. Roe. Dr. Woodson, not to interrupt you, but my time is 
up, so I have got a series of questions I want to submit to you 
all. But, I have found nothing in here today that reassures me 
that I am not going to be having this conversation five years 
from now.
    Mr. Chairman. Congressman, I have to make the observation 
that in 1988, we had the best opportunity to do this when the 
DoD adopted VistA through their contractor at that point. We 
diverged at that point even though we started on the same 
technology. I emphasize----
    Dr. Roe. Well, I think it is time to converge again, it 
sounds to me like and get on--we diverged 24 years ago, it is 
time to find out what does it cost? Can it be done? I mean, 
that ought to be fairly simple.
    I mean, how much would it cost? It is an older system, it 
has been upgraded, I am sure, like any automobile or any other 
technology has and with speeds and all that. And then go to one 
system, because I don't see this ever working if we don't. I 
yield back.
    Mr. Chairman. Mr. Baker, please.
    Mr. Baker. We are very clear from a VA perspective, we like 
the system, our clinicians like the system. It is maintainable, 
it is modern. As you point, if it is not the best, it is one of 
the best electronic health record systems out there. And it has 
one advantage over every other system, we already own it. We 
don't have to pay for it again. I think that is where the VA is 
in its selection of VistA.
    Ms. Melvin. Chairman Miller, if I may, I would like to 
offer a perspective.
    The Chairman. Yes, ma'am.
    Ms. Melvin. One of the things that has been discussed 
today, obviously, is in terms of cost and how much will it cost 
to get to this. I think there are some very fundamental 
deficiencies or weaknesses within the approaches that have been 
taken over the years.
    We have had a number--as I mentioned in my statement, over 
15 years that this has been going on. And one of the things of 
concern to us is in terms of VA and DoD having a joint approach 
to doing this, our work has pointed, in particular, to what we 
see as some critical barriers to the department's--both 
departments' ability to really get the types of answers that 
you are asking for today.
    The types of discussion, the information that they are 
relaying today is very critical. It is all very important 
information that does have to be discussed and considered as 
they consider how to go about getting to a unified electronic 
health record system.
    The problem though is that in the work that we have 
conducted over the years, there has not been joint strategic 
planning. There has not been an architecture defined. There 
have not been investment management processes in place to guide 
the efforts that these departments are undertaking, and as a 
result of that you get the situation that we are in today where 
there are many considerations that the departments are taking, 
but there aren't really any answers relative to what the 
particular defined end state is that these departments are 
trying to achieve in the way of having an integrated electronic 
record versus an integrated electronic health record system. 
And I think you have been talking about a unified system and 
that is what, ultimately, the goal has been to achieve.
    There are many considerations that have to go into that, 
from planning, from the standpoint of cost, risk, all of things 
that they have spoken of that are very important. But there is 
no defined roadmap at this point for getting there. And unless 
the departments take a step to look at what they need to get 
to, what they have in place right now and how they will 
transition from that in a very specific and a very defined way, 
I am afraid we might see ourselves in this same position in the 
future.
    The Chairman. Thank you very much for the additional 
information. What we as Members hear quite frequently is that 
nobody wants to blink between VA and DoD. And I sit on both 
Committees, so--I mean, I'm on HASC as well. But I hear more 
often than not that the agency that guards its turf the most is 
DoD and they don't want to give up any ground. Somebody has got 
to give in this process as we go through and we want to help.
    I mean, it is not--I am not saying that to be accusatory, 
that is just what I hear. I mean, I go to combat hospitals and 
the doctors in those hospitals in theory tell me that they like 
VA's platform better.
    And I just--we are fighting this fight, since 2004 we have 
had this discussion, we are going back to the same place. The 
other thing if you can think, you may have to get some 
information, but I understand that DoD did an RFI prior to the 
decision to change direction.
    Okay. So, is there an RFI out? And what was the date of 
that request?
    Ms. McGrath. Yes, the RFI was issued on February 8th, I 
believe that was a Friday, and the responses are due back 
today.
    The Chairman. Okay. Mr. O'Rourke?
    Mr. O'Rourke. Thank you. Ms. Melvin, you talked about 
longstanding institutional deficiencies and I think in your 
last statement you helped to define what those are. Do you have 
any specific recommendations to correct those longstanding 
deficiencies? You talked about lack of strategic planning and 
doing that planning in a joint manner. Anything more specific 
that we can hang a hat on, that someone could report back to, 
that we could chart progress against a specific goal related to 
those deficiencies?
    Ms. Melvin. There are specific criteria that are attached 
to the recommendations that we have made. We have three 
outstanding recommendations in those areas for VA and DoD at 
this point that still need to be addressed.
    We can certainly work to--or provide information relative 
to some of the specific things that they would need to look at. 
But, certainly, in terms of having defined plans, having 
integrated schedules, having performance goals and measures, 
those are particular things that the departments need to work 
to define for themselves in terms of--related to what they are 
trying to achieve.
    It is very difficult to tell them what that should be. They 
would need to look at, for example, the two systems that they 
are considering, all of those are options that have to be on 
the table. They have to look at the alternatives. They have to 
consider what other variables, what are the critical 
milestones, the risks, everything that is involved with that.
    So there are specific things that would go with having a 
strategic plan. There are certainly specific aspects to having 
a detailed architecture that would help define, you know, what 
their as-is state is, and what their future state is. And I 
think that is the critical piece, what the future state is that 
they are trying to get to.
    We have not seen information to really ever clearly define 
what that target state is supposed to be from the standpoint of 
what they are trying to achieve. So, all of those things, 
collectively, would have to come into play.
    Mr. O'Rourke. You also mentioned in your opening testimony 
poor oversight----
    Ms. Melvin. Yes.
    Mr. O'Rourke. --as one of the factors that has led to the 
frustrating position that we are in today. Could you go into a 
little bit more detail about that? Who is accountable for that 
poor oversight? How do we correct that problem?
    Ms. Melvin. Well, over the 15 or so years that we have 
looked at the systems we have seen poor oversight in different 
ways. We have seen it from the standpoint of there not being a 
defined or identified leader to take the helm of these 
particular initiatives.
    I think, at this point, we are looking at the integrated 
program office, the IPO, as the primary oversight body that is 
in place, to do that. When that office was put in place the 
intent was that it would be the point of accountability for 
them achieving the electronic health record. However, how 
accountability is defined and what mechanisms and measures they 
have had in place to really be accountable has been a concern 
to us.
    We have work ongoing right now that's looking at the 
effectiveness of that office. But we have had concerns in the 
past relative to the pace at which it was able to be staffed. 
Who was actually making decisions there and, quite frankly, the 
money has always been divided between VA and DoD up to now. And 
so, that has always been an issue also that is on the table in 
terms of how effectively this office could function in terms of 
overseeing and really being accountable for this effort.
    Mr. O'Rourke. And Mr. Gadd, I want to thank you for your 
testimony. You helped to put a human face on an issue that for 
many people can be reduced to processes or numbers or 
abstractions and having just had our Veterans Town Hall Meeting 
in El Paso this last weekend, 200 veterans showed up and many 
of these terms and phrases and, frankly, excuses that we are 
hearing are not going to be very helpful and will not give them 
the hope that they need. And more importantly will not meet the 
obligations that we owe to these veterans.
    One thing that you said that I know everyone can hang their 
hat on is--and it caught my attention is, you cited Pittsburgh 
and a 30 day turnaround. Can you talk a little bit about that? 
And then for the other Members of this panel, how do we get 
that turnaround in El Paso and in other VA systems throughout 
the country?
    Mr. Gadd. Thank you very much. And first off I would say we 
want one system. It is not a pie in the sky, it has been--
Congress has invested, our country has, our veterans want one 
system. We envision a system where any service officer that is 
filing a claim can put a name and a last four in and pull the 
record up. I mean, we are not IT guys either, but we just want 
to move that claim through. And part of the fully developed 
claims process is having all that collection of medical 
evidence ready to go.
    In fact, I talked to a veteran this morning and he said it 
has taken him six months at the D.C. VA Medical Center to get 
his paper copies of his records.
    I mean, they are the real loser in this. We can't wait ten 
years for the plans to change again or not have a record that 
truly gets them the transition and gets them into health care, 
moves their claims through.
    So, we would add with that fully developed claims process 
we see what it looks like when we have those things in place.
    Mr. O'Rourke. Is that Pittsburgh?
    Mr. Gadd. That's Pittsburgh, correct.
    Mr. O'Rourke. Okay. Thank you. Thank you.
    The Chairman. Mr. Denham?
    Mr. Denham. Thank you, Mr. Chairman. I did not come here 
with a list of prepared questions today. I came here to listen 
and understand why decades of inaction haven't been fixed yet.
    You know, I have got an interesting chart here from CRS. It 
starts in 1982--when I was a freshman in high school, 1982 
starting with a computer system and then '88 developing the 
system. I can tell you in '89 when I left active duty and was 
handed my little yellow shot records and they said, don't ever 
lose these, whether you are on reserve status or whether you 
completely depart the military, don't ever lose these shot 
records.
    I can tell you how disappointed I was when I had a 
conversation with Mr. Walz about a year and a half ago and Mr. 
Roe as we took a trip over to Afghanistan and I had to go 
search through my warehouse to find those little yellow shot 
records because several decades later we still don't have a 
system.
    Now during that time not only did I spend over 16 years 
between active duty and reserves, but I started a company where 
I can track every one of my thousands of plastic containers 
across the United States and some in other countries.
    I started a farm where I have got to know where my almonds 
are, you know, not only what lot or where they are sitting or 
where we are warehousing them, but what can they actually go 
in.
    Now, as a private individual, if I can figure out how to 
take today's technology and run a business, the question is why 
can't we do it in a Department of Defense? And so, we have 
asked this question now a couple of times. I have only been in 
Congress just over two years, but we have already had a couple 
of different hearings on this. We had both secretaries agree.
    So, my frustration is that not only have we let several 
decades go by, but you have been given directive by the 
President, by your agency secretaries to get this done. My 
belief is that you don't have the will to get it done. That we 
have such a big bureaucracy that everybody wants to control 
their own system rather than come together on one system.
    And these aren't the first times we have heard these 
excuses. Well, cost--sure, cost is always a factor. 
Sequestration, we really didn't understand that was coming. We 
haven't had a budget in four years, so we are not really sure 
what the budgets are going to be.
    Dammit, it is time to get over the excuses and get this 
fixed. We have brave men and women that are coming home at huge 
numbers right now. We don't want to see these backlogs of 
benefits continue to escalate.
    We have a very succinct opportunity to fix it today. We 
have the systems and know-how to get it done today. What we 
need is you guys to work together and if it takes the VA taking 
the lead because they are not as severally affected by 
sequestration, then get it done. But we need to have the VA 
working within the Department of Defense before these 
individuals leave active duty today and making sure that we 
have got one set of records. So they are not carrying around 
for several decades that little yellow shot record.
    This is inexcusable. I don't want to be sitting here next 
year with the same exact problem where we have got our benefits 
or our veterans still sitting with a larger backlog of benefits 
not being able to get through the system because it is taking 
40 to 50 days just to research their paper records that they 
may have just received months prior. It is inexcusable.
    So, I didn't have any questions today. I wanted to come in 
here and hear how the changes are happening, how the 
departments are working together, how we have one system that 
is ready to go because those that have volunteered at a time of 
war to serve our country, to put their lives on the line, 
deserve nothing less.
    They come home tomorrow, they ought to be in the system 
tomorrow, knowing what benefits they are able to receive, 
knowing what level of disability they are before they leave 
active duty and we ought to have one system that--whether they 
come back 20 years from now, it doesn't take a 50 day or a five 
day system to decide what eligibility they have.
    This is inexcusable and you need to get it right or we are 
going to force you to get it right. I believe that this is 
something that we can handle within the Federal government, 
that we have a duty and an obligation to get it handled within 
the Federal government.
    But I have got to tell you, the more time that goes by, the 
more conversations that this group has, I continue to lean more 
towards the private sector because I can get it done in the 
private sector. Because I have to have it done in the private 
sector. Because I have the will to keep my business alive.
    I don't always feel that same duty and obligation on behalf 
of those brave men and women that are willing to risk it all. 
This should not be a simple--it should not be a difficult task. 
This should be a very simple one with the technology and know-
how that is out there.
    And I don't believe that with the several decades that have 
gone by, the many budgets, the many allocations, the support of 
both secretaries and a President that has given a directive, 
that cost should be a factor in this as well.
    So, I am looking for some answers and I will come up with 
some questions, because what we have heard today, once again, 
is inexcusable. I yield back.
    The Chairman. Mrs. Negrete McLeod?
    Mrs. McLeod. Thank you, Mr. Chair. I guess I would just 
have to ask the common sense question, what do we do now? And 
where do we go now? And what is going to be done? Because I 
belong to Kaiser in Southern California, I can go to any Kaiser 
in Southern California and my records are there.
    The Chairman. Any comments? Ms. McGrath?
    Ms. McGrath. I think what has been laid out this morning is 
our commitment, certainly, to achieving the business outcomes 
we set out for an integrated electronic health record and 
making sure that patients--our servicemembers, active duty, 
reserve, veterans--have access to their information and those 
that serve them from our clinical community also have access to 
the information they need at the point of care.
    Mr. Baker laid out some of our focus areas that will be 
achieved within this calender year, namely getting the data 
right. The interoperable mapping of our core data is being done 
so that by the end of the year we can communicate in a very 
seamless way.
    Now, we have also identified the approach to the systems 
modernization and we would certainly be happy to keep this 
Committee informed on our progress as we move toward that 
decision, again, with the outcome of achieving jointly an 
integrated electronic health record.
    I think the departments really have worked very closely 
together, certainly since I have been a part of this for the 
last two years. Everything we do is joint, from the business 
process conversations with our clinical communities, we have 
joint clinical integrated product teams. We have a joint 
architecture review board. We have a joint portfolio management 
approach. We have a joint oversight of the program, involving 
Mr. Baker, myself, Dr. Woodson and Dr. Petzel and the Deputy 
Secretary, Under Secretary of Defense for Personnel and 
Readiness. Everything is done together and I would say the 
overall commitment of our organizations to get this done is 
strong.
    Mr. Michaud. Congressman Michaud. I would just add that as 
with Kaiser, you can go to any VA hospital around the country 
and your inpatient/outpatient complete and total medical record 
is available.
    Ms. Melvin. If I may, I would just reiterate the comments 
that I made earlier about the need--I agree that there are a 
lot of joint things that are happening. One thing though that I 
think it is important to have joint is the strategic planning 
in place, which involves really taking a close look at having a 
defined strategy going forward.
    I think it is important also that they take lessons learned 
from places like Kaiser or other entities that have done this 
to really build that into what they are doing and I know they 
are working with Kaiser as part of some of their initiatives. 
But, I think that is important to continue to do, to look at 
that more deliberatively relative to an overall strategic plan 
and an approach for actually getting to the future state.
    Mr. Gadd. And too, I would like to add that what we would 
like to see is for them to go back to doing the single unified 
record and moving that process forward, looking at VistA, 
looking at the ZOD platform and ways that they can modernize it 
to meet the needs of our veterans coming back in the 21st 
century.
    We need a system that is efficient, that is fast, that our 
veteran service officers can access to help these veterans 
coming back during their time of transition, to getting into 
health care and getting into claims. And it is unclear with 
this new direction that they are taken through this graphical 
user interface how that actually is going to happen.
    The Chairman. I think what is interesting is we talk about 
the jointness between the two and I can appreciate that, but in 
2008 in the NDAA, and this is really for the Committee's 
information, we mandated an inter-agency program office, which 
was supposed to be the central clearing house for all of this 
information and I've only heard a cursory mention of the IPO 
even sitting at the table this morning and so, it is 
interesting to me that, you know, this is an agency that has 
been out there that really hasn't produced anything, but its 
supposed to have been. Mr. Huelskamp?
    Mr. Huelskamp. Thank you, Mr. Chairman. I do find it 
interesting that--and I would like to hear from the IPO office 
about this issue. That would be, perhaps, very instructive.
    But, like my colleague, I didn't come with any prepared 
questions, but many have developed. First of all, I want to 
clarify some data. When the President stated his goal in April 
2009, at that time, zero percent of all veterans had the 
ability to have electronic health records transferred from the 
DoD to the VA. What is the percent today? Is it still zero 
percent?
    Mr. Woodson. Congressman, no. My understanding is that 
today all electronic information from the DoD kept in their 
medical record is transferred to the VA for use if the 
individual comes to the VA for service.
    Mr. Huelskamp. So, the--I guess I am confused. Mr. Gadd 
gave us an anticdote of the paper that had to be transferred 
over. What percentage of the records are not electronic?
    Mr. Petzel. Congressman, the vast majority of the DoD 
records that we need for medical care are electronic and we can 
get them through what we call the bidirectional information 
exchange. It is not realtime, but we do have access to those 
records.
    I think that what Mr. Gadd was talking about had to do with 
the benefits process, which is a different issue than the 
medical care process and in that process they need to get 
everything that is available including, in some cases, some 
written records.
    Mr. Huelskamp. So, the President's goal; what percentage of 
that goal has been met?
    Dr. Petzel. From the medical perspective, it is nearly 100 
percent.
    Mr. Woodson. So, just to clarify, to do proper adjudication 
of benefits you need medical records, personnel records and 
benefits information. What Dr. Petzel has just referred to is 
the ability to exchange medical records or health information. 
There is much work to be done on exchanging benefits and 
personnel information.
    The Chairman. Mr. Gadd?
    Mr. Gadd. If I can add to that. The DoD and VA do a great 
job through the military treatment facilities, for example, if 
someone is severely injured, you know, they have got care 
coordination there. But for the veteran coming back that is a 
combat veteran or a veteran, they still need in some cases--as 
I said this morning, I talked to a veteran who went to the D.C. 
VA. He asked for his records from them and they said that they 
had to get them for him and he waited six months to go to his 
mailbox and find those records.
    So, if it is really, you know, they are really able to do 
it instantaneously, he wouldn't have had to wait six months. 
So, I simply have to disagree with the panel.
    Mr. Huelskamp. Thank you, Mr. Gadd. Yes, I'm a little 
confused by that. So the President set out a goal and 
apparently the timeline has moved--well, actually, I don't know 
if the timeline has moved, according to the statements from DoD 
that said, ``We will achieve the President's goal far sooner 
and at a lower cost.'' So, when exactly is the timeline going 
to achieve that goal? When can we come in here and expect that 
achievement?
    Ms. McGrath. The full interoperability that we are talking 
about, using the standard data, the health data dictionary that 
has been mentioned many times today, all of the facets 
associated with that, will be done by the end of this calender 
year. So, by the end of 2013.
    What is also----
    Mr. Huelskamp. Excuse me. I must be a little confused. So, 
the President's goal will be completely achieved by the end of 
this year?
    Ms. McGrath. For the interoperability, the standardization 
of the data between the core data base in VA and the core data 
in the Department of Defense, yes. This will yield full 
interoperability between our two organizations.
    I think what also has been discussed here is the nationwide 
health information network utilization by the Federal space, 
us, and the private sector.
    Mr. Huelskamp. Well, we must be talking past each other, 
because I thought we had a major problem and you are telling me 
it will be done at the end of the year.
    Dr. Petzel. If I could clarify. I think the difference to 
your point is that there are a lot of records that are on paper 
and those aren't--they have to be requested by the benefits 
folks and they have to be transferred over if they are going to 
happen. The electronic information is transferring.
    But the electronic information relative to the service 
treatment record is to my understanding not a large part of the 
entire service treatment record. I don't want to get too far 
into that area, but thinking about it from the benefits 
perspective, I know that one of the main things our benefits 
folks have to do is request that paper service treatment record 
in order to do the benefits that folks are looking for and that 
can take awhile to get.
    Mr. Huelskamp. Well, I am sorry, I am about out of time. I 
think you are talking past my question. If you could provide 
the timeline? I don't have it in any of the data we have been 
provided for the Committee, but the full timeline of achieving 
that entire goal. As well as, you said the cost would be 
reduced, how much is the cost going to be reduced from 
originally projected?
    Ms. McGrath. To have an apples to apples comparison we 
would do the same type of cost estimate and we expect that cost 
estimate to be done in the summer.
    Mr. Huelskamp. Well, ma'am, just quickly. You said, ``We 
will achieve the President's goal far sooner and at a lower 
cost.'' So, you are telling me the President's goal is going to 
be achieved at the end of the year, I think, that is, 
obviously, not true, you are missing my question. But what is 
the lower cost estimate? That was from your testimony. Do you 
know what that lower cost estimate is, the savings?
    Ms. McGrath. We anticipate that the cost will be lower. I 
don't have a specific dollar value to give you today until I do 
the same level of engineering cost estimate that was done.
    Mr. Huelskamp. Thank you. I yield back.
    The Chairman. How can we assume that it would be lower if 
you don't have the cost estimate now?
    Ms. McGrath. As was identified earlier, the life cycle cost 
estimate when it was done was an engineering level estimate. By 
starting from a core set of capabilities that are already 
integrated, there will be integration costs that would have 
existed in sort of the previous way that will not exist in the 
proposed way forward. And so, by the nature of the design, I 
will have less integration to do if I start with a bundled core 
set of capabilities than if I did not. So that is what is the 
main driver, of the statement that it will be a lower cost, 
because I will be doing less integration.
    The Chairman. And tell us, again, why you won't use VistA?
    Ms. McGrath. We plan to evaluate VistA along with----
    The Chairman. How long has VistA existed?
    Ms. McGrath. I am not sure.
    The Chairman. And have you not had time to evaluate it?
    Ms. McGrath. We did an evaluation in 2010 of VistA 
actually, it was 2009, as it existed at the time. When the 
Department was going on its own path toward modernization prior 
to Secretary Gates and Secretary Shinseki deciding to, not use 
either of the Department's legacy systems and----
    The Chairman. That is three secretaries ago, right?
    Ms. McGrath. Yes. The Department made the commitment to go 
joint back in--actually, I believe it was March of 2011 and we 
did evaluate VistA when DoD was going on its own path. The 
decision was made to go joint. We have not assessed VistA in 
that interim timeframe.
    The Chairman. Why wouldn't you assess, I mean, that is--it 
is there. It works. People like it and you--DoD won't look at 
it.
    Ms. McGrath. The two secretaries agreed that we weren't 
going to use either of our legacy environments. AHLTA is the 
name of the DoD legacy system. VistA is the name of the VA's 
system.
    We decided not to use either of our legacy systems back in 
that timeframe and to take a joint path forward. We have been 
operating and moving down that path for the last two years.
    The decision was made again recently to adopt a core set of 
capabilities and build from a core. The VA decided to use VistA 
as their core. We are not as familiar with the system. We do 
not use it every day. The documentation--there's a lot of 
things that we would--to Dr. Woodson's point earlier, we would 
want to assess it so that we could understand the cost, the 
risk, the----
    The Chairman. I apologize. This is very interesting to me 
because I have an article in Fed Talks that it says, ``In an 
unprecedented move, the Department of Veterans Affairs posted a 
draft response to a Department of Defense request for 
information, which is the RFI, for an integrated electronic 
health platform. And in the draft posted by a senior advisor, 
the VA makes a case for deploying the Veterans Health 
Information System and Technology architecture.'' But, you 
are----
    Ms. McGrath. We posted the RFI, and asked for responses no 
later than today. This is one of those responses. We are 
evaluating that response, along with the others that we have 
received and will receive by close of business today and are 
absolutely doing the analysis on all the responses we receive.
    The Chairman. But the secretaries agreed not to use the 
Legacy platforms.
    Ms. McGrath. Back in 2011.
    The Chairman. So, now we are back to using the legacy 
platform again.
    Ms. McGrath. Well, the VA has decided to use a legacy 
platform.
    The Chairman. Okay. Mr. Takano? Mr. Brownley? Mr. Kaufman?
    Mr. Kaufman. Thank you, Mr. Chairman. Assistant Secretary 
Baker, in May of 2011 the VA stated that, ``The improvement 
rate of VistA can be increased without increasing current 
spending by better involving the private sector and true 
private sectors practices in both the governance and the 
development of the VistA system.'' Is this true? Can you 
explain why the Information Technology Acquisition Advisory 
Council, a 501C3 with a participation of transformation minded 
senior leaders from government, academia, industry and public 
interest has not been allowed to participate?
    Mr. Baker. I'm sorry, which organization? VistA is an open 
source. Anybody who wants to participate can participate. So, I 
would have to go back to the open source foundation to ask that 
question about, you know, why would anyone be excluded. But as 
an open source organization, I believe the definition in the 
bylaws is that anybody can participate.
    Mr. Kaufman. Well, the allegation is that there were 
organizations that were excluded. I wonder if you can get back 
to the Committee on that on record?
    Mr. Baker. I would be happy to do that. That absolutely 
should not be happening.
    Mr. Kaufman. This question is for Assistant Secretary 
Woodson and Assistant Secretary Baker. In May 2011, VA stated 
that, ``Based on industry examples, VA's expectation is that 
leveraging an open source community will increase the rate of 
improvement and innovation within VistA by drawing on new 
talent and new ideas from the commercial and public sectors.'' 
Has this proven to be a true statement, given the current state 
of this system?
    Mr. Baker. So, thank you, Congressman. We believe that is 
true and I can give you a very specific example. We have 
recently gone out for using the open source with a prize 
approach to delivering a scheduling package for VistA. Now, 
scheduling in VistA has a long history and it is not a good 
one, relative to the VA inside government trying to develop 
that.
    What we have done through the open source, making all of 
that code available to anyone who has a scheduling package, to 
integrate their scheduling package with VistA and provide us an 
example of that working with the open source. The big point 
there is, it is a tremendous risk reduction for us. When we do 
an acquisition of a scheduling package we will know that we can 
buy one that already works with VistA.
    So, just down that path, we have gone out and eliminated 
the possibility of what we did in the past, which was spend 
$127 million and get nothing. So, getting out of the typical 
governmental way of moving VistA forward and into a joint with 
the private sector--not with private sector as contractors, but 
with the private sector as full contributors to, how can you 
move this forward?
    Just one point I would make. There are over 100 non-VA 
hospitals that have picked up VistA outside the VA and 
implemented it. There are private sector partners with us in 
this open source. So, I view VistA as an ecosystem of an 
electronic health record that is nationally and internationally 
used.
    We are looking for that entire participation. The vendors 
that serve that community, the hospitals that use that and the 
VA, to work together to move VistA forward, not just the 
government.
    Mr. Kaufman. Assistant Secretary Woodson?
    Mr. Woodson. Thank you very much for that question. And as 
part of our evaluation of VistA, which is ongoing and should be 
complete by the end of March, we are considering this 
information about the accelerated rate of modernization and the 
issues of cost for modernization.
    We are also considering the issue, again, of total cost of 
ownership and evaluating these other issues of how we would 
transfer it over, because as I mentioned before, the evaluation 
of which system to choose is an acquisition decision no matter 
if we accept VistA or if we were to look in other commercial 
venues.
    So, we are evaluating--and that is exactly why we are 
taking another look at this time is because the situation may 
have changed since the previous evaluations were done, the 
analysis of alternatives back in 2009 and other reports that 
came out of the private sector that were commissioned by the 
VA, which called into question the ability to modernize VistA 
at that time. So, we are reevaluating that.
    The final thing I would say is that, you know, I think it 
is due diligence to look at the VistA system against the 
commercial market because it is about the rate of innovation. 
It is about the fact that technology advances rapidly and we 
have got to not only be able to acquire it, but we have got to 
understand what resources we will need to commit to constantly 
modernizing it.
    And all of the discussion this morning, including the GAO 
comments, have suggested that historically we have not done 
very well about how to modernize our system.
    So, Alta is a worldwide database and we can share records 
across the world, MTFs and alike, but we are not very good at 
modernizing. So we are looking at this at this time.
    Mr. Kaufman. Not very well is an understatement. Mr. 
Chairman, I yield back. Thank you.
    The Chairman. Thank you very much. Mr. Michaud?
    Mr. Michaud. I have one last question for the Department of 
Defense. When has DoD formally designate IEHR as a program of 
record?
    Ms. McGrath. The Department included the IEHR in its--I 
would like to get back to you to be certain, but I believe it 
was the 2010 budget.
    Mr. Michaud. So, you already have designated as a program 
of record?
    Ms. McGrath. Yes. I believe it was in the 2010, but again, 
I would like to go back and verify.
    Mr. Michaud. Okay. Thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you very much. Thank you, Members, for 
being here today. I would like to thank the panel. Please know 
that the frustration that the Committee shares is not with you 
individually, it is with the bureaucracy that exists. We have 
to work together to try to solve this problem that is out there 
today. We serve one mission and that is those that wear the 
uniform and become a veteran. It is a person and that is who we 
are serving.
    So, I would ask unanimous consent that all Members would 
have five legislative days to revise and extend and add any 
extraneous material without objection.
    With that, the panel is excused and this hearing is 
adjourned.

