[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


  EVALUATING VA IT: SCHEDULING MODERNIZATION AND CHOICE CONSOLIDATION

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

                              JOINT HEARING

                               BEFORE THE

               SUBCOMMITTEE ON OVERSIGHT & INVESTIGATIONS

                               JOINT WITH

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, APRIL 14, 2016

                               __________

                           Serial No. 114-63

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]        


         Available via the World Wide Web: http://www.fdsys.gov
         
         
         
                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
25-126 PDF                  WASHINGTON : 2017                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected].          
         
                     
                     
                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                        Thursday, April 14, 2016

                                                                   Page

Evaluating VA IT: Scheduling Modernization And Choice 
  Consolidation..................................................     1

                           OPENING STATEMENTS

Honorable Mike Coffman, Chairman, Subcommittee on Oversight & 
  Investigations.................................................
Honorable Dan Benishek, Chairman, Subcommittee on Health.........     2
Honorable Ann Kuster, Ranking Member, Subcommittee on Oversight & 
  Investigations.................................................     3
Honorable Julia Brownley, Ranking Member, Subcommittee on Health.     5

                               WITNESSES

Honorable David Shulkin, M.D., Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................     5
    Prepared Statement...........................................    30

        Accompanied by:

    Honorable LaVerne Council, Assistant Secretary for 
        Information and Technology and Chief Information Officer, 
        Office of Information Technology, U.S. Department of 
        Veterans Affairs

    Alan Constantian, Deputy Chief Information Officer, Office of 
        Information Technology, U.S. Department of Veterans 
        Affairs

                        STATEMENT FOR THE RECORD

The American Legion..............................................    37

 
  EVALUATING VA IT: SCHEDULING MODERNIZATION AND CHOICE CONSOLIDATION

                              ----------                              


                        Thursday, April 14, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Subcommittees met, pursuant to notice, at 10:03 a.m., 
in Room 334, Cannon House Office Building, Hon. Mike Coffman 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Coffman, Benishek, Lamborn, 
Bilirakis, Wenstrup, Kuster, Brownley, O'Rourke, Takano, Ruiz, 
and Walz.

           OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN

    Mr. Coffman. Good morning. This hearing will come to order. 
I want to welcome everyone, especially our good friends from 
the Subcommittee on Health, to today's joint hearing regarding 
VA's health information technology.
    Today we will examine the current state of key IT systems, 
and facilitate scheduling and community provider claims 
processing, or that--I am sorry, facilitate scheduling and 
community provider claims processing. And we will delve into 
VA's plan for modernizing them. The VHA and OI&T share 
responsibility for these systems.
    We will also examine VHA's strategy for the IT systems that 
will be necessary to consolidate community care. My friend, 
Subcommittee on Health Chairman Dr. Benishek, has done 
extensive work on the consolidation issue. VHA released a draft 
request for proposal yesterday afternoon for the consolidated 
community care network, and we need to know the IT 
requirements.
    Currently, VHA relies on the scheduling functions of VistA, 
the department's health information system, which was 
originally developed in the 1980s. Since late 2012, VA has been 
planning to procure commercial, state-of-the-art scheduling 
software. VA awarded a contract for this system, called the 
Medical Appointment Scheduling System, or MASS, in August 2015.
    VA planned to conduct an initial pilot of MASS in Boise, 
Idaho, through 2016, but it was never started and activity on 
MASS has apparently been suspended. VA has simultaneously been 
developing an intermediate solution to improve VistA scheduling 
while MASS rolls out.
    It consists of two parts: the VistA scheduling enhancement, 
or VSE; and a self-scheduling application called Veteran 
Appointment Request, or VAR. VSE gives VistA a modern look 
similar to a Microsoft Outlook calendar. It replaces VistA's 
black and white command prompt interface. VA has described VAR 
as ``limited.''
    Recently, VA determined that VSE and VAR appear to meet its 
scheduling needs and MASS is unnecessary. This decision is a 
dramatic about face. It means sticking with a government 
developed technology indefinitely. MASS has been stopped 
before, even its first pilot could be compared with VSE and 
VAR. The plan was to see what solution works best. It seems we 
will never know.
    VA's claim processing system, called the Fee Basis Claims 
System, or FBCS, is also badly in need of modernization. VHA 
claims processors use it to receive, examine, and approve 
claims for reimbursement from community health care providers. 
The volume of claims is up dramatically since the Choice Act 
and the processors are overwhelmed.
    On this Committee, we hear complaints from frustrated 
providers every day about not being paid, and VA lags far 
behind Medicare and TRICARE in processing claims. FBCS, as it 
exists now, has some fundamental limitations. Today, VHA has 34 
groups of staff around the country processing claims manually 
on 34 disconnected FBCS databases.
    Claims come in electronically and on paper. The paper 
claims don't enter the system at all until they are scanned, 
and GAO estimates scanning takes about two weeks. The 
electronic claims are immediately viewable and trackable, but 
there is no national view across the 34 locations of paper 
claims until they are actually approved for payment, and there 
is never a national view of paper claims that get denied. 
Claims information is too hard to find and they can get lost in 
the cracks.
    VHA's manual processing takes too long. VHA's policy is to 
pay or reject 90 percent of claims within 30 days, and GAO 
found that VHA only meets this standard 66 percent of the time. 
Instead of manual processing, Medicare and TRICARE used auto-
adjudication. Their systems automatically analyze claims for 
completeness and accuracy. FBCS can be upgraded to fix these 
problems.
    An upgrade to make the paper claims more transparent has 
been available since May 2015. VA still hasn't tested it. An 
initial auto-adjudication upgrade could have been available 
this month, but it can't move until the earlier upgrade is 
implemented.
    VA has a major decision to make about whether to upgrade 
FBCS now or to wait to put in a wholly different claims system 
as part of the consolidation plan. What is certain is we have a 
big claims paying problem right now, and payment delays chase 
away providers.
    I now yield to Chairman Benishek for his opening statement.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. Thank you. Well, it is a pleasure to be here 
this morning with the Members of the Subcommittee on Health and 
our colleague from the Subcommittee on Oversight and 
Investigations.
    Ensuring that the Department of Veteran Affairs is fully 
equipped with a modern, functional information technology 
system is a priority that we all share. Many of the 
deficiencies in the IT programs that underlie the VA health 
care system have already been laid out by Chairman Coffman, and 
I agree with his comments regarding the urgent nature of the 
ongoing efforts to modernize the VA scheduling and claims 
processing.
    We can't allow the failures that have characterized 
previous efforts in these two important areas to continue. We 
also can't continue to push decisions further down the road. 
Too often, IT projects have progressed to a critical decision 
point and then been abandoned in favor of another initiative or 
another plan. VA must realize that maintaining manual systems 
and deferring to archaic operating systems as a default cannot 
continue, we need a sense of urgency.
    As Chairman Coffman noted, improving VA IT is also 
important to community care consolidation. Many of the key 
features of the VA's plan to consolidate community care under 
Choice will require a contemporary IT infrastructure to support 
them.
    The VA has shared little information to date about what IT 
systems the VA intends to put in place to support community 
care consolidation, what those systems are going to cost, and 
when those systems will be up and running and ready to support 
the needs of veteran patients and the VA's community partners.
    I hope the VA's prepared to provide that information today 
at the hearing. I am also interested in hearing today about how 
the Veterans Health Administration, managed by Dr. Shulkin, and 
the VA Office of Information Technology, managed by Ms. 
Council, are working together to build a modern IT program in 
the VA health care system that we need to serve our veterans.
    The independent assessment of the VA health care system 
that was required by the Access, Choice, and Accountability Act 
found that the VHA and the OI&T did not collaborate effectively 
with respect to planning and executing IT strategies for 
managing and furnishing health care, and often disagreed on 
priorities for executing strategic plans.
    I would venture to say that the disconnect is why so many 
previous health IT efforts have failed to achieve success. 
Ensuring appropriate coordination and communication between the 
VHA and OI&T is vital to moving the VA health care system 
toward the 21st century. I look forward to hearing some 
specifics from Dr. Shulkin and Ms. Council about how they are 
personally working together, side by side, to make these things 
happen.
    So thank you all for being here this morning, and I will 
yield back to Chairman Coffman.
    Mr. Coffman. Thank you, Dr. Benishek, for your remarks.
    I now yield to Ranking Member Kuster for any opening 
remarks that she may have.

        OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you very much, Chairman Coffman and 
Chairman Benishek, and I appreciate you taking the time for 
this hearing, it's an important one, and to my Ranking Member 
Brownley. We appreciate the opportunity to be with you all 
today.
    The wait time crisis in Phoenix highlighted the VA's 
antiquated scheduling system and how difficult it was to use. 
And I have to say for many of us visiting VA facilities in our 
districts, we are having these same conversations.
    VA has made a number of efforts over the last 15 years to 
modernize and improve its scheduling system. But as a result of 
the crisis, the Choice Act enacted by Congress last year 
mandated assessment of VA's health IT systems. And we know that 
modern IT systems and processes are critical to ensuring that 
patients receive quality coordinated care and that physicians 
and health care providers are not wasting their time for people 
who don't show up.
    As we found after multiple hearings and assessments, VA's 
outdated and cumbersome patient scheduling system was a major 
contributor to patient access crisis, and remains a challenge.
    VA's announcement in 2015 of a contract for commercial off-
the-shelf solution to replace VA's scheduling system seemed 
like a promising response to the clear inadequacies of the 
current system, and we were all encouraged by that. There was 
concern that this would not be ready until 2017, but it was a 
promising step forward.
    This five-year $624 million contract was awarded in 2015. 
But now, after VA has spent $27.5 million on a pilot project 
for the Medical Appointment Scheduling System, or MASS, as the 
Chair has pointed out, we are told that the project has been 
put on hold. At the same time, VA has continued with its own 
in-house initiative to update their scheduling system.
    This seems like deja vu all over again to me. VA has 
already wasted 9 years, $127 million without an update to its 
scheduling system after finding a commercial product and 
abandoning that for an in-house solution that could not deliver 
an adequate update.
    We cannot, and will not, let this happen again. And I can 
say that on a bipartisan basis, this is very frustrating for 
those of us who have been sitting here, and some of my 
colleagues much longer than I have.
    I want to know what VA is doing to ensure that its 
scheduling system, EHR, and health care IT infrastructure are 
able to meet the current and future needs of our veterans. This 
means that VA must work toward developing a health care IT 
infrastructure that is interoperable with DoD. And I think some 
of us in the class of 2012 will remember, that was one of our 
very first hearings on this Committee was the frustration about 
the interoperability with the DoD, and the precious taxpayers 
that have been spent--taxpayer dollars that have been spent 
searching for a solution.
    We need to ask, regarding VA health care and IT, how does 
this better enable the VA to do what it should be doing: 
serving our veterans, providing and coordinating health care 
for veterans all across our country. We need VA's businesses' 
processes to work so that community providers are able to treat 
veterans and receive prompt payment for providing care.
    I continue to receive complaints from constituents in my 
district in New Hampshire that feel abandoned and forced to 
navigate their own care outside of the VA. I have community 
providers who have stopped participating in the Choice program 
because they are not paid on time, or the eligibility rules are 
simply too complex.
    Our veterans deserve timely, high quality care. Health 
information technology has the potential to transform the VA 
into a leader in the delivery and coordination of health care, 
and a health care organization that leverages health technology 
to deliver the best health care to our veterans. But VA needs 
to do its part to properly plan, implement, and oversee IT 
projects.
    And I know that the two of you are relatively new to the 
organization, so we don't blame you for past faults. We 
certainly want to work with you going forward. But you need to 
understand that Congress cannot continue to give VA a blank 
check to spend on IT projects without results.
    So I look forward to hearing from our witnesses on their 
suggestions and solutions. And I yield back. Thank you, Mr. 
Chairman.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    I now yield to Subcommittee on Health, Ranking Member 
Brownley for any opening remarks she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman, and thank you, and 
Chairman Benishek, for bringing this hearing together, and I 
thank my Ranking Member Kuster for holding this hearing as 
well.
    I will be brief because I think my colleagues have already 
laid out the issues that this Committee is concerned about. But 
I will say that our health Subcommittee has held a series of 
hearings on different aspects of the Choice program. We heard 
from VA on billing issues, eligibility, staffing, and provider 
networks, and most of them involved some component of 
technology that needed to be updated or fixed. It's fitting 
that we now hold a hearing on information technology and where 
the VA is going on this issue.
    We know that, as the second largest Federal agency after 
the Department of Defense, VA runs the largest integrated 
health system in the country and is tasked with providing high 
quality, safe health care to eligible veterans. So we need, and 
our veterans need, a very strong and healthy IT program to 
deliver that kind of care. And I will look forward to the 
testimony this morning.
    Mr. Coffman. Thank you, Congresswoman Brownley.
    I ask that all Members waive their opening remarks as per 
this Committee's custom. With that, I invite the first and only 
panel to the witness table.
    On the panel, we have the Honorable LaVerne Council, 
Assistant Secretary for Information and Technology and VA's 
Chief Information Officer. We have also the Honorable David 
Shulkin, Under Secretary for Health. They are accompanied by 
Dr. Alan Constantian, the VA's Deputy Chief Information 
Officer. I ask the witnesses to please stand and raise your 
right hand.
    [Witnesses sworn.]
    Mr. Coffman. Please be seated. And let the record reflect 
that all witnesses have answered in the affirmative.
    Ms. Council, you are now recognized for five minutes.

                STATEMENT OF DAVID SHULKIN M.D.