    (Whereupon, at 11:04 a.m., the Committee was adjourned)



                            A P P E N D I X

                              ----------                              

            Prepared Statement of Hon. Jeff Miller, Chairman
    Good morning.
    I would like to welcome everyone to today's hearing titled 
``Electronic Health Record U-Turn: Are VA and DoD Headed in the Wrong 
Direction?''
    Today's hearing is prompted by the recent announcement by the 
Departments of Defense and Veterans Affairs that they would no longer 
be developing a single, integrated electronic health record, or 
``iEHR.'' The announcement earlier this month was surprising to this 
Committee and the Congress given the number of previous statements that 
the health record was coming along as planned, even on an accelerated 
timeline.
    The other surprise about VA and DoD's announcement was that this 
Committee first heard about it from news reports instead of directly 
from VA itself. While that's not the first time this has happened, it 
is equally disappointing given the number of times that this Committee 
has voiced its willingness to work with the departments in support of 
making the iEHR a reality.
    In late 2010, both departments co-announced an integrated 
Electronic Health Record as ``a single solution to our common 
requirements.''
    In June 2012, the two departments set an expected timeline of a 
2017 rollout for the iEHR.
    In July 2012, both Secretaries testified to this Committee and the 
Armed Services Committee, reinforcing that a single integrated record 
was the way forward and that their respective departments would achieve 
that goal together.
    This past December, it was stated that VA and DoD could roll out 
the health record even faster, without much supporting detail.
    The latest news, a mere two months later, has us asking whether 
even the original 2017 timeline is realistic, and whether the end 
product will deliver that same level of integration for transitioning 
servicemembers.
    ``Interoperable'' is not the same as ``integrated.'' While I 
understand that information can still be shared, VA and DoD must better 
explain to this Committee, the Congress, and, most importantly, to 
servicemembers how this new way forward is going to deliver what has 
been mandated, is badly needed, and has been talked about for over a 
decade.
    I am concerned that this new approach is a step backwards toward 
the model that had been previously tried and failed, namely, 
maintaining two different systems between two departments and wishfully 
thinking that the two systems will eventually talk to one another. I am 
further concerned about the stewardship of taxpayer dollars over the 
past several years. I find it hard to think of another description than 
``down the drain'' for funding that may have produced little result- 
the same funding that could have gone toward taking care of active and 
former servicemembers.
    Assistant Secretary Baker, I understand you are leaving VA in the 
very near future and therefore won't directly oversee the joint 
electronic health record's development much longer. While I wish more 
progress had been made during your tenure, I can only hope that your 
successor doubles down on his or her efforts to make this a reality.
    The need for a seamless record hasn't been discussed for over a 
decade with the mere expectation that we'll just continue to discuss 
it. The time for action is long past, and each time the objective 
changes or the goalposts move, it is servicemembers and veterans who 
lose the most. That is unacceptable to this Committee, and should be to 
VA and DoD as well. I look forward to hearing more today about how, 
when, and in what form VA and DoD will finally bring about a joint 
electronic health record.

                                 
  Prepared Statement of Hon. Michael Michaud, Ranking Minority Member
    Thank you, Mr. Chairman.
    We, as a Nation, have a ``sacred trust'' to care for those who have 
served and sacrificed. To do this, we rely on a ``community of 
support.''
    DoD and VA are the pinnacle of that community. Together you are the 
front-end and the back-end of the veteran safety-net. You must come 
together seamlessly or veterans fall through the space between you.
    You have no greater mutual responsibility to those who have served 
you, and to those you serve, than to ensure a complete and smooth 
transition from the military back to civilian life.
    Key to that smooth transition is the transfer of the health records 
that document the physical and mental sacrifices of our Nation's 
heroes.
    The Integrated Electronic Health Record (iEHR) initiative is 
critical to ushering in a more fluid process for our servicemen and 
women who transition into the veteran world.
    Ideally, instead of servicemembers hand carrying paper records with 
them to medical appointments, access to their records would be readily 
available, electronically, to the providers and health care personnel 
who care for them when they take the uniform off and continue their 
lives as civilians.
    In transforming the VA into a 21st century agency, we envisioned a 
seamless record that could benefit the men and women who have served 
this country honorably.
    The idea of VA and DoD being capable of electronic communication 
was not a new one. We believed that VA and DoD could accomplish this 
task.
    For at least a decade the two largest agencies in the government 
have worked this issue - often taking two steps forward and one step 
back.
    I was under the impression, and in fact reassured, as late as 
September 2012 that the development of the iEHR, while challenging, was 
still on track to becoming the reality we intended.
    So, in early February when we read in the news of the decision that 
VA and DoD were ``modifying its strategy'' from the planned iEHR 
approach and focus, I was disappointed and disheartened.
    It seems to me that we have regressed back to 2004 when the 
Bidirectional Health Information Exchange was the way electronic 
information was exchanged. I am hoping this is not the case.
    There are questions that must be answered as to the future of the 
iEHR and plans to move forward.
    The original strategy - the intent of iEHR - was to design, build 
and implement a new, single system ``from scratch.'' In revising your 
life cycle cost estimates, you have determined that approach is too 
expensive.
    So, you ``modified your strategy'' to use a core set of 
capabilities from existing EHR technologies. But rather than selecting 
one system from those currently available, your modified strategy is 
for each Department to separately select a core system of choice.
    VistA, the VA's current system is old and by all accounts replacing 
VistA with an existing Commercial Off The Shelf package is estimated to 
be $16 billion dollars, according to a September 6, 2011 letter.
    VA believes that leveraging open source methodologies will increase 
the rate of improvement within VistA and will be much cheaper.
    DoD is looking to explore commercial options for its core system 
and won't have a selection decision until March.
    How does this modified strategy live up to the initial intent of 
iEHR to be a single, integrated system?
    I am currently not comfortable with the direction we seem to be 
heading.
    I am sure everyone in here would agree that we cannot afford to 
continue moving forward and back on this issue. VA was once a leader in 
electronic health recordkeeping - today, it is one that is simply 
trying to keep up.
    This must change. You - we - owe more to the Nation's 
servicemembers and veterans.
    I look forward to the testimony today and a frank, open discussion 
on the way ahead.

                                 
    Prepared Statement of Hon. Roger W. Baker and Dr. Robert Petzel
    Good morning Chairman Miller, Ranking Member Michaud, and Members 
of the committee. We appreciate the opportunity to appear before you 
today to discuss the Department of Veterans Affairs' (VA) efforts to 
develop an integrated Electronic Health Record (iEHR) with the 
Department of Defense (DoD). Our testimony will address the current and 
future state of iEHR. We will also address the decision to utilize the 
Veterans Health Information Systems and Technology Architecture (VistA) 
as VA's core for iEHR.
    First, we would like to dispel any notion that VA and DoD are 
moving away from a single, joint, electronic health record--both 
Secretary Shinseki and Secretary Panetta reaffirmed our commitment to 
this in public statements on February 5th. What has changed is the 
strategy that we will use to accomplish that goal.
Initiation of the iEHR
    In April of 2009, President Obama charged the Departments of 
Defense and Veterans Affairs to make Servicemember and Veteran health 
record information seamlessly available so that all information about a 
Servicemember or Veteran is available when they seek service from VA or 
DoD. In May of 2009, as VA and DoD established the Virtual Lifetime 
Electronic Record (VLER) program to provide portability and 
accessibility of health, benefits, and administrative data for every 
Servicemember and Veteran, regardless of status, for the remainder of 
their lives, addressing the challenges many Veterans experience 
transitioning to VA service.
    In addition to the exchange of information facilitated by VLER, in 
March of 2011, Secretaries Shinseki and Gates agreed that VA and DoD 
would work together to establish a joint plan to create a single, joint 
electronic health record (iEHR). Key to the decision to work together 
was the fact that both VA and DoD were pursuing paths to modernize 
their existing EHR platforms. DoD was planning to replace its current 
EHR, the Armed Forces Health Longitudinal Technology Application 
(AHLTA), with a new electronic health record, and VA was planning to 
improve VistA by establishing an Open Source consortium and gradually 
replacing parts of the system with packages acquired from private 
sector developers. In June of 2011, the Secretaries accepted the plan 
put forth by the Departments, which included the fundamental 
architecture, governance, and approach that would deliver an iEHR.
iEHR Governance
    To address the challenges in achieving a large-scale, joint DoD-VA 
initiative, the iEHR program established a governance structure 
designed to support interagency decision-making. The Interagency 
Program Office (IPO), established under PL 110-181, serves as the 
single point of accountability for the joint development and 
implementation of iEHR. The IPO receives direction, supervision, and 
control from the Department Secretaries and guidance from the IPO 
Advisory Board and Joint Executive Committee (JEC). The IPO receives 
requirements from and collaborates with DoD / VA Health and Benefits 
Executive Councils (HEC and BEC) and the JEC reviews the implementation 
of iEHR activities.
    The governance structure was established to ensure decisions are 
made and executed at the appropriate level in the organization. The IPO 
Advisory Board co-chairs are the DoD Deputy Chief Management Officer 
(DCMO) and the VA Assistant Secretary for Information and Technology. 
In 2013, an Executive Committee of the IPO Advisory Board was 
established to oversee the execution of the iEHR program and the IPO. 
In the event the Executive Committee cannot reach a consensus, issues 
are addressed by the JEC, and then to the two Secretaries, if 
necessary.
iEHR Cost Estimates
    The IPO has approximately 135 federal employees, several hundred 
contractor employees, and approximately $758 million in planned 
spending for FY 2013. Despite these resources, the IPO has been 
challenged to meet its program deadlines. The initial estimate of the 
cost for the iEHR presented to the Secretaries in 2011 projected the 
cost to develop the iEHR at between $4 and $6 billion. VA and DoD 
agreed to split the costs of iEHR development equally, and a cost 
sharing memorandum of understanding was completed in 2012. In September 
of 2012, the IPO produced a new estimate of the cost of the iEHR that 
doubled the estimated cost of development of the system. While no 
missed milestone has yet caused a change in the ``critical path'' 
toward Initial Operating Capability (IOC) in 2014, the program has met 
very few of the milestones it has set.
Revised iEHR Plan
    In December of 2012, when presented with the revised cost and 
schedule information, the Secretaries directed that the Interagency 
Program Office (IPO) Advisory Board Co-Chairs and the Health Executive 
Committee (HEC) Co-Chairs prepare and provide a report within 30 days 
that would assess the current program strategy, provide ``quick win'' 
recommendations to accelerate interoperability and recommend changes to 
the governance structure and budget impacts. As a result, the IPO 
Advisory Board Co-Chairs and HEC Co-Chairs provided a plan which the 
Secretaries approved that included:

      Program Strategy: Adjusted the iEHR acquisition business 
rules agreed to in March 2011 from ``buy'' commercially available 
solutions for joint use, ``adopt'' a Department-developed application 
if a modular commercial solution is not available and one Department 
has a solution, ``create'' a joint application on a case by case basis 
if neither a modular commercial or Department-developed solution are 
available, to ``adopt, buy, create'' to leverage existing capabilities 
for joint use. The Departments will also define a ``core'' set of iEHR 
capabilities that would allow us to evaluate the selection of existing 
EHR products to reduce program risks and costs while accelerating 
implementation.
      Quick Wins: Accelerate the federation of VA and DoD 
clinical health data, to include VA's mapping of the Health Data 
Dictionary (HDD) to their Corporate Data Warehouse (CDW) and update the 
CDW to provide near real-time patient data access. This data 
interoperability work will be completed by January 2014. The VA will 
also rapidly adopt the common DoD-VA identity management solution and 
create the VA-DoD Medical Community of Interest network and security 
infrastructure. VA and DoD will continue to expand and accelerate 
patient access to data through the ``Blue Button'' initiatives.
      Governance: Established an Executive Committee of the IPO 
Advisory board consisting of the DoD Deputy Chief Management Officer, 
the DoD Assistant Secretary for Health Affairs, the VA Under Secretary 
for Health, and the VA Assistant Secretary for Information and 
Technology.

    Additionally the Secretaries approved deployment of the JANUS 
Graphical User Interface (GUI) to five VA polytrauma rehabilitation 
centers and two associated Military Treatment Facilities.
    Under this plan, VA has committed to use the ``core'' technology of 
VistA, while DoD will evaluate available alternatives in order to make 
a ``core'' technology selection that will best fit its needs. In order 
to achieve the desired data interoperability between both Departments, 
both ``cores'' will conform to an agreed-upon set of standards that 
enable the secure and interoperable exchange of information.
    While the immediate focus is on accelerating data interoperability 
between the two Departments, our end goal remains the same - to make 
certain that we are creating a single, joint electronic health record 
for each Servicemember and Veteran.
VA Selection of VistA
    VA chose the ``core'' technology of VistA to reduce the costs and 
risks associated with the selection and implementation of a different 
technology. Most importantly, while we are engaged in continuously 
improving VistA, it is still one of the best EHR systems available 
worldwide. And, because the source code to VistA is available via Open 
Source, we know that we will always be able to achieve competitive 
pricing for any changes we need to make.
    VistA's current Graphic User Interface known as the Computerized 
Patient Record System (CPRS), allows providers to update a patient's 
medical history, place a variety of orders, and review test results and 
drug prescriptions. Its tabbed chart interface organizes problem lists, 
pharmacy data, orders, lab results, progress notes, vital signs, 
radiology results, transcribed documents, and reports from various 
studies such as echocardiograms in a clinically relevant manner. CPRS 
enables clinicians to enter, review, and continuously update all order-
related information connected with any patient. With CPRS, a clinician 
can order lab tests, medications, diets, radiology tests and 
procedures, record a patient's allergies or adverse reactions to 
medications, request and track consults, and enter progress notes, 
diagnoses, and treatments for each encounter, and enter discharge 
summaries. Close integration with the Clinical Reminders and Text 
Integration packages allows better record keeping and compliance with 
Clinical Guidelines and medical record requirements.
    The system has been implemented at all VA medical centers and at VA 
outpatient clinics, long-term care facilities, and domiciliaries - 
1,300 sites of care throughout the Veterans Health Administration. VA 
is the largest installation of VistA, with over 250,000 daily users at 
152 of the nation's largest hospitals and over 800 community-based 
outpatient clinics nationwide. VA serves over 6 million unique Veterans 
each year, and every visit is tracked and supported through the VistA 
EHR. The largest individual VistA ``sites'' each have more than 80 
million orders in their individual databases and each of these sites 
creates and handles an average of 22-28 thousand new orders per 
weekday.
    VistA consists of approximately 160 applications (modules) which 
cover all aspects of health care and health care delivery (i.e. 
hospital operations). More than half are clinically focused; the rest 
are supportive/administrative applications that are integral to 
delivering efficient, comprehensive, and safe patient care for the 
largest medical system in the US. VistA functionality reaches far 
beyond the general hospital/health care EHR requirements. Highly 
complex, government-specific regulations related to health care 
coordination, reporting, compliance, billing, and countless other 
functions. VistA represents a deep and comprehensive integration of 
services.
    In 2012, the VA health care system was honored to have 16 of its 
health care entities named to the 2012 ``Most Wired'' hospitals list. 
The list that is released by Hospitals & Health Networks annually, in 
partnership with McKesson, the College of Healthcare Information 
Management Executives (CHIME), and the American Hospital Association 
(AHA), is a result of a national assessment aimed at ranking hospitals 
which are leveraging health information technology in new and 
innovative ways.
Conclusion
    Mr. Chairman, the iEHR has proven to be a very challenging program, 
but both DoD and VA are committed to achieving the President's goal of 
making Servicemember and Veteran information seamlessly available 
across the two Departments. As part of our efforts to make rapid 
progress on data interoperability, we are pleased to announce that in 
the coming months VA will be deploying the Janus Graphic User Interface 
to five VA polytrauma rehabilitation centers and two associated 
Military Treatment Facilities; standardizing health care data to 
facilitate interoperability; upgrading the Corporate Data Warehouse to 
enable the near real-time exchange of data between Departments; and 
enabling patients in both Departments to download and transmit their 
medical records using national standards in with what is known as the 
Blue Button.
    We appreciate the opportunity to appear before you today, and we 
are prepared to respond to any questions you may have

                                 
Prepared Statement of The Hon. Jonathan Woodson, and Hon. Elizabeth A. 
                                McGrath
    Chairman Miller, Ranking Member Michaud, and members of this 
distinguished Committee, thank you for extending the invitation to both 
the Department of Defense and Department of Veterans Affairs to testify 
today on our integrated Electronic Health Record (iEHR) program.
    In April 2009, the President charged our two Departments to, ``work 
together to define and build a seamless system of integration with a 
single goal: when a member of the Armed Forced separates from the 
military, he or she will no longer have to walk paperwork from a DoD 
duty station to a local VA health center; their electronic records will 
transition along with them and remain with them forever.'' This goal is 
important not only to Service members' continued medical care, but also 
to their benefits processing. Given the President's clear direction, 
our Departments have been working on two very important efforts 
simultaneously. First, we are committed to ensuring that all health 
data for an individual can be brought together into a seamless 
electronic health record. Second, we are both committed to modernizing 
and replacing our legacy health information technology systems.
    In March 2011, the two Departments agreed to pursue a common 
approach to develop and implement the next generation of EHR 
capabilities meeting both goals for two Departments. Specifically, we 
agreed to implement a common architecture, data and services, data 
centers, interface/exchange standards and presentation layer. The plan 
had been to design, build and implement this new system from the ground 
up and jointly purchase individual clinical applications that could 
``plug-in'' to the common architecture.
    Since that time, the following significant important work has been 
done to develop and pilot capabilities to facilitate the exchange of 
information between Departments and improve the information accessible 
to doctors and patients in both VA and DoD medical systems.

      The first step in creating interoperability between two 
computer systems is to make sure that the exchanged data means the same 
thing. DoD has a Health Data Dictionary to make sure that its various 
health IT systems can exchange information. VA is currently mapping 
VistA data elements to the same data dictionary, ensuring that we have 
data interoperability between the two Departments.
      By locating both Departments' health data in the same 
place, we improve our ability to access and distribute the data. VA is 
migrating its health data to the DoD Defense Information Systems Agency 
(DISA) data centers;
      Currently, to upgrade a single component of our current 
systems requires considerable work at great expense. Our joint service 
oriented architecture approach and purchase of a shared enterprise 
service bus allows greater flexibility in designing and upgrading 
software applications for each Department and promotes agility and 
flexibility with regards to communication and interaction between 
applications

      We have selected a single DoD-VA joint Single Sign On/
Context Management (SSO / CM) solution and are in the process of 
installing it across the DoD. Medical Single Sign-On allows users to 
log in once to the health care systems and move from application to 
application without having to reenter passwords. Health care providers 
can focus on documenting patient care instead of remembering their 
multiple passwords. Patient Context Management allows users to choose a 
patient in one application and have the patient context follow to other 
participating clinical applications once they are launched.

      When clinicians are treating patients who receive health 
care from both Departments, it is useful to have patient information 
presented to the clinician in a single view. We have implemented a 
joint Graphical User Interface (GUI) pilot at North Chicago, Tripler, 
and San Antonio that displays information from both DoD and VA systems 
to allow providers from both Departments a single common view for 
patient information.
      As we look to purchase clinical applications for joint 
use, our medical providers must identify the requirements or 
functionality that each application should provide. We are well on our 
way to jointly completing business process mapping for initial clinical 
capabilities.

    During this time, we also completed an initial Life Cycle Cost 
estimate for the program and identified various development plans, 
which included an option to accelerate functionality, and to reduce 
costs and technical risks to the program.
    We discovered that there were specific actions that we could take 
together to accelerate availability of seamless information across the 
two Departments. These ``quick wins'' were approved by Secretaries 
Panetta and Shinseki on February 5, 2013, and include:

    1. Expanding our ``Blue Button'' capability so that VA and DoD 
patients can securely download and transmit their medical records to 
the destinations of their choice, using national standards, via the 
internet in industry standard formats by May 2013;
    2. Accelerating a common display or viewer that will allow 
clinicians to see a virtual consolidation of patient data at nine key 
sites, including our VA's five polytrauma rehabilitation centers by 
July 2013;
    3. Completing the mapping of VA health data to the Health Data 
Dictionary by September 2013; and
    4. Accelerating the ``real-time'' availability of VA health data by 
December 2013 so that providers have access to the most recent and best 
data to care for patients .

    In addition to these efforts to accelerate availability of seamless 
information, both Departments are also working to modernize or replace 
our underlying information technology systems. To reduce cost and 
technical risk, the two Departments agreed to modify the strategy. 
Instead of designing, building, and implementing a new system ``from 
scratch'', we would use a ``core'' set of applications from existing 
EHR technology, to which could be added additional modules or 
applications, as could be added. DoD is reviewing available commercial 
and governmental options, and anticipates a decision on this issue by 
the end of March. VA has decided to use its current system, VistA, as 
its core.
    Some have interpreted this shift in strategy as backing away from 
our commitment to achieve an integrated electronic health record. 
Nothing could be further from the truth. The two Departments intend to 
create an integrated electronic health record and remain committed to 
shared, standard data, shared applications, and a shared common user 
interface. By focusing on a number of quick wins to accelerate 
availability of seamless information across the two Departments this 
year we will achieve the President's goal far sooner, and at a lower 
cost.
    Going forward, we look to leverage existing government and 
commercial EHR technology as a way to reduce risks and overall costs of 
modernizing our health information technology systems, while 
accelerating the delivery of new capabilities.
    By establishing exchange and increased functionality across our two 
systems by 2014, we will create a ``Virtual Lifetime Electronic 
Record'' for each Service Member and Veteran, thus achieving the 
President's vision of every separating Service member having his or her 
information available for a smooth transition to Veteran status, 
whether it is to coordinate the delivery of health care or achieve 
rapid adjudication of benefits. The voluntary service of our Service 
members is indispensable to the freedoms we enjoy as a nation. Our 
Service Members, Veterans, retirees, and eligible family members 
deserve nothing less than the best possible care and service our 
Departments can provide. We will maintain our focus and momentum and 
will continue to provide you updates on our progress and achievements.
    We look forward to your questions.