    Dr. Shulkin. Great. Good morning, Chairman Coffman, 
Chairman Benishek, Ranking Member Kuster, Ranking Member 
Brownley, and all Members of the Subcommittee. Thank you for 
the opportunity to discuss the progress being made by VHA and 
the Office of Information Technology, what we call OI&T, to 
provide veterans timely access to care. I do appreciate all the 
opening statements. I think your candor and the issues that you 
want to discuss are exactly the issues that we think need to be 
discussed as well.
    I'm pleased to be joined today, as the Chairman said, by 
the Honorable LaVerne Council, the VA's Chief Information 
Officer and Assistant Secretary for OI&T, and Alan Constantian, 
the Deputy Chief Information Officer for OI&T.
    Ms. Council and I joined the VA at the same time, in July 
of last year. We went through the confirmation process together 
as partners. And during that process, we committed to 
continuing this partnership throughout the terms of our office. 
We began our work with one goal: to make VA work better for 
veterans. I'm proud to say that we are holding that commitment.
    VA has a history of innovation that is deep and indelible, 
and we are proud to be part of it. The creation of the Veterans 
Health Information Systems and Technology Architecture, what we 
call VistA, is one of the flagship examples of that spirit.
    Forty years ago, leaders of VHA recognized that technology 
in health care had reached a monument of mutual opportunity, a 
time when patients and clinical needs were growing more complex 
and IT capability was quickly improving; VistA was that result.
    That initial visionary leadership, the recognition of a key 
moment in time, the collaborative partnership of the 
technologist, clinician, and the legislature led to the Nations 
first electronic health record and was the driver for today's 
health care environment.
    But that was 40 years ago, and much has changed. The 
veteran, in 1975, had an average age of 46. Today, veterans 
average 60 years old. In 1975, we served 500,000 female 
veterans, today we serve over 2 million female veterans. In 
1975, VA focused primarily on the physical needs of the average 
veteran, now we have an ever growing suite of comprehensive 
health care services such as prosthetics and mental health.
    In 1975, VistA supported a handful of clinical processes, 
now it has over 200 applications, each having multiple 
processes, and there are over 130 different versions of VistA 
throughout VHA.
    In 1975, the veteran was carrying a paper folded by hand 
between points of care. Today, the veteran is tech savvy, she 
has email, uses a cell phone, and wears a personal health 
tracker. As our veterans have changed, so has technology. We 
must keep pace and we must make the right decisions to do so.
    We sit before you today with over 55 years of experience in 
transformational leadership. Today, we're bringing our years of 
industry experience and a sense of urgency, that Dr. Benishek 
called for, to our work at VA. As partners, we view every 
decision through that lens.
    When Ms. Council and I arrived, the VistA evolution program 
was beginning its work on VistA 4. VistA 4 enables 
interoperability and focuses on care coordination, providing 
tools to better manage population health. Its development 
concludes in fiscal year 2018.
    We sit before you 40 years after the creation of VistA and 
two years prior to its final development milestone, and want 
you to know we take our responsibility to do the right thing 
for veterans very seriously.
    We want to be certain that continuous modernization of a 
40-year-old electronic medical record is an appropriate 
decision, as well as our approach to modernizing scheduling. We 
are asking our teams very difficult questions every day.
    Ms. Council demonstrated this commitment to asking 
difficult questions and taking difficult steps shortly after 
entering office. With the support of her team, she developed an 
actionable, far-reaching cyber security strategy and 
implementation plan for VA to Congress that was delivered in 
September of 2015 as promised.
    VA, its core constituents, and external partners are all 
subject to a wide variety of cyber security threats. VA's 
enterprise cyber security strategy identifies key challenges 
and goals and is focused on building a comprehensive cyber 
security strategy that is aggressive, proactive, and addresses 
the unique needs of each of VA's business lines. This strategy 
is a major step forward in safeguarding veteran information and 
VA data with a complex environment, and we are proud of it.
    Our approach to the Choice program, or care in the 
community, is an example of the success we can experience 
through a close partnership and critical evaluation. On October 
30th of 2015, VA provided Congress with a plan to consolidate 
all VA's purchased care programs.
    This transformation will require a stronger health IT 
platform that allows for bidirectional flow of information 
between providers and ensures continuity of patient care. The 
joint VHA and OI&T team are working to take on this issue, and 
meeting daily to ensure continuous progress and address 
obstacles. They are evaluating each health care and technology 
decision through a critical lens, ensuring we are making the 
right choices for the veterans and the taxpayers.
    In all areas of our partnership, we must choose our path 
carefully and strategically as our work will lay the foundation 
for the next phase of VA's health care and technology 
environments. We are engaging industry leaders in technology 
and health care as well as domain knowledge for our teams to 
ensure that the path we choose is the right one.
    As Ms. Council and I have the opportunity to evaluate more 
information from our health care technology initiatives, we 
gain more insight into which turn of the path will be the right 
one. We will share this vision with you this summer. We remain 
committed to making VA a better place for veterans, our 
employees, and taxpayers.
    We appreciate the opportunity to appear before you today, 
and we'll be pleased to answer your questions at this time.