                                 
                Prepared Statement of Valerie C. Melvin
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee:
    Thank you for the opportunity to participate in today's hearing on 
efforts of the Department of Veterans Affairs (VA) to share electronic 
health records with the Department of Defense (DOD). As you know, VA 
and DOD operate two of the nation's largest health care systems, which, 
in fiscal year 2013, are projected to provide coverage to approximately 
6.3 million veterans and 9.6 million active duty service members and 
their beneficiaries at estimated costs of about $53 billion and $49 
billion, respectively.
    Both VA and DOD have long recognized the importance of advancing 
the use of shared health information systems and capabilities to make 
patient information more readily available to their health care 
providers, reduce medical errors, and streamline administrative 
functions. Toward this end, the two departments have an extensive 
history of working to achieve shared health care resources, dating back 
to the 1980s. \1\ Our work has examined the departments' efforts over 
the past 15 years in undertaking a variety of initiatives to share data 
between their individual health information systems and to develop 
interoperable health record capabilities. In this regard, reports that 
we issued between 2001 and 2012 have noted various degrees of progress 
by the departments; however, we have also highlighted, and recommended 
that VA and DOD address, pervasive and persistent management challenges 
that have impeded their ability to achieve fully interoperable 
electronic health record capabilities. \2\ My testimony today (1) 
summarizes VA's and DOD's efforts, and challenges faced, in 
electronically sharing health information and (2) describes the 
departments' recent change in their approach to developing an 
integrated electronic health record.
---------------------------------------------------------------------------
    \1\ Since the 1980s, VA and DOD have entered into many types of 
collaborations to provide health care services--including emergency, 
specialty, inpatient, and outpatient care--to VA and DOD beneficiaries, 
reimbursing each other for the services provided. These collaborations 
vary in scope, ranging from agreements to jointly provide a single type 
of service to more coordinated ``joint ventures,'' which encompass 
multiple health care services and facilities and focus on mutual 
benefit, shared risk, and joint operations in specific clinical areas.
    \2\ See for example, Computer-Based Patient Records: Better 
Planning and Oversight by VA, DOD, and IHS Would Enhance Health Data 
Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001); Electronic 
Health Records: DOD and VA Have Increased Their Sharing of Health 
Information, but More Work Remains, GAO-08-954 (Washington, D.C.: July 
28, 2008); Electronic Health Records: DOD's and VA's Sharing of 
Information Could Benefit from Improved Management, GAO-09-268 
(Washington, D.C.: Jan. 28, 2009); Electronic Health Records: DOD and 
VA Efforts to Achieve Full Interoperability Are Ongoing; Program Office 
Management Needs Improvement, GAO-09-775 (Washington, D.C.: July 28, 
2009); Electronic Health Records: DOD and VA Interoperability Efforts 
Are Ongoing; Program Office Needs to Implement Recommended 
Improvements, GAO-10-332 (Washington, D.C.: Jan. 28, 2010); and 
Electronic Health Records: DOD and VA Should Remove Barriers and 
Improve Efforts to Meet Their Common System Needs, GAO-11-265 
(Washington, D.C.: Feb. 2, 2011).
---------------------------------------------------------------------------
    In developing this testimony, we relied on our previous work. We 
also obtained and reviewed information on the departments' actions in 
response to our previous recommendations. We conducted our work in 
support of this testimony during February 2013. All work on which this 
testimony is based was performed in accordance with generally accepted 
government auditing standards. Those standards require that we plan and 
perform the audit to obtain sufficient, appropriate evidence to provide 
a reasonable basis for our findings and conclusions based on our audit 
objectives. We believe that the evidence obtained provides a reasonable 
basis for our findings and conclusions based on our audit objectives.
Background
    The use of information technology (IT) to electronically collect, 
store, retrieve, and transfer clinical, administrative, and financial 
health information has great potential to help improve the quality and 
efficiency of health care. Historically, patient health information has 
been scattered across paper records kept by many different caregivers 
in many different locations, making it difficult for a clinician to 
access all of a patient's health information at the time of care. 
Lacking access to these critical data, a clinician may be challenged to 
make the most informed decisions on treatment options, potentially 
putting the patient's health at greater risk. The use of electronic 
health records can help provide this access and improve clinical 
decisions.
    Electronic health records are particularly crucial for optimizing 
the health care provided to military personnel and veterans. While in 
military status and later as veterans, many VA and DOD patients tend to 
be highly mobile and may have health records residing at multiple 
medical facilities within and outside the United States. Making such 
records electronic can help ensure that complete health care 
information is available for most military service members and veterans 
at the time and place of care, no matter where it originates.
    Although they have identified many common health care business 
needs, both departments have spent large sums of money to develop and 
operate separate electronic health record systems that they rely on to 
create and manage patient health information. VA uses its integrated 
medical information system--the Veterans Health Information Systems and 
Technology Architecture (VistA)--which was developed in-house by VA 
clinicians and IT personnel. The system consists of 104 separate 
computer applications, including 56 health provider applications; 19 
management and financial applications; 8 registration, enrollment, and 
eligibility applications; 5 health data applications; and 3 information 
and education applications. Besides being numerous, these applications 
have been customized at all 128 VA sites. \3\ According to the 
department, this customization increases the cost of maintaining the 
system, as it requires that maintenance also be customized.
---------------------------------------------------------------------------
    \3\ A site includes one or more facilities--medical centers, 
hospitals, or outpatient clinics--that store their electronic health 
data in a single database.
---------------------------------------------------------------------------
    In 2001, the Veterans Health Administration undertook an initiative 
to modernize VistA by standardizing patient data and modernizing the 
health information software applications. In doing so, its goal was to 
move from the hospital-centric environment that had long characterized 
the department's health care operations to a veteran-centric 
environment built on an open, robust systems architecture that would 
more efficiently provide both the same functions and benefits of the 
existing system and enhanced functions based on computable data. VA 
planned to take an incremental approach to the initiative, based on six 
phases (referred to as ``blocks'') that were to be completed in 2018. 
Under this strategy, the department planned to replace the 104 VistA 
applications that are currently in use with 67 applications, 3 
databases, and 10 common services. VA reported spending almost $600 
million from 2001 to 2007 on eight projects, including an effort that 
resulted in a repository containing selected standardized health data, 
as part of the effort to modernize VistA. In April 2008, the department 
estimated an $11 billion total cost to complete, by 2018, the 
modernization that was planned at that time. However, according to VA 
officials, the modernization effort was terminated in August 2010.
    For its part, DOD relies on its Armed Forces Health Longitudinal 
Technology Application (AHLTA), which comprises multiple legacy medical 
information systems that the department developed from commercial 
software products that were customized for specific uses. For example, 
the Composite Health Care System (CHCS), which was formerly DOD's 
primary health information system, is still in use to capture 
information related to pharmacy, radiology, and laboratory order 
management. In addition, the department uses Essentris (also called the 
Clinical Information System), a commercial health information system 
customized to support inpatient treatment at military medical 
facilities. DOD obligated approximately $2 billion for AHLTA between 
1997 and 2010.
    A key goal for sharing health information among providers, such as 
between VA's and DOD's health care systems, is achieving 
interoperability. Interoperability enables different information 
systems or components to exchange information and to use the 
information that has been exchanged. This capability allows patients' 
electronic health information to move with them from provider to 
provider, regardless of where the information originated. If electronic 
health records conform to interoperability standards, they can be 
created, managed, and consulted by authorized clinicians and staff 
across more than one health care organization, thus providing patients 
and their caregivers the necessary information required for optimal 
care. (Paper-based health records--if available--also provide necessary 
information, but unlike electronic health records, do not provide 
decision support capabilities, such as automatic alerts about a 
particular patient's health, or other advantages of automation.)
    Interoperability can be achieved at different levels. At the 
highest level, electronic data are computable (that is, in a format 
that a computer can understand and act on to, for example, provide 
alerts to clinicians on drug allergies). At a lower level, electronic 
data are structured and viewable, but not computable. The value of data 
at this level is that they are structured so that data of interest to 
users are easier to find. At a still lower level, electronic data are 
unstructured and viewable, but not computable. With unstructured 
electronic data, a user would have to find needed or relevant 
information by searching uncategorized data. Beyond these, paper 
records can also be considered interoperable (at the lowest level) 
because they allow data to be shared, read, and interpreted by human 
beings.
VA and DOD Have Pursued Various Efforts over Many Years but Have Been 
        Challenged in Achieving Fully Interoperable Electronic Health 
        Records
    Since 1998, VA and DOD have relied on a patchwork of initiatives 
involving their health information systems to achieve electronic health 
record interoperability. These have included efforts to: share viewable 
data in existing (legacy) systems; link and share computable data 
between the departments' modernized health data repositories; establish 
interoperability objectives to meet specific data-sharing needs; 
develop a virtual lifetime electronic health record to track patients 
through active service and veteran status; and implement IT 
capabilities for the first joint federal health care center. While, 
collectively, these initiatives have yielded increased data-sharing in 
various capacities, a number of them have nonetheless been plagued by 
persistent management challenges, which have created barriers to 
achieving the fully interoperable electronic health record capabilities 
long sought.
Early Efforts to Share Information in Legacy Systems Suffered from 
        Project Planning and Management Weaknesses
    Among the departments' earliest efforts to achieve interoperability 
was the Government Computer-Based Patient Record (GCPR) initiative, 
which was begun in 1998 with the intent of providing an electronic 
interface that would allow physicians and other authorized users of 
VA's and DOD's health facilities to access data from either of the 
other agency's health facilities. \4\ The interface was expected to 
compile requested patient health information in a temporary, 
``virtual'' record that could be displayed on a user's computer screen. 
However, in reporting on this initiative in April 2001, we found that 
accountability for GCPR was blurred across several management entities 
and that basic principles of sound IT project planning, development, 
and oversight had not been followed, thus, creating barriers to 
progress. \5\ For example, clear goals and objectives had not been set; 
detailed plans for the design, implementation, and testing of the 
interface had not been developed; and critical decisions were not 
binding on all partners. While both departments concurred with our 
recommendations that they, among other things, create comprehensive and 
coordinated plans for the effort, progress on the initiative continued 
to be disappointing. The department subsequently revised the strategy 
for GCPR and, in May 2002, narrowed the scope of the initiative to 
focus on enabling DOD to electronically transfer service members' 
electronic health information to VA upon their separation from active 
duty. The initiative--renamed the Federal Health Information Exchange 
(FHIE)--was completed in 2004.
---------------------------------------------------------------------------
    \4\ Initially, the Indian Health Service (IHS) was also part of 
this initiative, having been included because of its population-based 
research expertise and its long-standing relationship with VA. However, 
IHS was not included in a later revised strategy for electronically 
sharing patient health information.
    \5\ GAO-01-459.
---------------------------------------------------------------------------
    Building on the architecture and framework of FHIE, VA and DOD also 
established the Bidirectional Health Information Exchange (BHIE) in 
2004, which was aimed at allowing clinicians at both departments 
viewable access to records on shared patients (that is, those who 
receive care from both departments, such as veterans who receive 
outpatient care from VA clinicians and then are hospitalized at a 
military treatment facility). The interface also enabled DOD sites to 
see previously inaccessible data at other DOD sites.
    Further, in March 2004, the departments began an effort to develop 
an interface linking VA's Health Data Repository and DOD's Clinical 
Data Repository, as part of a long-term initiative to achieve the two-
way exchange of health information between the departments' modernized 
systems--known as CHDR. The departments had planned to be able to 
exchange selected health information through CHDR by October 2005. 
However, in June 2004, we reported that the efforts of VA and DOD in 
this area demonstrated a number of management weaknesses. \6\ Among 
these were the lack of a well-defined architecture for describing the 
interface for a common health information exchange; an established 
project management lead entity and structure to guide the investment in 
the interface and its implementation; and a project management plan 
defining the technical and managerial processes necessary to satisfy 
project requirements. Accordingly, we recommended that the departments 
address these weaknesses and they agreed to do so.
---------------------------------------------------------------------------
    \6\ GAO, Computer-Based Patient Records: VA and DOD Efforts to 
Exchange Health Data Could Benefit from Improved Planning and Project 
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
---------------------------------------------------------------------------
    In September 2005, we testified that the departments had improved 
the management of the CHDR program, but that this program continued to 
face significant challenges--in particular, with developing a project 
management plan of sufficient specificity to be an effective guide for 
the program. \7\ In a subsequent testimony, in June 2006, we noted that 
the project did not meet a previously established milestone: to be able 
to exchange outpatient pharmacy data, laboratory results, allergy 
information, and patient demographic information on a limited basis by 
October 2005. \8\ By September 2006, the departments had taken actions 
which ensured that the CHDR interface linked the departments' separate 
repositories of standardized data to enable a two-way exchange of 
computable outpatient pharmacy and medication allergy information. 
Nonetheless, we noted that the success of CHDR would depend on the 
departments' instituting a highly disciplined approach to the project's 
management.
---------------------------------------------------------------------------
    \7\ GAO, Computer-Based Patient Records: VA and DOD Made Progress, 
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T 
(Washington, D.C.: Sept. 28, 2005).
    \8\ GAO, Information Technology: VA and DOD Face Challenges in 
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006).
---------------------------------------------------------------------------
Efforts to Comply with 2008 Mandate to Achieve Fully Interoperable 
        Health Records Capabilities Lacked Project Plans and Measures 
        of Effectiveness
    To increase the exchange of electronic health information between 
the two departments, the National Defense Authorization Act (NDAA) for 
Fiscal Year 2008 included provisions directing VA and DOD to jointly 
develop and implement, by September 30, 2009, fully interoperable 
electronic health record systems or capabilities. \9\ To facilitate 
compliance with the act, the departments' Interagency Clinical 
Informatics Board, made up of senior clinical leaders who represent the 
user community, began establishing priorities for interoperable health 
data between VA and DOD. In this regard, the board was responsible for 
determining clinical priorities for electronic data sharing between the 
departments, as well as what data should be viewable and what data 
should be computable. Based on its work, the board established six 
interoperability objectives for meeting the departments' data-sharing 
needs:
---------------------------------------------------------------------------
    \9\ Pub. L. No. 110-181, Sec.  1635, 122 Stat. 3, 460-463 (2008).

      Refine social history data: DOD was to begin sharing with 
VA the social history data that are currently captured in the DOD 
electronic health record. Such data describe, for example, patients' 
involvement in hazardous activities and tobacco and alcohol use.
      Share physical exam data: DOD was to provide an initial 
capability to share with VA its electronic health record information 
that supports the physical exam process when a service member separates 
from active military duty.
      Demonstrate initial network gateway operation: VA and DOD 
were to demonstrate the operation of secure network gateways to support 
joint VA-DOD health information sharing.
      Expand questionnaires and self-assessment tools: DOD was 
to provide all periodic health assessment data stored in its electronic 
health record to VA such that questionnaire responses are viewable with 
the questions that elicited them.
      Expand Essentris in DOD: DOD was to expand its inpatient 
medical records system (CliniComp's Essentris product suite) to at 
least one additional site in each military medical department (one 
Army, one Air Force, and one Navy, for a total of three sites).
      Demonstrate initial document scanning: DOD was to 
demonstrate an initial capability for scanning service members' medical 
documents into its electronic health record and sharing the documents 
electronically with VA.

    The departments asserted that they took actions that met the six 
objectives and, in conjunction with capabilities previously achieved 
(e.g., FHIE, BHIE, and CHDR), had met the September 30, 2009, deadline 
for achieving full interoperability as required by the act. 
Nonetheless, the departments planned additional work to further 
increase their interoperable capabilities, stating that these actions 
reflected the departments' recognition that clinicians' needs for 
interoperable electronic health records are not static. In this regard, 
the departments focused on additional efforts to meet clinicians' 
evolving needs for interoperable capabilities in the areas of social 
history and physical exam data, expanding implementation of Essentris, 
and additional testing of document scanning capabilities.
    Even with these actions, however, we identified a number of 
challenges the departments faced in managing their efforts in response 
to the 2008 NDAA. Specifically, we identified challenges with respect 
to performance measurement, project scheduling, and planning. For 
example, in a January 2009 report, we noted that the departments' key 
plans did not identify results-oriented (i.e., objective, quantifiable, 
and measurable) performance goals and measures that are characteristic 
of effective planning and can be used as a basis to track and assess 
progress toward the delivery of new interoperable capabilities. \10\ We 
pointed out that without establishing results-oriented goals and 
reporting progress using measures relative to the established goals, 
the departments and their stakeholders would not have the comprehensive 
picture that they need to effectively manage their progress toward 
achieving increased interoperability. Accordingly, we recommended that 
DOD and VA take action to develop such goals and performance measures 
to be used as a basis for providing meaningful information on the 
status of the departments' interoperability initiatives. In response, 
the departments stated that such goals and measures would be included 
in the next version of the VA/DOD Joint Executive Council Joint 
Strategic Plan (known as the joint strategic plan). However, that plan 
was not approved until April 2010, 7 months after the departments 
asserted they had met the deadline for achieving full interoperability.
---------------------------------------------------------------------------
    \10\ GAO-09-268.
---------------------------------------------------------------------------
    In addition to its provisions directing VA and DOD to jointly 
develop fully interoperable electronic health records, the 2008 NDAA 
called for the departments to set up an Interagency Program Office 
(IPO) to be accountable for their efforts to implement these 
capabilities by the September deadline. Accordingly, in January 2009, 
the office completed its charter, articulating, among other things, its 
mission and functions with respect to attaining interoperable 
electronic health data. The charter further identified the office's 
responsibilities in carrying out its mission in areas such as oversight 
and management, stakeholder communication, and decision making. Among 
the specific responsibilities identified in the charter was the 
development of a plan, schedule, and performance measures to guide the 
departments' electronic health record interoperability efforts.
    In July 2009, we reported that the IPO had not fulfilled key 
management responsibilities identified in its charter, such as the 
development of an integrated master schedule and a project plan for the 
department's efforts to achieve full interoperability. \11\ Without 
these important tools, the office was limited in its ability to 
effectively manage and provide meaningful progress reporting on the 
delivery of interoperable capabilities. We recommended that the IPO 
establish a project plan and a complete and detailed integrated master 
schedule. In response to our recommendation, the office began to 
develop an integrated master schedule and project plan that included 
information about its ongoing interoperability activities.
---------------------------------------------------------------------------
    \11\ GAO-09-775.
---------------------------------------------------------------------------
    It is important to note, however, that in testifying before this 
committee in July 2011, the office's former Director stated that the 
IPO charter established a modest role for the office, which did not 
allow the office to be the single point of accountability for the 
development and implementation of interoperable electronic health 
records. \12\ Instead, the office served the role of coordination and 
oversight for the departments' efforts. Additionally, as pointed out by 
this official, control of the budget, contracts, and technical 
development remained with VA and DOD. As a result, each department had 
continued to pursue separate strategies and implementation paths, 
rather than coming together to build a unified, interoperable approach.
---------------------------------------------------------------------------
    \12\ Legislative Hearing on H.R. 2383, H.R. 2243, H.R. 2388 and 
H.R. 2470, Before the Subcommittee on Oversight and Investigations of 
the Committee on Veterans' Affairs, U.S. House of Representatives, 
112th Cong., First Session (July 20, 2011) (statement of Debra M. 
Filippi, Former Director, U.S. Department of Defense/U.S. Department of 
Veterans Affairs Interagency Program Office), February 25, 2012, http:/
/veterans.house.gov/prepared-statement/prepared-statement-debra-m-
filippi-former-director-us-department-defenseus.
---------------------------------------------------------------------------
Virtual Lifetime Electronic Record Initiative Lacked Comprehensive 
        Planning
    In another attempt at furthering efforts to increase electronic 
health record interoperability, in April 2009, the President announced 
that VA and DOD would work together to define and build the Virtual 
Lifetime Electronic Record (VLER) to streamline the transition of 
electronic medical, benefits, and administrative information between 
the two departments. VLER is intended to enable access to all 
electronic records for service members as they transition from military 
to veteran status, and throughout their lives. Further, the initiative 
is to expand the departments' health information sharing capabilities 
by enabling access to private sector health data.
    Shortly after the April 2009 announcement, VA, DOD, and the IPO 
began working to define and plan for the initiative. In June 2009, the 
departments adopted a phased implementation strategy consisting of a 
series of 6-month pilot projects to deploy a set of health data 
exchange capabilities between existing electronic health record systems 
at local sites around the country. Each VLER pilot project was intended 
to build upon the technical capabilities of its predecessor, resulting 
in a set of baseline capabilities to inform project planning and guide 
the implementation of VLER nationwide.
    The first pilot, which started in August 2009, in San Diego, 
California, resulted in VA, DOD, and Kaiser Permanente being able to 
share a limited set of test patient data. Subsequently, between March 
2010 and January 2011, VA and DOD conducted another pilot in the 
Tidewater area of southeastern Virginia, which focused on sharing the 
same data as the San Diego pilot plus additional laboratory data. The 
departments planned additional pilots, with the goal of deploying VLER 
nationwide at or before the end of 2012.
    In June 2010, DOD informed us that it planned to spend $33.6 
million in fiscal year 2010, and $61.9 million in fiscal year 2011 on 
the initiative. Similarly, VA stated that it planned to spend $23.5 
million in fiscal year 2010, and had requested $52 million for fiscal 
year 2011.
    However, in a February 2011 report on the departments' efforts to 
address their common health IT needs, we noted that although VA and DOD 
identified a high-level approach for implementing VLER and designated 
the IPO as the single point of accountability for the effort, they had 
not developed a comprehensive plan identifying the target set of 
capabilities that they intended to demonstrate in the pilot projects 
and then implement on a nationwide basis at all domestic VA and DOD 
sites by the end of 2012. \13\ Moreover, the departments conducted VLER 
pilot projects without attending to key planning activities that are 
necessary to guide the initiative. For example, as of February 2011, 
the IPO had not developed an approved integrated master schedule, 
master program plan, or performance metrics for the VLER initiative, as 
outlined in the office's charter. We noted that if the departments did 
not address these issues, their ability to effectively deliver 
capabilities to support their joint health IT needs would be uncertain. 
We recommended that the Secretaries of VA and DOD strengthen their 
ongoing efforts to establish VLER by developing plans that include 
scope definition, cost and schedule estimation, and project plan 
documentation and approval. Officials from both departments agreed with 
the recommendation, and we are monitoring their actions toward 
implementing them. Nevertheless, the departments were not successful in 
meeting their goal of implementing VLER nationwide by the end of 2012.
---------------------------------------------------------------------------
    \13\ GAO-11-265.
---------------------------------------------------------------------------
Poor Project Planning Contributed to Information Technology Delays at 
        the Joint Federal Health Care Center
    VA and DOD also continued their efforts to share health information 
and resources in 2010 following congressional authorization of a 5-year 
demonstration project to more fully integrate the two departments' 
facilities that were located in proximity to one another in the North 
Chicago, Illinois, area. As authorized by the National Defense 
Authorization Act for fiscal year 2010, \14\ VA and DOD facilities in 
and around North Chicago were integrated into a first-of-its-kind 
system known as the Captain James A. Lovell Federal Health Care Center 
(FHCC). The FHCC is unique in that it is to be the first fully 
integrated federal health care center for use by both VA and DOD 
beneficiaries, with an integrated workforce, a joint funding source, 
and a single line of governance.
---------------------------------------------------------------------------
    \14\ Pub. L. No. 111-84, div. A, title XVII, 123 Stat. 2190, 2567-
2574 (2009).
---------------------------------------------------------------------------
    In April 2010, the Secretaries of VA and DOD signed an Executive 
Agreement that established the FHCC and defined the relationship 
between the two departments for operating the new, integrated facility, 
in accordance with the 2010 NDAA. Among other things, \15\ the 
Executive Agreement specified three key IT capabilities that VA and DOD 
were required to have in place by the FHCC's opening day, in October 
2010, to facilitate interoperability of their electronic health record 
systems:
---------------------------------------------------------------------------
    \15\ The Executive Agreement identified 12 areas of integration for 
the FHCC, one of which is information technology.

      medical single sign-on, which would allow staff to use 
one screen to access both the VA and DOD electronic health record 
systems;
      single patient registration, which would allow staff to 
register patients in both systems simultaneously; and
      orders portability, which would allow VA and DOD 
clinicians to place, manage, and update clinical orders from either 
department's electronic health records systems for radiology, 
laboratory, consults (specialty referrals), and pharmacy services.

    However, in a February 2011 report that identified improvements the 
departments' could make to the FHCC effort, we noted that project 
planning for the center's IT capabilities was incomplete. \16\ We 
specifically noted that the departments had not defined the project 
scope in a manner that identified all detailed activities. 
Consequently, they were not positioned to reliably estimate the project 
cost or establish a baseline schedule that could be used to track 
project performance. Based on these findings, we expressed concern that 
VA and DOD had jeopardized their ability to fully and expeditiously 
provide the FHCC's needed IT system capabilities. We recommended that 
the Secretaries of VA and DOD strengthen their efforts to establish the 
joint IT system capabilities for the FHCC by developing plans that 
included scope definition, cost and schedule estimation, and project 
plan documentation and approval. Although officials from both 
departments stated agreement with our recommendation, the departments' 
actions were not sufficient to preclude delays in delivering the FHCC's 
IT system capabilities, as we subsequently described in July 2011 and 
June 2012.
---------------------------------------------------------------------------
    \16\ GAO-11-265.
---------------------------------------------------------------------------
    Specifically, our 2011 report noted that none of the three IT 
capabilities had been implemented by the time of the FHCC's opening, as 
required by the Executive Agreement; \17\ however, FHCC officials 
reported that the medical single sign-on and single patient 
registration capabilities subsequently became operational in December 
2010.
---------------------------------------------------------------------------
    \17\ GAO, VA and DOD Health Care: First Federal HealthCare Center 
Established, but Implementation Concerns Need to Be Addressed, GAO-11-
570 (Washington, D.C.: July 19, 2011).
---------------------------------------------------------------------------
    In June 2012, we again reported on the departments' efforts to 
implement the FHCC's required IT capabilities, and found that portions 
of the orders portability capability--related to the pharmacy and 
consults components--remained delayed. \18\ VA and DOD officials 
described workarounds that the departments had implemented as a result 
of the delays, but did not have a timeline for completion of the 
pharmacy component, and estimated completion of the consults component 
by March 2013.
---------------------------------------------------------------------------
    \18\ GAO, VA/DOD Federal Health Care Center: Costly Information 
Technology Delays Continue and Evaluation Plan Lacking, GAO-12-669 
(Washington, D.C.: June 26, 2012). In this report, we noted that orders 
portability for radiology had become operational in June 2011 and for 
laboratory in March 2012.
---------------------------------------------------------------------------
    The officials reported that as of March 2012, the departments had 
spent about $122 million on developing and implementing IT capabilities 
at the FHCC. However, they were unable to quantify the total cost for 
all the workarounds resulting from delayed IT capabilities.
VA and DOD Recently Changed Their Approach to Developing an Integrated 
        Electronic Health Record
    Beyond the aforementioned initiatives, in March 2011 the 
Secretaries of VA and DOD committed the two departments to developing a 
new common integrated electronic health record (iEHR), and in May 2012 
announced their goal of implementing it across the departments by 2017. 
According to the departments, the decision to pursue iEHR would enable 
VA and DOD to align resources and investments with common business 
needs and programs, resulting in a platform that would replace the two 
departments' electronic health record systems with a common system. In 
addition, because it would involve both departments using the same 
system, this approach would largely sidestep the challenges they have 
encountered in trying to achieve interoperability between separate 
systems.
    To oversee this new effort, in October 2011, the IPO was re-
chartered and given authority to expand its staffing level and provided 
with new authorities under the charter, including control over the 
budget. According to IPO officials, the office was expected to have a 
staff of 236 personnel--more than 7 times the number of staff 
originally allotted to the office by VA and DOD--when hiring under the 
charter was completed.
    However, IPO officials told us that, as of January 2013, the office 
was staffed at approximately 62 percent and that hiring additional 
staff remained one of its biggest challenges.
    Earlier this month, the Secretaries of VA and DOD announced that 
instead of developing a new common integrated electronic health record 
system, the departments would now focus on integrating health records 
from separate VA and DOD systems, while working to modernize their 
existing electronic health record systems. VA has stated that it will 
continue to modernize VistA while pursuing the integration of health 
data, while DOD has stated that it plans to evaluate whether it will 
adopt VistA or purchase a commercial off-the-shelf product. The 
Secretaries offered several reasons for this new direction, including 
cutting costs, simplifying the problem of integrating VA and DOD health 
data, and meeting the needs of veterans and service members sooner 
rather than later.
    The numerous challenges that the departments have faced in past 
efforts to achieve full interoperability between their existing health 
information systems heighten longstanding concerns about whether this 
latest initiative will be successful. We have ongoing work--undertaken 
at the request of the Chairman and Ranking Member of the Senate 
Committee on Veterans Affairs--to examine VA's and DOD's decisions and 
activities related to this endeavor.
Barriers Exist to Jointly Addressing VA's and DOD's Health Care System 
        Needs
    VA's and DOD's revised approach to developing iEHR highlights the 
need for the departments to address barriers they have faced in key IT 
management areas. Specifically, in a February 2011 report, we 
highlighted barriers that the departments faced to jointly addressing 
their common health care system needs in the areas of strategic 
planning, enterprise architecture, and investment management. \19\ In 
particular, the departments had not articulated explicit plans, goals, 
and time frames for jointly addressing the health IT requirements 
common to both departments' electronic health record systems, and their 
joint strategic plan did not discuss how or when they propose to 
identify and develop joint solutions to address their common health IT 
needs. In addition, although DOD and VA had taken steps toward 
developing and maintaining artifacts related to a joint health 
architecture (i.e., a description of business processes and supporting 
technologies), the architecture was not sufficiently mature to guide 
the departments' joint health IT modernization efforts. Further, the 
departments had not established a joint process for selecting IT 
investments based on criteria that consider cost, benefit, schedule, 
and risk elements, limiting their ability to pursue joint health IT 
solutions that both meet their needs and provide better value and 
benefits to the government as a whole. We noted that without having 
these key IT management capabilities in place, the departments would 
continue to face barriers to identifying and implementing IT solutions 
that addressed their common needs.
---------------------------------------------------------------------------
    \19\ GAO-11-265.
---------------------------------------------------------------------------
    In our report, we identified several actions that the Secretaries 
of Defense and Veterans Affairs could take to overcome these barriers, 
including the following:

      Revise the departments' joint strategic plan to include 
information discussing their electronic health record system 
modernization efforts and how those efforts will address the 
departments' common health care business needs.
      Further develop the departments' joint health 
architecture to include their planned future state and transition plan 
from their current state to the next generation of electronic health 
record capabilities.
      Define and implement a process, including criteria that 
consider costs, benefits, schedule, and risks, for identifying and 
selecting joint IT investments to meet the departments' common health 
care business needs.

    Officials from both VA and DOD agreed with these recommendations, 
and we have been monitoring their actions toward implementing them. 
Nonetheless, important work remains, and it takes on increased urgency 
in light of the departments' revised approach to developing the iEHR. 
For example, with respect to planning, the departments' joint strategic 
plan does not describe the new approach to how the departments will 
address their common health care business needs. Regarding 
architecture, in February 2012, the departments established the Health 
Architecture Review Board to provide architecture oversight, approval, 
and decision support for joint VA and DOD health information technology 
programs. While the board has generally met monthly since May 2012 and 
has been working to establish mechanisms for overseeing architecture 
activities, the extent to which the departments' revised approach to 
iEHR is guided by a joint health architecture remains to be seen. With 
regard to defining a process for identifying and selecting joint 
investments, the departments have established such a governance 
structure, but the effectiveness of this structure has not yet been 
demonstrated. In particular, the departments have not yet demonstrated 
the extent to which criteria that consider costs, benefits, schedule, 
and risks have been or will be used to identify and select planned 
investments.
    In summary, while VA and DOD have made progress in increasing 
interoperability between their health information systems over the past 
15 years, these efforts have faced longstanding challenges. In large 
part, these have been the result of inadequate program management and 
accountability. In particular, there has been a persistent absence of 
clearly defined, measurable goals and metrics, together with associated 
plans and time frames, that would enable the departments to report 
progress in achieving full interoperability. Moreover, the Integrated 
Program Office has not functioned as it was intended--as a single point 
of accountability for efforts to implement fully interoperable 
electronic health record systems or capabilities. The 2011 decision to 
develop a single, integrated electronic health record system to be used 
across both departments could have avoided or mitigated some of these 
challenges. However, the more recent decision to reverse course and 
continue to operate separate systems and develop additional 
interoperable capabilities raises concern in light of historical 
challenges. Further, although the departments have asserted that their 
now planned approach will deliver capabilities sooner and at lower 
cost, deficiencies in key IT management areas of strategic planning, 
enterprise architecture, and investment management could continue to 
stand in the way of VA's and DOD's attempts to jointly address their 
common health care system needs in the most efficient and effective 
manner.
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee, this concludes my statement. I would be pleased to respond 
to any questions that you may have.
GAO Contact and Staff Acknowledgments
    If you have any questions concerning this statement, please contact 
Valerie C. Melvin, Director, Information Management and Technology 
Resources Issues, at (202) 512-6304 or [email protected]. Other 
individuals who made key contributions include Mark T. Bird, Assistant 
Director; Heather A. Collins; Kelly R. Dodson; Lee A. McCracken; Umesh 
Thakkar; and Eric L. Trout.
                     GAO Highlights of GAO-13-413T
ELECTRONIC HEALTH RECORDS
Long History of Management Challenges Raises Concerns about VA's and 
        DOD's New Approach to Sharing Health Information
Why GAO Did This Study
    VA and DOD operate two of the nation's largest health care 
systems--systems that serve populations of veterans and active service 
members and their dependents. To better serve these populations, VA and 
DOD have been collaborating for about 15 years on a variety of 
initiatives to share data among the departments' health information 
systems. The use of IT to electronically collect, store, retrieve, and 
transfer such data has the potential to improve the quality and 
efficiency of health care. Particularly important in this regard is 
developing electronic health records that can be accessed throughout a 
patient's military and veteran status. Making such information 
electronic can ensure greater availability of health care information 
for service members and veterans at the time and place of care. 
Although they share many common business needs, both VA and DOD have 
spent large sums of money to develop and maintain separate electronic 
health record systems that they use to create and manage patient health 
information.
    GAO was asked to testify on (1) the departments' efforts, and 
challenges faced, in electronically sharing health information and (2) 
the recent change in their approach to developing an integrated 
electronic health record. In preparing this statement, GAO relied 
primarily on previously published work in this area.
What GAO Recommends
    Since 2001, GAO has made numerous recommendations to improve VA's 
and DOD's management of their efforts to share health information.
What GAO Found
    The Departments of Veterans Affairs (VA) and Defense (DOD) have 
undertaken a number of patchwork efforts over the past 15 years to 
achieve interoperability (i.e., the ability to share data) of records 
between their information systems, however, these efforts have faced 
persistent challenges. The departments' early efforts to achieve 
interoperability included enabling DOD to electronically transfer 
service members' electronic health information to VA; allowing 
clinicians at both departments viewable access to records on shared 
patients; and developing an interface linking the departments' health 
data repositories. As GAO reported, however, several of these efforts 
were plagued by project planning and management weaknesses, inadequate 
accountability, and poor oversight, limiting their ability to realize 
full interoperability.
    To further expedite data sharing, the National Defense 
Authorization Act of 2008 directed VA and DOD to jointly develop and 
implement fully interoperable electronic health record capabilities by 
September 30, 2009. The departments asserted that they met this goal, 
though they planned additional work to address clinicians' evolving 
needs. GAO identified weaknesses in the departments' management of 
these initiatives, such as a lack of defined performance goals and 
measures that would provide a comprehensive picture for managing 
progress. In addition, the departments' Interagency Program Office, 
which was established to be a single point of accountability for 
electronic health data sharing, had not fulfilled key management 
responsibilities.
    In 2009, the departments began work on the Virtual Lifetime 
Electronic Record initiative to enable access to all electronic records 
for service members transitioning from military to veteran status, and 
throughout their lives. To carry this out, the departments initiated 
several pilot programs but had not defined a comprehensive plan that 
defined the full scope of the effort or its projected cost and 
schedule. Further, in 2010, VA and DOD established a joint medical 
facility that was, among other things, to have certain information 
technology (IT) capabilities to facilitate interoperability of the 
departments' electronic health record systems. Deployment of these 
capabilities was delayed, however, and some have yet to be implemented.
    In 2011, the VA and DOD Secretaries committed to developing a new 
common integrated electronic health record system, with a goal of 
implementing it across the departments by 2017. This approach would 
largely sidestep the challenges in trying to achieve interoperability 
between separate systems. However, in February 2013, the Secretaries 
announced that the departments would focus on modernizing their 
existing systems, rather than developing a single system. They cited 
cost savings and meeting needs sooner rather than later as reasons for 
this decision. Given the long history of challenges in achieving 
interoperability, this reversal of course raises concerns about the 
departments' ability to successfully collaborate to share electronic 
health information. Moreover, GAO has identified barriers to the 
departments' jointly addressing their common needs arising from 
deficiencies in key IT management areas, which could continue to 
jeopardize their pursuits. GAO is monitoring the departments' progress 
in overcoming these barriers and has additional ongoing work to 
evaluate their activities to develop integrated electronic health 
record capabilities.