    [The prepared statement of Dr. David Shulkin appears in the 
Appendix]

    Mr. Coffman. Thank you, Dr. Shulkin.
    Ms. Council, do you have an opening statement?
    [Inaudible.]
    Mr. Coffman. Okay. Thank you, Dr. Shulkin. And the written 
statements of those who have just provided oral testimony will 
be entered into the hearing record. We will now proceed with 
questioning.
    Ms. Council, what is VA's definition of sufficient 
capability in a scheduling system, and how did you determine 
VSE and VA--and how did you determine whether VSE and VAR met 
it?
    Ms. Council. The requirements driven by the business in VSE 
and VOSVAR as well as the MASS decision were ones that were in 
place when we arrived. At the end of the day, we have a joint 
team led by business leaders as well as IT. The business 
leaders have really driven the requirements, and then the IT 
organization is responsible for creating the technology.
    So we see it as one that would allow the veteran to get the 
demand met, and that we would have a clear understanding of the 
capacity to meet that demand.
    Mr. Coffman. The plan was to pilot VSE and VAR alongside 
MASS and see which is the best solution. How did you rule out 
MASS--how did you rule MASS out before ever piloting it?
    Dr. Shulkin. Chairman, I would be glad to take that. We 
have not ruled out MASS, I want to be absolutely clear about 
that.
    Here's the situation that we faced, and I appreciate that 
the frustration of Congress in this, and I appreciate the input 
that you will give us on this. But this is what made sense to 
us.
    VSE is available today, right now, it's actually in the 
field being used. I agree with Ranking Member Kuster that the 
wait time crisis in 2014 was in part caused by an archaic 
scheduling system that is almost impossible to figure out. If 
you haven't seen it, this is our current scheduling system. It 
is DOS, it's what we used when computers first came out.
    This is VSE. Okay? This is available right now, and this is 
in VAs today, in two VAs, soon to be eleven VAs with a national 
rollout in the next couple months. This makes scheduling errors 
a lot less likely to occur with this type of Microsoft Outlook 
type feel.
    So let me just give you the numbers very quickly, why we 
put a pause on MASS, we did not cancel it at all. It is a 
contract that we can execute at any time. The entire VSE 
project, the national rollout, will cost taxpayers $6.4 
million. It's available today; it will help veterans and 
schedulers today.
    If we roll out MASS, which is an absolute option for us, 
the pilot alone will be $152 million. It will take us ten 
months to roll it out in three sites. The pilot, as you said 
Chairman, was to start in Boise, two other sites selected, 
three sites $152 million, ten months. And that's if VA stays on 
schedule with its pilots.
    So we felt the very, very best decision for veterans and 
taxpayers--who we're trying to make these decisions for--was to 
roll out VSE because it's available today and we're going to 
get it all rolled out this summer, make a decision very, very 
quickly whether VSE meets all the needs for veterans and our 
employees and taxpayers, and if not, we'll proceed with MASS. 
We think that's a reasonable decision. If you have different 
thoughts on that, we're glad to hear it.
    Mr. Coffman. Ms. Council, why hasn't VA implemented the 
FBCS upgrade to improve tracking of the paper claims?
    Ms. Council. The requirements around paper claims are 
currently being developed with the care and the community team. 
We have the dollars, and the team is currently developing that 
capability.
    Alan, do you have anything you want to add?
    Mr. Constantian. Only that we are--some of the VOCA funds 
that we have received, we are looking at the Fee Based Claim 
System and making the improvements that we see are most 
necessary in the short term.
    Mr. Coffman. Okay. Ms. Council, what self-scheduling 
capability will VAR give veterans? How is it more limited 
compared to MASS?
    Ms. Council. The best way I can explain MASS, MASS is a--is 
based on really capacity scheduling and work planning system 
within EPIC, so it's a much broader tool. It looks at 
everything, all your resources, your work flow, and everything, 
not just the schedule. And that's why it is a larger, more 
impactful set of solutions.
    And VAR, is--which is the mobile device, which would allow 
the veterans to schedule, to cancel, for mental health as well 
as basic care, is currently also going through process. So DVAR 
is related to the mobile, VSE is the enhancements to VistA, 
and, of course, MASS includes not only scheduling, but the much 
broader workflow, capacity planning, and everything you need 
around BIZ, and DOCS, and Offices.
    Dr. Shulkin. I would just add, VA needs the ability to have 
veterans schedule appointments themselves. No question about 
it. That's what veterans want, and we want that for them. VAR, 
again, is available today. I spoke to a doctor last night who 
works at the Washington D.C. VA, and 25 of his patients at the 
Washington VA are using VAR.
    So you can actually schedule mental health, primary care 
and cancel appointments on your mobile phone. It is planned to 
be rolled out to seven additional sites in the next month or 
two. So that is, again, an immediate solution. Whether MASS 
provides a better opportunity or not, I think we are going to 
decide that in the very near future, but our goal is to give 
veterans tools today because we still have an access crisis, 