                                 
                  Prepared Statement of Jacob B. Gadd
    ``I'm asking the Department of Defense and the Department of 
Veterans Affairs to work together to define and build a seamless system 
of integration with a simple goal: when a member of the Armed Forces 
separates from the military, he or she will no longer have to walk 
paperwork from a DoD duty station to a local VA health center; their 
electronic records will transition along with them and remain with them 
forever.'' - President Barack Obama April 9, 2009

    It began as a simple goal, something seemingly well within the 
grasp of a modern, twenty-first century nation - create a seamless, 
single health record for veterans. Sadly, four years and a billion 
dollars later, veterans are left with the feeling their government is 
throwing in the towel. Veterans are left with the feeling that the two 
great agencies they have served in and been served by, the Department 
of Defense (DOD) and the Department of Veterans Affairs (VA), have been 
unable to come to a simple compromise that would have provided a 
single, unified record. According to a February 5, 2013 press 
conference involving both Secretary Panetta of DOD and Secretary 
Shinseki of VA, a stop gap measure to access both record systems will 
be put in place and both VA and DOD will continue to maintain and use 
their legacy systems. This is not what the veterans of America were 
promised.
    Chairman Miller, Ranking Member Michaud and distinguished Members 
of the Committee:
    The American Legion is grateful for the opportunity to come before 
you today and represent the views of our 2.4 million members on this 
topic. This is a decision that will have a lasting impact on the entire 
veterans' community, as well as on active duty service members serving 
today and the men and women of the future who have yet to answer the 
call to serve.
    The American Legion supported the creation and implementation of a 
Virtual Lifetime Electronic Record (VLER). The veterans and service 
officers of our organization saw firsthand the vital need for seamless 
communication between VA and DOD. In a resolution passed at our 
National Convention in Milwaukee, WI in the summer of 2011, not only 
did our members call for implementation of this record as soon as 2013, 
we also supported the concept strongly enough to note features such a 
record should include to be of best use to veterans.
    The American Legion recommended Veterans Service Organizations 
(VSOs) and other key stake holders be included in the planning process 
so we could share our vital experience in the implementation of VLER. 
Yet VSOs have been left out of the majority of planning. We called for 
a single system to improve communication between VA, DOD and elements 
of VA such as the Veterans Benefits Administration (VBA), Veterans 
Health Administration (VHA) and National Cemetery Administration (NCA) 
yet this does not appear to be any part of the integrated plan moving 
forward. The American Legion supported innovation within this system to 
improve scheduling for veterans' appointments with their healthcare 
system, yet VHA still struggles with timely appointments for veterans.
    The American Legion recommended specific ways in which VLER could 
help veterans with receive the benefits they earned with their service 
and sacrifice. With a truly integrated record, when a service member 
was injured or took ill on active duty, their record could be flagged 
automatically. Years later, following discharge from service, when VA 
went back to look at the single, unified record, those flags would 
stand out and make service connection for those disabilities, a benefit 
earned by the veteran, far easier and less time consuming. Because VA 
and DOD steadfastly cling to their previous legacy system, it seems 
likely this will be impossible and the true benefit of technology 
cannot be implemented on behalf of the veteran.
    Veterans' healthcare records are hurting the disability claims 
process. This is happening at every level, from currently transitioning 
veterans to veterans who have been out of service for come time. 
Improving the healthcare records will help the claims process and will 
aid VA in their goal to break the back of the backlog. Most 
importantly, it will help veterans get the benefits they deserve in the 
timely fashion they deserve.
    Current service members transitioning out of the military for 
medical reasons are experiencing lengthy delays in the Medical 
Evaluation Board (MEB)/Physical Evaluation Board (PEB) process. The 
average number of days pending for an MEB/PEB case is 374 days. Much of 
the delay time involves medical records and scheduling appointments. 
These are service members who have not even left service yet, and the 
delays with records are impacting their claims.
    When they go to transition, even greater problems arise. During an 
American Legion visit to a DOD/VA Joint Venture site Legion staff had 
the opportunity to interview veterans about the transition process. One 
veteran expressed that the transition process had actually worked very 
well, ``except for my records.'' The veteran explained ``I enrolled in 
VA and they asked me for my DOD treatment records [because they did not 
have access to them]. I walked over to DOD and they told me the base 
had run out of paper to print the record and to come back in a few 
weeks.'' That our government could not handle this extremely basic task 
during the transition period for a veteran should be a source of 
national embarrassment.
    The American Legion's work on the Fully Developed Claims (FDC) 
pilot project has shown what an impact having quick, easy access to 
records can have. These claims require getting all of the information 
together up front to expedite the process for veterans, something that 
would be improved for all veterans if there was a single, unified 
electronic record. While the average days pending for regular claims in 
the system is 257 days, in the FDC program, claims are averaging 120 
days, which is under Secretary Shinseki's stated goal of 125 days for a 
veteran's claim. Furthermore, in some locations, such as Pittsburgh, 
The American Legion has been seeing claims decided accurately in 30-35 
days. This is the impact of having all the useful information available 
right up front for VA. This can be the key towards breaking the 
backlog.
    The American Legion recognizes that some benefit has come from the 
collaboration. There has been some improvement in communication between 
VA and DOD over the past four years, although there is certainly room 
for much more. The collaboration on this project has led to some 
beneficial results for veterans in the form of eBenefits Portal, the 
``Blue Button'' which allows for the download of healthcare information 
and some improvement to transition. However, in the end, the veterans 
are still not receiving what they were promised - a single, integrated 
system to track their health from the moment they volunteer to serve to 
the time their families must access their earned benefits from the 
National Cemetery Administration.
    While VA and DOD may still be pursing improved communications, they 
have abandoned the Integrated Electronic Health Record (iEHR) and that 
should justly raise an alarm amongst the veterans' community. This may 
save money now, but it wastes a portion of the billion dollars already 
spent. Furthermore, as illustrated by the impact of having readily 
accessible records in the claims process, it's an abandonment of 
technological solutions to the difficult problems the claims system 
faces.
    Veterans should be able to expect 21st century technological 
solutions that are forward looking, not a retreat to the legacy of the 
past where VA and DOD maintain their own separate camps. The men and 
women who serve chose to serve one government, so one government should 
be able to deliver one healthcare record to them. This technology 
should not be out of our grasp.
    I thank you on behalf of The American Legion for the opportunity to 
provide our viewpoint on this critical matter.
Executive Summary
    The Department of Defense (DOD) and the Department of Veterans 
Affairs (VA) may still be moving forward with some stop gap measure to 
allow for access to veterans' health records, but it breaks the promise 
of a single record from the start of their military career throughout 
their life. This is important because a single unified record will help 
streamline the benefits process and allow for improved treatment and 
health care as they access the VA and DOD systems.

      Having all of the records up front drastically reduces 
processing time for claims and will help slash the claims backlog. The 
American Legion has seen this first hand through our work on the Fully 
Developed Claims program.
      By abandoning a single, unified record, key 
functionality, such as the ability to ``flag'' a file when a veteran is 
injured or takes ill on active duty, will hurt the claims process and 
the ability for any caregiver accessing the file to have a full 
disability picture of the veteran and render the best possible care.
      Ultimately, this is not what veterans were promised, and 
furthermore to abandon this project after a billion dollars worth of 
development with little to show for it is a breach of trust.
      The American Legion recognizes VA and DOD are still 
working to some kind of solution, and applauds them for the progress 
made on some components, such as the eBenefits portal, however we urge 
them to keep their promise to veterans and deliver the single record 
the veterans deserve.

                                 
                        Questions For The Record

Letter and Questions From: Hon. Jeff Miller, Chairman, To: Hon. Eric K. 
        Shinseki, Secretary, U.S. Department of Veterans Affairs

    March 15, 2013

    The Honorable Eric K. Shinseki
    Secretary
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Mr. Secretary:

    I request your response to the enclosed questions for the record I 
am submitting in reference to the House Veterans' Affairs Committee 
hearing entitled ``Electronic Health Record U-Turn: Are VA and DoD 
Headed in the Wrong Direction?'' that took place on February 27, 2013. 
I would appreciate if you could answer the enclosed hearing questions 
by the close of business on April 26, 2013.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Bernadine Dotson at [email protected]. If you have 
any questions, please call Mr. Eric Hannel, Majority Staff Director of 
the Oversight & Investigations Subcommittee, at 202-225-3527.

    Sincerely,

    JEFF MILLER
    Chairman

    JM/eg
Questions for the record:
    1. Now that the Department of Veterans Affairs (VA) and the 
Department of Defense (DoD) have decided against one longitudinal 
electronic health record (EHR) for all the military personnel, how will 
interoperability between the two systems be achieved? Will you 
competitively bid for a system that guarantees the exchange of patient 
information where the data is treated with the utmost security? How 
will you test the systems in advance and ensure that software upgrades 
to continua interoperability will be included in the price? What will 
the penalties be for failure to deliver and maintain a system that 
above all provides patient safety through a comprehensive patient 
record?

    2. What effect has the organizational culture had on VA's inability 
to continue developing the iEHR as it was originally portrayed?

    3. Please provide a full accounting of the staffing levels at the 
Interagency Program Office (IPO), including how many VA employees are 
there as of February 27, 2013, how many DoD employees are there as of 
February 27, 2013, and what the total number of employees from both 
departments are expected to be at the IPO.

    4. If DoD goes with a commercial-off-the-shelf (COTS) product for 
the health record, what measures are in place to ensure this will 
integrate with VistA and the development efforts to date on a joint 
electronic health record?

    5. Please provide VA's criteria for halting or terminating a major 
IT project.

    6. A study released in 2009 by Kaiser Permanente showed that 
implementation of a comprehensive, integrated EHR system for 225,000 
ambulatory care patients decreased the ``total office visit rate 
decreased 26.2 percent, the adjusted primary care office visit rate 
decreased 25.3 percent, and the adjusted specialty care office visit 
rate decreased 21.5 percent.'' It also increased ``Scheduled telephone 
visits increased more than eightfold, and secure e-mail messaging, 
which began in late 2005, increased nearly sixfold by 2007.''Kaiser 
Permanente concluded that, ``Introducing an EHR creates operational 
efficiencies by offering nontraditional, patient-centered ways of 
providing care. EHRs can help achieve more-efficient contacts between 
patients and providers, while maintaining quality and satisfaction.'' 
Given the high number of veterans who are elderly and/or living in 
rural areas, have DoD and VA considered how an integrated, rather than 
interoperable, system could lessen the travel burden while maintaining 
care for those veteran populations?

    7. According to the Institute of Medicine, ``the success of any 
health-care system rests not only on its physical infrastructure and 
care providers but on how it collects, maintains, transfers, and 
processes health information, especially patient records.'' In your 
opinions would an integrated electronic health record system enable 
better care than making multiple systems interoperable?

    8. How does your plan of interoperability differ from that of the 
joint DoD-VA hospital at Lovell Health Care Center, which attempted 
interoperability that the Institute of Medicine found to ``raise the 
specter of patient injury because of negative drug ...or allergy 
interactions ...'' and posed ``an unacceptable threat to patient 
safety''?

    9. Do you believe an integrated DoD-VA electronic health record 
system would decrease the amount of time veterans have to wait to see a 
physician?

    10. What has prevented VA and DoD from establishing a comprehensive 
electronic health record system? Why did the IPO's cost estimates of 
$4-6 billion for integrated electronic health record development double 
from 2011 to 2012?

    11. What effect do you think an integrated electronic health record 
system would have on delivery of mental health care?

    12. Do you believe a comprehensive integrated health record system 
between DoD and VA is achievable? What is your current timeline for 
achieving this if so?

                                 
Responses From: Department of Veterans Affairs, To: Hon. Jeff Miller, 
        Chairman
    1. Question: Now that the Department of Veterans Affairs (VA) and 
the Department of Defense (DoD) have decided against one longitudinal 
electronic health record (EHR) for all military personnel, how will 
interoperability between the two systems be achieved? Will you 
competitively bid for a system that guarantees the exchange of patient 
information where the data is treated with the utmost security? How 
will you test the systems in advance and ensure that software upgrades 
to continual interoperability will be included in that price? What will 
the penalties be for failure to deliver and maintain a system that 
above all provides safety through a comprehensive patient record?

    VA Response: The Department of Veteran Affairs (VA) and the 
Department of Defense (DoD) have two distinct goals and are committed 
to doing both in the most efficient and effective way possible:

    1. Create a seamless health record integrating VA and DoD data
    2. Modernize the software supporting DoD and VA clinicians

    The first goal targets the President's vision of having one 
longitudinal electronic health record for all military personnel. The 
two Departments are taking aggressive actions in 2013 to create a 
seamless health record, meaning that:

      VA and DoD doctors will be able to see and act on the 
same integrated patient information.
      Service members and Veterans will be able to go from one 
care facility to another and their records will follow them.
      Service members and Veterans will be able to securely 
download and share their medical records with others--creating health 
record portability for patients.

    Lots of information is exchanged across the DoD and the VA today. 
However most of the information we share today is not standardized or 
available in real time to support urgent clinical decisions. As an 
example, different names for ``blood glucose'' in the DoD and VA 
systems make it impossible to integrate and track blood sugar levels 
for diabetics across the two systems. Once these data are mapped to 
standard codes it will be possible to chart and track the blood sugar 
levels across time and across DoD and VA records.
    So our number one task is taking key clinical information in DoD 
and VA health records and making it standardized, integrated and 
immediately available for clinicians so they have the information they 
need to make critical medical decisions.

    2. Question: What effect has the organizational culture had on VA's 
inability to continue developing the iEHR as it was originally 
portrayed?

    VA Response: VA and DoD are bound by different constraints when it 
comes to information technology (IT) delivery. VA is bound by the 
Program Management Accountability System (PMAS), which requires 
delivery every 6 months or less and uses agile methodology. DoD is 
bound by DoD 5000, among other things, which is different than the PMAS 
management process. DoD funds executed for iEHR must be compliant with 
appropriate governing statutes and regulations, and this can present 
challenges when trying to execute projects using agile and incremental 
delivery as required by VA's PMAS process.
    Working within these constraints we are taking immediate steps to 
deliver seamless, integrated health information on an accelerated 
basis:
    We are creating a Data Management Service that will give DoD and VA 
clinicians access to integrated patient health record information. The 
service will retrieve data from across DoD and VA for a given patient 
for seven critical clinical areas-- medications, problems, allergies, 
lab results, vitals, immunizations, note titles--representing the vast 
majority of most patients' clinical information.
    The data will be mapped to open national standards--the same as 
those being adopted by the private sector--making the data computable 
and supporting health information sharing not only across the DoD and 
the VA, but also with private sector providers. The data will be 
available in near real-time, so clinicians can rely on it for urgent 
clinical decisions. The standardized, integrated data will fuel a 
variety of apps, tools and views supporting clinicians. The Data 
Management Service will be developed and deployed by the beginning of 
CY 2014. At the beginning of CY 2014, nine high priority sites will 
have access to these data through a single integrated view. DOD and VA 
intend to make standardized, integrated clinical record data broadly 
available to clinicians across the DoD and VA later in CY 2014.
    We are also enhancing ``Blue Button'' functionality, giving 
patients the ability to download and share their own electronic medical 
record information (in structured and coded format), helping them take 
control of their own health.

    3. Question: Please provide a full accounting of staffing levels at 
the Interagency Program Office (IPO), including how many VA employees 
are there as of February 27, 2013, how many DoD employees are there as 
of February 27, 2013, and what the total number of employees from both 
departments are expected to be at the IPO.

    VA Response: As the chart below illustrates, DoD and VA remain 
committed to providing appropriate staffing resources to the DoD/VA 
Interagency Program Office (IPO). As of February 27, 2013, IPO employed 
86 DoD employees and 86 VA employees. Total employment as of February 
27, 2013, was 172. Including staff detailed to IPO, IPO was staffed to 
72.9 percent as of February 27, 2013. IPO is authorized for a total of 
236 full-time equivalent positions.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    4. Question: If DoD goes with a commercial-off-the-shelf (COTS) 
product for the health record, what measures are in place to ensure 
that will integrate with VistA and the development efforts to date on a 
joint electronic health record?

    VA Response: Both DoD and VA intend to leverage open standards, 
open architecture and open published APIs, ensuring the best-value 
solution for their future clinical software. This approach will avoid 
vendor lock-in and will foster a thriving, competitive marketplace.
    DoD and VA will each deploy a ``core'' set of capabilities as early 
as possible; this ``core'' set of capabilities will provide the initial 
base around which a modernized EHR system will be assembled.
    VA decided earlier this year to deploy an iEHR ``core'' based on 
VistA. DoD will pursue a competitive process to select its ``core,'' 
selecting from the vibrant EHR marketplace, to include VistA-derived 
alternatives, to deliver a best-value solution. Each agency will expand 
its ``core'' capabilities to deliver a full suite of modernized 
clinical support to patients and medical personnel.

    5. Question: Please provide VA's criteria for halting or 
terminating a major IT project?

    VA Response: All major IT projects within VA are managed through 
PMAS. Projects are made up of increments. An increment is the segment 
of the project that produces an agreed-to portion of a functional 
business capability. A project increment has the following 
characteristics:

      Is a body of work that delivers capability directly 
related to a project;
      Has a defined start and end date, which does not exceed 6 
months;
      Has a defined budget; and
      Requires Business Sponsor acceptance of the delivered 
capability or capabilities, also known as the incremental deliverable.

    The PMAS Guide offers guidance on how to evaluate VA IT projects 
and increments under varying circumstances if the need to halt or 
terminate a project arises. PMAS offers means to inform VA leadership 
of changes and/or risks that may impact project cost, schedule, scope, 
and quality, known as Yellow and Red Flags. In addition, two PMAS 
states provide opportunities for halting or terminating projects, the 
Paused State and the Closed State.
    Increments enter the Paused State when it is determined that the 
increment needs to perform additional planning activities before 
continuing in the Active State. Increments only enter the Paused-
Planning State from the Active State. An increment may enter the 
Paused-Unfunded State from any PMAS State other than the Closed State. 
This decision is made by the office of responsibility, or through a 
TechStat meeting. A project will be Paused after missing three 
increment deliverables. If, during an early TechStat (fewer than three 
missed dates) it is determined that the increment is off track, an 
increment will be placed in the Paused State. In addition, an increment 
may be placed into the Paused State if the increment loses funding, but 
still has a valid business need.

    There are two types of Paused States:

      Paused-Planning: Projects that are placed in the Paused 
State to complete additional planning activities after missing three 
increment deliverables or as determined in an early TechStat as 
described above. A project or increment may enter the Paused-Planning 
State only from the Active State.
      Paused-Unfunded: Increments that have lost funding. An 
increment may enter the Paused-Unfunded State from any PMAS State other 
than the Closed State.

    The Assistant Secretary for Information and Technology or designee 
can enter an increment into Closed-Stopped State if an increment needs 
to be halted or terminated. An increment enters or is placed in the 
Closed State for a variety of reasons. These reasons include, but are 
not limited to, the following:

      Business priorities have changed; and
      Poor performance.

    A project that is stopped will not have the opportunity to restart 
unless the Business Sponsor indicates that the need for the project 
still exists and a new project is initiated to accomplish the business 
need.

    6. Question: A study released in 2009 by Kaiser Permanente showed 
that implementation of a comprehensive, integrated EHR system for 
225,000 ambulatory care patients decreased the ``total office visit 
rate decreased by 26.2 percent, the adjusted primary care office visit 
rate decreases 25.3 percent, and the adjusted specialty care office 
visit rate decreased 21.5 percent.'' It also increased ``Scheduled 
telephone visits increased more than eightfold, and secure e-mail 
messaging, which began in late 2005, increased nearly sixfold by 
2007.'' Kaiser Permanente concluded that, ``Introducing an EHR creates 
operational efficiencies by offering nontraditional, patient-centered 
ways of providing care. EHRs can help achieve more-efficient contacts 
between patients and providers, while maintaining quality and 
satisfaction.'' Given the high number of veterans who are elderly and/
or living in rural areas, have DoD and VA considered how an integrated, 
rather than interoperable, system could lessen the travel burden while 
maintaining care for those veteran populations?