and we have to act with the urgency that I think all of you 
have asked us to act with.
    Mr. Coffman. Ranking Member Kuster, you are now recognized 
for five minutes.
    Ms. Kuster. Thank you very much, and thank you for helping 
us dive right into this. And as you can tell, we are not IT 
experts, so the acronyms can take us a minute.
    I want to start, and I think I have asked some of you this 
before, but I just am curious. Couple years ago, I met with a 
company, the name of the company I believe is Zocdoc, do you 
know this story? So about efficiency because one of the things 
that we deal with--we want to serve the veterans and we are 
tasked with protecting the taxpayers, and the story that I hear 
over and over is veterans miss appointments because maybe they 
can't get a ride, maybe it is scheduled two months in advance 
and they don't get reminded, and this system is an IT system 
that improves efficiency by having reliable patients scheduled 
in the morning, less reliable patients in the afternoon, but 
you can double book in the afternoon so we don't have 
physicians waiting around for patients who don't show. Do you 
know about this? Have you talked to them? How could we speed 
this up? They could help you.
    Dr. Shulkin. First of all, I've known Zocdoc since they 
were little tiny start up in Manhattan in 2007. I can--
    Ms. Kuster. It just seems like one of those great ideas.
    Dr. Shulkin. No question about it. There are many, many 
commercial companies out there, Zocdoc clearly is a leader in 
that area, but I know this field extremely well. We need this 
capability, you are exactly right. This is what VAR was 
developed to do. Whether VAR meets all the requirements and 
whether we should abandon it and go with a commercial system, I 
think that we're open to that. What we don't want to do is 
start over when we have VAR that actually is ready to be put 
out into seven of our VAs--
    Ms. Kuster. So, and my time is limited I don't mean to be 
rude.
    Dr. Shulkin. Yes.
    Ms. Kuster. So VAR, you are in pilot right now for veterans 
to be able to self-schedule, and will that be tiered that way 
so it is done efficiently from the workflow end of things--from 
the VA end of things?
    Dr. Shulkin. It does not have all the features that you've 
talked about, about adding the ability to over book and 
capacity management. There may be some more features that may 
have what MASS has, and that's part of what we are going to 
evaluate. But what it begins to do is to let veterans schedule 
appointments themselves or cancel appointments themselves.
    Ms. Kuster. Which is also very important. My father-in-law 
used the VA, it is important to know when you can get a ride 
there, when it works for you. So, and then, I want to follow-
up. So I am beginning to understand the big picture. MASS is a 
much bigger platform, it is going to be able to deal with the 
work processes, et cetera.
    Can you give me a few specifics--two minutes and then lots 
of people are going to ask you the same question or more--what 
is the timing? What can we expect? And what is the cost? And we 
want to work with you, we want to solve this problem, we will 
go to our colleagues, Rs and Ds, and ask them for the funds, 
but we need some accountability.
    Dr. Shulkin. I will try to do it briefly and then ask Ms. 
Council if she wants to add anything. I think you mentioned 
this in your opening statement, the project cost for MASS is up 
to $624 million. The pilot alone for three sites would be $152 
million. We have spent to date on MASS, in the planning, $11.8 
million.
    Ms. Kuster. Okay.
    Dr. Shulkin. The entire cost for VSE, the alternative 
scheduling system, is $6.4 million.
    Ms. Kuster. Okay.
    Dr. Shulkin. The rollout for VSE would be over the summer 
to do a national rollout. The rollout for MASS would be a ten-
month pilot at three sites--
    Ms. Kuster. Okay.
    Dr. Shulkin [continued]. --which we could start at any 
point if we want to. And then the rollout nationally beyond the 
three sites would be a much longer period of time. I don't have 
the exact, but I would guess it would be a year or greater.
    Ms. Kuster. Could we, my time is almost up, but it occurs 
to me, could we come and have a demonstration so that we could 
actually understand? I mean, for the taxpayers, 6.4 million 
sounds better, but obviously it doesn't do the same thing, and 
we want long-term savings, long-term accessibility for 
physicians' capability for the whole system.
    But the frustration we have is that we keep hearing about 
great systems and then we get halfway into it then it didn't 
work, so we gave that project up. And, you know, where I come 
from, 600 million that is a lot of money. That is a lot. So I 
am going to yield back, but I would love to--if we could work 
with the Committee to--
    Dr. Shulkin. We'd be glad to do that--
    Ms. Kuster [continued]. --schedule a demonstration so we 
have a better understanding.
    Dr. Shulkin. And what we're trying to say very 
transparently is, we think it's a lot of money too. We're 
trying to make the best decision for, exactly as you're saying, 
the veterans and the taxpayers, and everything's on the table. 
We'd be glad to show you this and get your thoughts on it. 
Anybody would be welcome.
    Ms. Kuster. That would be very helpful. Thank you. I yield 
back.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    Dr. Benishek, you are now recognized for five minutes.
    Mr. Benishek. Thank you, Mr. Chairman. Good morning. Ms. 
Council, in the past, you have testified that, thanks to a 
joint VA and DoD effort, we expect that interoperability will 
be certified with the DoD as defined by the 2014 National 
Defense Authorization Act eight months ahead of the December 
2016 deadline. Well, that is where we are today. What is the 
story with that?
    Ms. Council. We have an interoperability agreed to, we are 
interoperable with DoD on the JLV, that took place on April 
8th. So DoD and VA have that handshake, and we are fully 
interoperable eight months ahead of schedule. In August--
    Mr. Benishek. So if I go to the VA, then I can get the 
patient's DoD record for, not every veteran, but what is the 
story, how many veterans actually have access to the DoD if I 
walk into the VA?
    Dr. Shulkin. Yeah. So April 8th we've signed off on it, it 
is attested, we are interoperable. Today, 55,062 active users 
in VA and 60,000 users in the Department of Defense are able to 
do exactly what you're saying: able to get access to the 
records on any serviceman or member of the VA. And that number 
will grow to 120,000 during the course of this year of users.
    Mr. Benishek. So VA personnel have access?
    Dr. Shulkin. 55,000 are using it today.
    Mr. Benishek. How many veterans are in that?
    Dr. Shulkin. I actually do have that number. It is--let me 
get back to you, Dr. Benishek, with the exact number, but I was 
reviewing it last night, I think it's several hundred thousand 
veterans' records have already been accessed through the Joint 
Legacy Viewer.
    Ms. Council. Exactly.
    Mr. Benishek. Yeah. Well, that is the key issue, right?
    Dr. Shulkin. Yep. Oh, here--I'm sorry--what? 457,265 
veterans are--oh, that's through the Health Information 
Exchange. Let me get you the exact number through the Joint 
Legacy Viewer.
    Mr. Benishek. All right. Well, you understand the point I 
am trying to make is that so 60,000 VA employees have access, 
but are there, are we actually taking--is there a significant 
amount of veterans that we have access to those records? So 
that is a key issue. I would appreciate that.
    The other issue that I am interested in, and it has already 
come up a little bit in testimony, is the self-scheduling 
piece. As you know, in the private sector, people schedule 
their own appointments. So you talked about it a little bit 
with an app, but that doesn't help most of the veterans that I 
deal with, because they can't figure out how to use an app on 
their phone, you know what I mean? That is just a limited 
amount of people I think. So what is the timeline for that, and 
how is that going to actually work for most people?
    Dr. Shulkin. Well, you're right, there are two ways to give 
veterans more control of the experience of scheduling 
appointments, which is what our goal is: to put health care 
back in the hands of the veterans. So there is the app, and 
increasingly more and more people are comfortable with smart 
phones, but even--the veteran population does lag behind the 
general population. So we have to wait until more people catch 
up on that.
    The other way, of course, is the telephone. And this past 
week we announced something called the declaration of access 
that will put the decision about scheduling and canceling 
appointments into the hands of the veteran. We have a system 
right now that's very, what I call, paternalistic, which is 
called a recall system; we actually tell you when you're going 
to come for your appointment.
    Mr. Benishek. No, no, I--
    Dr. Shulkin. We're going to stop that.
    Mr. Benishek [continued]. I understand that problem. So is 
the eligibility going to be all figured out in advance then? 
Will the patient have an opportunity to schedule an appointment 
in their locale in the private sector or at the VA? Tell me how 
that's going to work.
    Ms. Council. Actually, the largest users coming on JLV are 
actually the VBA in the benefit side so they can be ahead of 
the eligibility question. We only expected to have about 35,000 
users of JLV, and we are actually--
    Mr. Benishek. JLV, what's JLV again?
    Ms. Council. The JLV is interoperability capabilities. So 
you can see--the Joint Legacy Viewer--so you can actually see 
the eligibility of the active duty soldier, and then, why they 
would be eligible as a veteran. It's really important that 
the--it's interesting that the VBA is really one of the bigger 
users now, and that's really helping to make this eligibility 
happen faster and much more accurately.
    Mr. Benishek. I guess I don't quite understand that. But I 
want to follow-up with you later since I am out of time.
    Mr. Coffman. Thank you, Dr. Benishek.
    Ranking Member Brownley, you are now recognized for five 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman. I just wanted to go 
back to the Joint Legacy Viewer, and you said you were going to 
give us the number of veterans that are on there at this 
particular point. But I am just curious to know, is it 
generally within the population of new veterans or is it, you 
know, veterans after 1975, or is it just a random number of 
veterans across the spectrum?
    Ms. Council. No, it's not random at all. It is the holistic 
look at the DoD's--
    Ms. Brownley. No, no, no, I know, just in terms of the 
capability we have right now in terms of numbers of veterans, 
you know, within the system that users can actually see. So I 
am just wondering, is it sort of--did you start with the most 
current ones and go down a list or is it random across the 
board?
    Ms. Council. No, it's not random. It's just taking the 