    VA Response: This specific study cites impacts of implementing a 
comprehensive electronic medical record (EMR) system using an 
integrated health care delivery system. It is important to note that 
this is not to be confused with attempts to integrate two disparate 
health care systems across organizational boundaries. It is also 
important to note that this study was done in a health system that had 
only limited prior experience with an EMR. Only a third of Kaiser's 
facilities had used a fully functional EMR for approximately 2 years; 
the others used a read only EMR in parallel with paper records. An 
integrated health care delivery system is one which integrates an 
organization's EHR across inpatient and outpatient care settings, 
clinical decision support, and real-time connectivity to laboratory, 
pharmacy, radiology, and other ancillary systems. DoD and VA both have 
extensively implemented EMRs in both inpatient and outpatient settings 
for many years, but independently within each Department. As such, the 
Departments have already realized many of the efficiencies noted in 
this article within their respective health care systems.
    The challenge is to extend those efficiencies across Departmental 
boundaries to make care in effect seamless for those who transition 
from one system to the other. The Departments are taking steps to 
coordinate workflow, availability of data for decision-making and 
clinical decision support across the two Departments.

    7. Question: According to the Institute of Medicine, ``the success 
of any health-care system rests not only on its physical infrastructure 
and care providers but on how it collects, maintains, transfers, and 
processes health information, especially patient records.'' In your 
opinions would an integrated electronic health record system enable 
better care than making multiple systems interoperable?

    VA Response: We agree that this is a top priority. The key issue is 
to make key patient data--whether from the private sector, the DOD or 
VA--seamlessly available for clinical decisions. This does not require 
that the two Departments use the same software systems.
    For example, two different email systems can send email to each 
other, because email records are easily exchangeable and sharable. 
Private sector experience shows, using the same system does not 
guarantee that information can be shared. The important thing is that 
both systems use national standards to express the content and format 
of the information. Since these are the same standards being used in 
private sector systems, DoD and VA clinicians will be able to exchange 
information with each other as well as with private providers.

    8. Question: How does your plan of interoperability differ from 
that of the joint DoD-VA hospital at Lovell Health Care Center, which 
attempted interoperability that the Institute of Medicine found to 
``raise the specter of patient injury because of negative drug . . . or 
allergy interactions . . . '' and posed ``an unacceptable threat to 
patient safety''?

    VA Response: As noted in the Institute of Medicine (IOM) report, 
the two independent systems currently in place at the James A. Lovell 
Federal Health Care Center (JALFHCC) have limited ability to share 
patient information, which significantly reduces clinical efficiency. 
The lack of ability to share patient data results in time-consuming 
workarounds, including manual checking of important drug interactions. 
By providing a seamless flow of health care data, quality, safety, and 
efficiency gains can be realized at JALFHCC. As we indicated 
previously, our number one task is taking key clinical information in 
DoD and VA health records and making it standardized, integrated and 
immediately available for clinicians so they have the information they 
need to make critical medical decisions.

    9. Question: Do you believe an integrated DoD-VA electronic health 
record system would decrease the amount of time veterans have to wait 
to see a physician?

    VA Response: Our accelerated actions in 2013 to make available a 
seamless health record that integrates DOD and VA information for 
clinicians is likely to increase productivity in the health care 
delivery system, resulting in decreased appointment waiting time. This 
is separate and distinct from our plans to modernize the software 
supporting DoD and VA clinicians.

    10. Question: What has prevented VA and DoD from establishing a 
comprehensive electronic health record system? Why did the IPO's cost 
estimates of $4-6 billion for integrated electronic health record 
development double from 2011 to 2012?

    VA Response: The original budget estimate in 2011 projected a 
development and deployment budget of $4-$6 billion, this estimate was 
conducted using analogous work based on the requirements and 
architecture known at that early stage. IPO recently developed a 
bottom-up life cycle cost estimate (LCCE) in September 2012. This LCCE 
was nearly double the budget estimate that was made when the program 
was just beginning. The development of LCCE was required as part of the 
Milestone B approval process, a part of DoD's acquisition process and 
the process adopted across the broader iEHR Program. While VA agrees 
with the methodology used to develop the new LCCE, VA is still working 
with IPO to adjust the LCCE to reflect the lesser costs seen by VA as a 
result of fully embracing PMAS.
    However, the recent decision to accelerate data interoperability 
capabilities and shift the strategy to select a minimal core set of 
capabilities from an existing EHR system is likely to drive costs down.

    11. Question: What effect do you think an integrated electronic 
health record system would have on delivery of mental health care?

    VA Response: The work of both Departments to create a seamless 
health record that integrates data from both systems will improve care 
coordination and accelerate selection of effective treatments or 
identification of treatments that have been tried and proven 
ineffective for an individual. Having seamless, integrated information 
available longitudinally will also help in the identification of best 
practices in treatment of mental health conditions. Longitudinal health 
records for individuals receiving mental health care will also help 
identify potential risk factors and improve care delivery for both 
departments.

    12. Question: Do you believe a comprehensive integrated health 
record system between DoD and VA is achievable. What is your current 
timeline for achieving this if so?

    VA Response: DoD, VA, and the DoD/VA IPO believe that taking key 
clinical information in DoD and VA health records and making it 
standardized, integrated and immediately available for clinicians so 
they have the information they need to make critical medical decisions. 
These seamless, integrated data will be available in certain sites in 
2013, and broadly available to DoD and VA clinicians in 2014. In 
addition, we also expect that DoD and VA patients will be able to 
download and transmit their health records via Blue Button in the 
industry standard formats published by the Department of Health and 
Human Services no later than May 31, 2013.

                                 
Letter and Questions From: Hon. Michael Michaud, Ranking Minority 
        Member, To: Hon. Chuck Hagel, Secretary of Defense

    March 5, 2013

    The Honorable Chuck Hagel
    Secretary of Defense
    1000 Defense Pentagon
    Washington, DC 20301-1000

    Dear Mr. Secretary:

    In reference to our Full Committee hearing entitled, ``Electronic 
Health Record U-Turn: Are VA and DoD Headed In The Right Direction?'' 
that took place on February 27, 2013, I would appreciate it if you 
could answer the enclosed hearing questions by the close of business on 
April 15, 2013.
    Committee practice permits the hearing record to remain open to 
permit Members to submit additional questions to the witnesses. 
Attached are additional questions directed to you.
    In preparing your answers to these questions, please provide your 
answers consecutively and single-spaced and include the full text of 
the question you are addressing in bold font. To facilitate the 
printing of the hearing record, please e-mail your response in a Word 
document, to Carol Murray at [email protected] by the close 
of business on April 15, 2013. If you have any questions please contact 
her at 202-225-9756.

    Sincerely,

    MICHAEL H. MICHAUD
    Ranking Member

    CW:cm
Questions Submitted by Ranking Member Michaud
    1. When was iEHR designated a Program of Record? What acquisition 
type and category is it, and what acquisition activities and milestones 
have been accomplished since designation?

    2. Please provide the Committee with the budgetary resources 
provided to the IPO since its inception and the anticipated resource 
requirements for FY 2014 through FY 2017.

    3. Please provide the Committee with all previous milestones 
announced by the IPO and whether or not these milestones have been 
reached. If a milestone has been reached has it been reached by the 
projected date?

    4. In your testimony you state that ``[t]o reduce cost and 
technical risk, the two Departments agreed to modify the strategy.'' 
Please provide the Committee with supporting materials to support the 
conclusion that the revised strategy will indeed ``reduce cost and 
technical risk'', including alternatives considered

                                 
Question #1 From: Hon. Michael Michaud, Ranking Minority Member, To: 
        DCMO McGrath
    Question: When was iEHR designated a Program of Record? What 
acquisition type and category is it, and what acquisition activities 
and milestones have been accomplished since designation?
    Answer: Following the decision between the Secretaries of Defense 
and Veterans Affairs on March 17, 2011 and the subsequent re-chartering 
of the Interagency Program Office in October 2011, iEHR was identified 
in the DoD FY2013 budget submission in February 2012.
    The Deputy Chief Management Officer as Milestone Decision Authority 
(MDA) signed an Acquisition Decision Memorandum on April 18, 2012 to 
define the iEHR acquisition program based on prior agreements reached 
by the Secretaries of Defense and Veterans Affairs. iEHR is a Major 
Automated Information System.
    The MDA approved iEHR Increment 1 Milestone B and Increment 2 
Milestone A on December 4, 2012 and approved the Increment 1 
Acquisition Program Baseline on February 13, 2013. Currently, Increment 
1 functionality testing continues in a laboratory environment, and 
operational testing is scheduled to begin in May 2013.
    Other related acquisition activities and milestones include:

      Implemented Single Sign-On and Context Management 
capabilities at site in San Antonio.
      Achieved Development and Test Center / Development and 
Test Environment Initial Operational Capability.
      Conducted Increment 1 Test Readiness Review.
      Conducted Increment 2 Initial Design Review.
      Awarded Service-Oriented Architecture/Enterprise Service 
Bus contract.
      Released Technical Specifications Request for Information 
(RFI).
      Released RFI for Pharmacy capability and update.
      Released RFI for Immunization capability.

    The Department is exercising close oversight of this program to 
limit government liability and expenditure of funds to specific 
increments, deliverables and outcomes.

                                 
Question #2 From: Hon. Michael Michaud, Ranking Minority Member, To: 
        DCMO McGrath
    Question: Please provide the Committee with the budgetary resources 
provided to the IPO since its inception and the anticipated resource 
requirements for FY2014 through FY2017.
    Answer: The IPO was re-chartered in October 2011 to serve as the 
joint program office for the new DoD/VA iEHR mission. Below, you will 
find a table summarizing the FY2012 and FY2013 funds that were 
appropriated to DoD for iEHR, as well as the funding proposed in the 
President's FY2014 Budget Submission for FY2014 - FY2017. Please note 
that many of the FY2012 and FY2013 funds are multi-year appropriations 
and that DoD has spent $185.43M of these budgeted funds to date.

 
----------------------------------------------------------------------------------------------------------------
             $M                  FY 2012       FY 2013       FY 2014       FY 2015       FY 2016       FY 2017
----------------------------------------------------------------------------------------------------------------
DoD iEHR                         $449.795      $331.016      $344.101      $216.022      $217.100      $218.094
----------------------------------------------------------------------------------------------------------------


                                 
Question #3 From: Hon. Michael Michaud, Ranking Minority Member, To: 
        DCMO McGrath
    Question: Please provide the Committee with all previous milestones 
announced by the IPO and whether or not these milestones have been 
reached. If a milestone has been reached has it been reached by the 
projected date?
    Answer: The following are key deliverables identified by the IPO in 
support of iEHR. While you will notice that some of these milestones 
have been delayed, significant progress has been made, and we believe, 
in conjunction with our new revised strategy, the iEHR initiative 
remains on a path to deliver on the President's vision.
Lifecycle Cost Estimate

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Deliver Life Cycle Cost Estimate                    8/29/12                   8/29/12
 (LCCE) for iEHR Increments 1
 through 6
----------------------------------------------------------------------------------------------------------------


Single Sign On / Context Management (SSO/CM) with Virtualization 
        Platform (AVHE) Capability Deliveries
    ``Single Sign-On'' enables a user to access multiple applications 
after logging in only once. ``Context Management'' allow clinicians to 
choose a patient once during an encounter and have all required 
applications are able to present information on the patient being 
treated. This capability has been successfully deployed to the 
Development Test Center (DTC) for testing.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Select single SSO/CM solution for                   5/17/11                   5/17/11
 use by both Departments
----------------------------------------------------------------------------------------------------------------
Complete installation at San                       10/31/12                   11/2/12
 Antonio
----------------------------------------------------------------------------------------------------------------
Complete installation at            12/31/12, 2/28/13, 3/29/                             Product implementation
 Portsmouth, Tripler, and                                13                             challenges identified in
 Landstuhl                                                                                     SATX resulted in
                                                                                              decision to delay
                                                                                                additional site
                                                                                                  installations
----------------------------------------------------------------------------------------------------------------


Janus Graphical User Interface (GUI) Pilot Capability Deliveries
    Janus Joint Legacy Viewer (JLV) is a key enabler for the iEHR User 
Experience (UX), providing an integrated read-only view of the 
longitudinal patient record from DoD and VA sources. This deliverable 
tracks the implementation of the first delivery of an early UX pilot 
application focusing on the ability to ``read'' information contained 
in the iEHR system. Future deliveries will include the ability to write 
new information to the health record.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Implement Janus JLV at the James                    12/1/11                   12/1/11
 A. Lovell Federal Health Care
 Center
----------------------------------------------------------------------------------------------------------------
Implement Janus JLV at Audie                        9/30/12                  11/28/12
 Murphy VAMC and Brooke Army
 Medical Center in San Antonio
 (3rd Site)
----------------------------------------------------------------------------------------------------------------


Development and Test Center (DTC)
    The DTC provides a testing configuration that mimics the 
operational healthcare environment and infrastructure.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Install hardware                                    3/30/12                   6/15/12
----------------------------------------------------------------------------------------------------------------
Receive Authority to Operate                        1/15/12                   6/19/12
----------------------------------------------------------------------------------------------------------------
Install infrastructure                             12/30/12                             Delays primarily due to
                                                                                          manpower availability
                                                                                            caused by competing
                                                                                         operational capability
                                                                                        priorities and external
                                                                                                   organization
                                                                                                   dependencies
----------------------------------------------------------------------------------------------------------------
Install legacy clinical                            12/30/12
 applications
----------------------------------------------------------------------------------------------------------------


Establish Service Oriented Architecture (SOA) Suite / Test Environment
    The SOA Suite and Enterprise Service Bus (ESB) are the heart of the 
infrastructure that supports clinical applications. These two component 
parts allow the communications between the data, services and 
applications that will comprise iEHR. The first deliverable stands up 
the SOA Suite and ESB in a test environment.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Award contract                                    9/30/2011                 3/20/2012   Initial award voided due
                                                                                             to vendor protest.
                                                                                                               Contract re-awarded.
----------------------------------------------------------------------------------------------------------------
Install SOA/ESB in contractor                       4/19/12                   4/19/12
 sandbox
----------------------------------------------------------------------------------------------------------------
Install SOA/ESB in government                       7/26/12                   7/26/12
 sandbox
----------------------------------------------------------------------------------------------------------------
Conduct SOA Suite demonstration                     9/19/12                   9/17/12
 and evaluation
----------------------------------------------------------------------------------------------------------------
Install SOA/ESB in DTC                             11/19/12                  11/19/12
----------------------------------------------------------------------------------------------------------------
Receive SOA/ESB Authority to                        1/18/13                   2/27/13
 Operate
----------------------------------------------------------------------------------------------------------------
Install SOA/ESB in San Antonio and                  3/15/13                   3/15/13
 Hampton Roads DoD Sites
----------------------------------------------------------------------------------------------------------------


Health Data Dictionary Made Openly Available and VA Legacy Data Mapping
    The 3M Health Data Dictionary (HDD) is the common data model used 
by all DoD medical treatment facilities. A key tenet of the iEHR 
initiative is VA's agreement to adopt this data model, which is based 
on national standards and will ensure integrated common data for all 
patient information across DoD and VA.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Sign license agreement to make HDD                  7/31/11                   5/23/12        Protracted license
 publicly available                                                                        negotiations with VA
----------------------------------------------------------------------------------------------------------------
Award contract for VA legacy data                    8/6/12                    8/6/12
 mapping
----------------------------------------------------------------------------------------------------------------
Issue final report on data mapping                 12/15/12                   1/31/13
----------------------------------------------------------------------------------------------------------------
Release core HDD content                            9/21/12                   9/21/12
----------------------------------------------------------------------------------------------------------------
Issue collaboration specifications                   2/4/13                    2/4/13
----------------------------------------------------------------------------------------------------------------


Integrated Program Level Requirements Approved by the Health Executive 
        Council (HEC)
    With the active participation of clinical staff from both 
Departments, the iEHR program will harmonize healthcare delivery 
processes. The DoD/VA Interagency Clinical Informatics Board (ICIB) and 
the IPO have jointly prioritized clinical capabilities and grouped them 
into planning increments based on functional priority, technical 
feasibility, and financial viability. The ICIB has provided the 
integrated Program Level Requirements (iPLR), which detail the 
functional requirements for the defined joint capabilities and serve as 
the foundation of the iEHR program. Definition of iEHR functional 
requirements is overseen by the ICIB with approval by the DoD/VA HEC.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Approve Integrated Program-Level                     5/1/12                   7/27/12                         ICIB and HEC approval
 Requirements                                                                                            delays
----------------------------------------------------------------------------------------------------------------
Approve Lab and Access Control                      8/30/12                  10/17/12                         ICIB and HEC approval
 Business Justification Packages                                                                         delays
 (BJPs)
----------------------------------------------------------------------------------------------------------------
Approve Immunization BJP                            6/18/12                  11/30/12                         ICIB and HEC approval
                                                                                                         delays
----------------------------------------------------------------------------------------------------------------
Approve Identity Management BJP                     8/14/12                  10/17/12                         ICIB and HEC approval
                                                                                                         delays
----------------------------------------------------------------------------------------------------------------
Approve Pharmacy BJP                               11/30/12                  11/30/12
----------------------------------------------------------------------------------------------------------------


Make iEHR Architecture Artifacts Available to Potential Vendors and 
        Complete Initial Technical Design
    The Technical Specifications Package (TSP) contains technical 
documents including architecture artifacts that provide high-level 
technical and business requirements that define the needs for a 
standardized and interoperable DoD/VA iEHR solution. These artifacts 
have been uploaded to http://www.tricare.mil/tma/ipo/vendor.aspx and 
have been updated since then.

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Publish Technical Specification                     5/11/12                   5/11/12
 Package
----------------------------------------------------------------------------------------------------------------
Conduct iEHR Initial Design Review                 10/12/12                  11/28/12
----------------------------------------------------------------------------------------------------------------


Acquire Clinical Capabilities

 
----------------------------------------------------------------------------------------------------------------
             Milestone                    Planned Date             Completion Date               Comment
----------------------------------------------------------------------------------------------------------------
Issue Pharmacy RFI                                  5/31/12                   5/31/12
----------------------------------------------------------------------------------------------------------------
Issue Laboratory RFI                                6/12/12                   6/12/12
----------------------------------------------------------------------------------------------------------------
Issue Immunization RFI                               8/6/12                    8/6/12
----------------------------------------------------------------------------------------------------------------


                                 
Question #4 From: Hon. Michael Michaud, Ranking Minority Member, To: 
        DCMO McGrath
    Question: In your testimony you state that ``[t]o reduce cost and 
technical risk, the two Departments agreed to modify the strategy.'' 
Please provide the Committee with supporting materials to support the 
conclusion that the revised strategy will indeed ``reduce cost and 
technical risk'', including alternatives considered.
    Answer: Our revised strategy provides a number of advantages as DoD 
and VA work toward our joint goals of ensuring that all health data for 
an individual can be brought together into a seamless electronic health 
record and modernizing or replacing our legacy health information 
technology systems. Broadly, the new strategy accelerates the delivery 
of important data interoperability and other benefits and ensures that 
those benefits are not dependent on the delivery of a new system. It 
also simplifies an extremely complex program by using a core set of 
applications from existing EHR technology, to which additional modules 
or applications could be added as necessary, thereby also reducing 
cost.
    First, for the rest of this year, our efforts are focused on 
completing the data interoperability work that will create a single 
health record for all personnel, regardless of whether they are treated 
at a DoD or VA hospital. This work can be done without replacing the 
underlying health information technology systems for either Department. 
By quickly delivering on a key component of the President's commitment 
to our veterans, this work significantly reduces the overall risk of 
the program.
    Second, in December 2012, a group of clinical and technical experts 
from DoD and VA came together to evaluate the concept of a tightly 
integrated set of Core iEHR capabilities, provided by a single vendor, 
as a foundation for facilitating Clinical Transformation while 
maximizing patient safety and optimal functionality. A number of 
benefits result from acquiring a core set of clinical applications, 
including:

    1. Allowing the government to consider the use of commercially 
available existing Generation 3 electronic health record systems, which 
are already deployed and proven. This would allow for the system to 
evolve with industry, reducing the risk of needing to modify or 
modernize the system in the near future.

    2. Ensuring that the clinical capabilities which must be tightly 
integrated to ensure patient safety are already integrated when 
implemented. Reducing the number of interfaces between key capabilities 
and storing and retrieving patient data in a single database minimizes 
the likelihood of error or degradation in collecting, transmitting, 
computing or interacting with patient data, thereby improving patient 
safety.

    3. Reducing the amount of government integration and interfacing 
required. Rather than the government bearing the cost, time, and risk 
of integrating as many as 50 clinical applications one-by-one, a core 
set of a dozen or more clinical applications will be delivered at one 
time.

    4. Reducing reliance on legacy systems by accelerating the timeline 
for implementation and migration of business processes into the new 
system.

    5. Ensuring that Clinical Capabilities fulfill a series of key care 
scenarios, rather than just conforming to a list of individual, 
disparate functional requirements.

                                 
Question #5 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: Former Army Surgeon General Schoomaker and several other 
military leaders testified in 2009 that the DoD needs to replace their 
current clinical system, AHLTA, in order to improve quality of care, 
patient engagement, provider satisfaction, and efficiency. The VA's 
clinical system VistA needs significant modernization. I understand 
that the DoD was well into planning for commercial clinical system 
acquisition when those plans were halted in order to coordinate with 
the VA. Isn't it true that after two years of planning among the DoD 
and VA, the proposed combined system would force the DoD to wait until 
2017 to replace core clinical systems (8 years after General 
Schoomaker's testimony)?
    Answer: No, it is not correct that the proposed combined system 
would force the DoD to wait until 2017. Access to the Armed Forces 
Health Longitudinal Technology Application (AHLTA) will be turned off 
as each hospital gets the complete set of integrated electronic health 
record (iEHR) capabilities.
    The original iEHR plan proposed by the Department of Defense (DoD)/
Department of Veterans Affairs (VA) Interagency Program Office (IPO) 
planned for the development of six increments over a five year period 
ending 2017. Each increment will be deployed after it is developed. 
Early increments will take about two years to deploy across the entire 
enterprise because we also have to develop and deploy the new 
infrastructure that support the increments. Later increments will 
deploy much faster because they will be installed in the then-existing 
regional data centers allowing the later increments to be `turned on' 
for each hospital in the region. As the increments are deployed to each 
hospital, and when that particular hospital acquires enough of the new 
capabilities that replace AHLTA, then access to AHLTA from that 
hospital would be turned off. AHLTA will be finally turned off with the 
deployment of the iEHR to that last hospital. This plan meets the 
requirement of providing global access to Service member's healthcare 
record under both the legacy electronic health record system (EHRS) and 
new iEHR as we transition. There is a very similar plan under 
development to support a decision for an iEHR core by DoD- no matter 
which core DoD chooses.

                                 
Question #6 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: The plans announced by the Secretaries earlier this month 
would allow the DoD to rapidly replace their failing system with a 
commercial system. Why shouldn't we let the DoD adopt a commercially 
available system that can meet their patient care and safety needs 
today even if it's not the same as the VA's system?
    Answer: The Department of Defense's (DoD) is currently doing an 
analysis in support of selecting a core from an electronic healthcare 
record system (EHRS). This analysis includes an assessment of the 
Department of Veterans Affairs' (VA) VistA system EHRS as well as what 
is available from the commercial EHRS market, as part of the effort to 
accelerate the development and deployment of the integrated electronic 
health record (iEHR) with reduced risk, in less time, with more 
capabilities, and less cost. A decision by DoD should be announced soon 
where DoD will select either VistA or decide to execute an acquisition 
plan for a commercial EHRS core. If DoD decides to acquire a commercial 
EHRS core, it will fully support healthcare data interoperability 
between DoD and VA.
    A critical requirement of the EHRS solution is to ensure that 
healthcare data are shared and interoperable between DoD and VA. This 
will be achieved through the use of healthcare data standards as well 
as the use of a common data model supported by the Health Data 
Dictionary (HDD). All healthcare data will be stored using these 
standard formats. This ensures that clinicians can capture, retrieve, 
and view the healthcare data from either a DoD or VA EHRS.

                                 
Question #7 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: Members of this committee have fairly voiced their 
concerns about the Secretaries' recent decision and whether the DoD and 
VA will be able to share patient information if they are on separate 
systems, as this has been challenging to do with their current 
government-developed systems. Commercial systems can use standard 
methods to exchange patient information. Couldn't the DoD use these 
methods to share patient information with the VA if they adopted a 
commercial system? I also understand that the DoD and VA share as many 
if not more patients with commercial healthcare organizations as they 
do among the two agencies. If they used commercial systems, wouldn't 
the DoD and VA be able to exchange information with the commercial 
healthcare neighbors that are providing care to their members?
    Answer: Yes, the Department of Defense (DoD) could use standard 
methods to share patient information with the Department of Veterans 
Affairs (VA) if DoD adopted a commercial system. If DoD and VA used 
commercial systems, they would be able to exchange information with the 
commercial healthcare neighbors. The exchange of healthcare data, and 
standardized healthcare data interoperability, is built into the 
integrated electronic health record (iEHR) solution. By using a common 
information infrastructure framework (CIIF), common shared federated 
date repositories, the Enterprise Service Bus / Service Oriented 
Architecture (ESB/SOA), common healthcare data standards, and the 
Health Data Dictionary (HDD), the Departments will be able to exchange 
regardless of whether either Department uses commercial system 
components.
    It is this focus on exchange of standardized data that will also 
enable exchange with private sector providers.

                                 
Question #8 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: Our nation's healthcare leaders have switched from self-
developing complex clinical systems to purchasing commercially 
available systems. These groups include Johns Hopkins Medicine, 
Partners HealthCare, and Kaiser Permanente. They report that commercial 
systems lower operating costs, increase efficiency, and improve care. 
George Halverson, the CEO of Kaiser Permanente, has said that they 
transformed their care delivery, improved their patients' outcomes, and 
are saving $5 billion per year as a result of their electronic systems. 
Why shouldn't the DoD follow the same path?
    Answer: It is possible that the Department of Defense (DoD) could 
follow the same path as the major healthcare delivery organizations 
(HDOs) in the nation have followed in moving away from self-developed 
electronic health record systems (EHRSs) and towards a commercially 
available EHRS. DoD is performing an analysis in support of selecting 
an EHRS core. This analysis will assess the Department of Veterans 
Affairs' (VA) VistA EHRS along with offerings from the commercial EHRS 
market leading to an EHRS solution that has a lower risk, lower cost, 
with more capacities, and in a shorter time, as contrasted to a 
government-integrated solution. DoD will likely assess a number of 
factors including risk, safety, schedule, capabilities, and costs. The 
DoD decision is imminent.
    Regardless of the direction DoD goes in selecting its EHRS core, 
commercially available software capabilities are very much a part of 
the integrated electronic health record (iEHR) plan. The DoD/VA 
Interagency Program Office (IPO) has identified a number of joint 
capabilities that will be shared between the Departments, married to a 
shared infrastructure that will be acquired using an adopt/buy/create 
process. This means that IPO will first seek the adoption of viable 
Government Off The Shelf (GOTS) or open source (OS) software, then 
consider buying Commercial Off The Shelf (COTS) software, before it 
creates EHRS software itself. The government has learned many times 
that the adoption or purchase of existing software results in a far 
lower total cost of ownership as contrasted to the development of in-
house software. Nevertheless, there are some cases where these adopt/
buy alternatives don't exist so that IPO will have to develop 
solutions. Every effort will be made to keep the `create' approach to a 
minimum.

                                 
Question #9 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: Why should we ask our service member and families to wait 
for a newly-developed system when there are commercially available 
systems running our nation's top ranked hospitals and clinics?
    Answer: We do not intend to make our service members and their 
families wait for a newly developed system. Today, the DoD's electronic 
health record system allows for world-class care to be provided at all 
DoD medical facilities, and we have empowered our beneficiaries to 
actively engage in their own care by reviewing and downloading their 
personal health information. In addition, DoD and the Department of 
Veterans Affairs (VA) currently share more health information than any 
two organizations in the nation.
    As we move forward to continue to enhance our care of service 
members and their families, we have been working on two important 
tasks: the replacement of our aging legacy electronic health record 
system while simultaneously establishing full data interoperability 
with VA (i.e., creation of a single integrated electronic health 
record). First, by achieving interoperability of health care data, 
patients will be able to download/transmit their health records and 
doctors will be able to get the data they need to inform clinical 
decisions, regardless of where the user sits and where care is 
provided. The second area of emphasis has been the replacement of our 
current underlying health information technology (IT) systems. If we 
accomplish the first objective, we will achieve the President's goal. 
The second objective is eventually necessary for both DoD and the VA, 
but does not have to be done to achieve data interoperability. In 
addition, the replacement of our legacy health IT system will be done 
in a way that is transparent to the patients that we serve.
    We agree that there are viable commercially available health IT 
systems, and so we are currently evaluating the full range of options 
for DoD's ``core'' system, to include best commercial solutions. We 
believe that this approach of beginning with a core set of capabilities 
will reduce the cost and time required to replace our legacy system.

                                 
Question #10 From: Hon. Beto O'Rourke, To: Hon. Jonathan A. Woodson
    Question: By waiting for a new system to be developed, what 
opportunities could the DoD and VA be missing to improve health 
outcomes that commercial healthcare organizations are already achieving 
today through the use of their commercial system?
    Answer: Our goal is to continue to improve health outcomes and take 
advantage of advances in the commercial marketplace as quickly as 
possible. As we move forward to continue to enhance our care of service 
members and their families, we are currently evaluating the full range 
of options for DoD's ``core'' system, to include best commercial 
solutions. We intend to make a decision on how we will proceed within 
30 days and then will move as rapidly as possible to acquire the best 
possible solution.

                                 
Letter From: Hon. Michael Michaud, Ranking Minority Member, To: Hon. 
        Gene L. Dodaro, Comptroller General of the United States, 
        Government Accountability Office
    May 2, 2013

    The Honorable Gene L. Dodaro
    Comptroller General of the United States
    Government Accountability Office
    441 G Street NW
    Washington, DC 20548

    Dear Mr. Dodaro:

    In reference to our Full Committee hearing entitled, ``Electronic 
Health Record U-Turn: Are VA and DoD Headed In The Right Direction?'' 
that took place on February 27, 2013, I would appreciate it if you 
could answer the enclosed hearing questions by the close of business on 
June 2, 2013.
    Committee practice permits the hearing record to remain open to 
permit Members to submit additional questions to the witnesses. 
Attached are additional questions directed to you.
    In preparing your answers to these questions, please provide your 
answers consecutively and single-spaced and include the full text of 
the question you are addressing in bold font. To facilitate the 
printing of the hearing record, please e-mail your response in a Word 
document, to Carol Murray at [email protected] by the close 
of business on June 2, 2013. If you have any questions please contact 
her at 202-225-9756.

    Sincerely,

    MICHAEL H. MICHAUD
    Ranking Member

    CW:cm:jz

                                 
Question From: Hon. Beto O'Rourke, To: Ms. Valerie C. Melvin, Director, 
        Information Management and Technology Resources Issues, U.S. 
        Government Accountability Office
    Ms. Valerie Melvin

    1. The same 2011 GAO report states that we have already invested 
$600 million in VistA modernization over 6 years and $2 billion on 
AHLTA over 13 years. Can we justify spending ongoing tax payer dollars 
to support these expensive systems while an entirely different system 
is being developed? Couldn't we begin immediately replacing these 
expensive systems if the DoD and VA purchased commercial systems?

                                 
Letter From: Ms. Valerie C. Melvin, Director, Information Management 
        and Technology Resources Issues, U.S. Government Accountability 
        Office, To: Hon. Michael Michaud, Ranking Minority Member
    June 14, 2013

    The Honorable Michael H. Michaud
    Ranking Member
    Committee on Veterans' Affairs
    House of Representatives

    Subject: Department of Veterans Affairs and Department of Defense 
Electronic Health Records: Response to Post-Hearing Questions for the 
Record

    Dear Mr. Michaud:

    This letter responds to your May 2, 2013, request that we address 
questions submitted for the record by Representative Beto O'Rourke, 
related to our statement at the February 27, 2013, hearing on the 
direction of the Department of Veterans Affairs (VA) and Department of 
Defense (DOD) Integrated Electronic Health Record (iEHR). \1\ At the 
hearing, we discussed, among other things, the two departments' efforts 
over the past 15 years to achieve interoperable electronic health 
records and the persistent challenges that they have faced as a result 
of project planning and management weaknesses, inadequate 
accountability, and poor oversight. The enclosure provides 
Representative O'Rourke's questions and our responses, which are based 
on our previously issued products.
---------------------------------------------------------------------------
    \1\ GAO, Electronic Health Records: Long History of Management 
Challenges Raises Concerns about VA's and DOD's New Approach to Sharing 
Health Information, GAO-13-413T (Washington, D.C.: February 27, 2013).
---------------------------------------------------------------------------
    If you have questions regarding the responses, please contact me at 
(202) 512-6304 or [email protected].

    Sincerely yours,

    Valerie C. Melvin
    Director, Information Management and Technology Resources Issues

    Enclosure-1
          Questions Submmitted by Representative Beto O'Rourke
    1. The same 2011 GAO report states that we have already invested 
$600 million in VistA modernization over 6 years and $2 billion on 
AHLTA over 13 years. Can we justify spending ongoing tax payer dollars 
to support these expensive systems while an entirely different system 
is being developed? Couldn't we begin immediately replacing these 
expensive systems if the DOD and VA purchased commercial systems?
    Regardless of the direction of the departments' plans, DOD and VA 
will need to operate and sustain their existing health information 
systems until new or modernized systems are ready for operation. As you 
have noted, both departments have invested significant time and 
resources on health system modernizations; however, the departments 
have not yet been successful in these efforts. Consequently, at this 
time, they will need to rely on their existing electronic health 
information systems to collect, store, and retrieve patient health 
information in order to provide care for military personnel and 
veterans. \2\
---------------------------------------------------------------------------
    \2\ GAO-13-413T and GAO, Electronic Health Records: DOD and VA 
Should Remove Barriers and Improve Efforts to Meet Their Common System 
Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 2011).
---------------------------------------------------------------------------
    The purchase of commercial systems could potentially represent an 
effective approach to modernizing or replacing the departments' 
existing electronic health information systems. However, as we have 
reported, the effective acquisition of commercial information 
technology (IT) systems is a complex undertaking that should 
incorporate activities to ensure that (1) commercial product 
modification is effectively controlled, (2) relationships among 
commercial products are understood before acquisition decisions are 
made, and (3) the organizational impact of using new system 
functionality is proactively managed. \3\ Both DOD and VA have 
struggled to successfully manage their respective major IT 
acquisitions. Specifically, we reported in 2010 that six of nine DOD 
implementations of commercial enterprise resource planning systems had 
experienced schedule delays ranging from 2 to 12 years, and five had 
incurred cost increases ranging from $530 million to $2.4 billion. \4\ 
Further, in March 2013, we issued a report on cost, schedule, and 
performance of DOD's major automated information systems and found that 
11 selected programs were either costing more than planned, taking 
longer than planned to deliver, and/or had not performed as intended. 
\5\ Similarly, VA has been challenged in successfully managing its 
major IT acquisitions. For example, we reported in May 2010 that VA's 
effort to replace its outpatient scheduling system was hindered by 
ineffective oversight and weaknesses in key project management areas, 
including acquisition planning, requirements development, and risk 
management. \6\ Until these project management weaknesses are 
addressed, the two departments will continue to jeopardize their 
ability to achieve modernized health information systems--whether 
through their own development or commercial acquisitions.
---------------------------------------------------------------------------
    \3\ GAO, Information Technology: DOD's Acquisition Policies and 
Guidance Need to Incorporate Additional Best Practices and Controls, 
GAO-04-722 (Washington, D.C.: July 30, 2004).
    \4\ GAO, DOD Business Transformation: Improved Management Oversight 
of Business System Modernization Efforts Needed, GAO-11-53 (Washington, 
D.C.: Oct. 7, 2010) and High-Risk Series: An Update, GAO-13-283 
(Washington, D.C.: Feb. 14, 2013).
    \5\ GAO, Major Automated Information Systems: Selected Defense 
Programs Need to Implement Key Acquisition Practices, GAO-13-311 
(Washington, D.C.: Mar. 28, 2013).
    \6\ GAO, Information Technology: Management Improvements Are 
Essential to VA's Second Effort to Replace Its Outpatient Scheduling 
System, GAO-10-579 (Washington, D.C.: May 27, 2010).

                                 
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