information that the DoD holds and actually finding that 
veteran and mapping it with the information that the VA has if 
they are coming into the VA. So it doesn't take it based on 
newest first or easiest first, it is the active duty records 
tied with the current state health records.
    Ms. Brownley. Right. But right now it is limited because it 
only has a current amount of veterans--
    Dr. Shulkin. Uh-uh.
    Ms. Brownley. No?
    Dr. Shulkin. No.
    Ms. Council. No, no.
    Ms. Brownley. Okay. Then I am misunderstanding.
    Ms. Council. No, I think what we're talking about are 
users. When we say users, those aren't actually patients, those 
are users, docs, the people that leverage information.
    Ms. Brownley. Okay. Okay.
    Dr. Shulkin. I did find the number I was looking for that 
Dr. Benishek asked for, which is that we just, last week, 
reached more than 1 million record lookups in the Joint Legacy 
Viewer.
    Ms. Browley. Okay.
    Dr. Shulkin. So those are veterans.
    Ms. Brownley. Okay. Very good. So on the scheduling piece, 
it--so for the Choice program then, veterans--will veterans be 
able to call the VA, find out if they're eligible, and then 
make an appointment with a community doctor? How will that 
work?
    Dr. Shulkin. Well, today--
    Ms. Brownley. I mean, because some of that problem--
    Dr. Shulkin. Yes.
    Ms. Brownley [continued]. --with the Choice program--
    Dr. Shulkin. Yes.
    Ms. Brownley [continued]. --is waiting for the VA to say 
whether you are eligible or not.
    Dr. Shulkin. Today, we follow the current rules of Choice--
    Ms. Brownley. Right.
    Dr. Shulkin [continued]. --which is to use the TPA--
    Ms. Brownley. Yep.
    Dr. Shulkin [continued]. --where you have to call and get--
    Ms. Brownley. But ultimately--
    Dr. Shulkin [continued]. --eligible through them.
    Ms. Brownley. But ultimately will we get to a place where 
the veteran knows he or she is eligible and can make the 
appointment with a community doctor?
    Dr. Shulkin. That's exactly our hope.
    Ms. Brownley. Very good. And so another question that I 
have. It seems as you lay it out, VSE versus MASS, it seems 
like you are making the right decision going down a path that 
is going to be veteran-centric, help the taxpayers, and a 
quicker timeframe. So that all, you know, that all sounds 
really good. My concern is, are we building that system on a 
sort of a weaker foundation, i.e. VistA, you know VistA was at 
one point in time way back when, you know, a state of the art 
system, it is no longer and so, as Ms. Kuster was asking, you 
know, the longer-term ramifications here are we building a 
network of strength that is going to sustain over a period of 
time and really make the VA veteran-centric, veteran friendly 
system?
    Ms. Council. Chairman Brownley, actually Dr. Shulkin and 
myself had this conversation the end of last year and we 
decided that we needed to lay out a new strategy as it relates 
to EHR and what a great veteran experience health care system 
would look like because it is time.
    The EHR today is really just the heartbeat of the organism, 
but it does not have everything that is needed to mandate and 
manage care in the community to deal with the needs of the 
female veteran, and also to support just the overall veteran 
experience and the clinical management.
    I have given to Dr. Shulkin the recommendation around a 
state of the art, world-class system. He is evaluating it from 
a clinician's point of view, which is the appropriate thing to 
do, and that's what he's laying out is, the summer would be 
when we can unveil that as this is what we suggest that the VA 
does.
    What I will tell you is, it is incredibly responsive, it is 
aligned with the world-class technology that everyone's seeing 
today, using today, and things like Facebook and Google and 
other capabilities. But it also is agile and it leverages what 
is called a FHIR capability, which is FAST HEALTH 
INTEROPERABILITY RESOURCES, which means we can bring things in, 
we can use them, we can change them, we can respond.
    And so when he and I spoke about it, we sort of did the 
right leap and we said what we are going to do. We believe that 
VA is an innovator, we believe that VHA and health care should 
continue to be one, and we have provided innovative solution 
based on industry experts coming back and assessing it as that.
    Ms. Brownley. Thank you. I apologize, Mr. Chairman, and I 
yield back.
    Mr. Coffman. Thank you, Ranking Member Brownley.
    Mr. Lamborn, you are now recognized for five minutes.
    Mr. Lamborn. Yeah. Thank you, Mr. Chairman, and thanks for 
having this hearing along with Dr. Benishek.
    Ms. Council or Dr. Shulkin, I understand you are working on 
another contract to provide program integration support to the 
Choice consolidation, and it has IT and non-IT elements. Are 
you going to combine the IT work with the non-IT work or 
separate them?
    Dr. Shulkin. As you know, we have asked for the access to 
the 802 funds to be able to improve the Choice program. Of the 
$421 million that we have asked for to build the infrastructure 
for the new veterans Choice program, about $300 million is for 
IT and the rest are non-IT costs. So they are essentially 
combined at this point into the combined $421.
    Mr. Lamborn. Okay. Okay, good. That was good for 
background. Ms. Council, your written testimony says ``VA has 
obligated $510 million in development funds to build VistA 
capabilities since fiscal year 2014. VA has also obligated $151 
million in IT sustained funds, and $110 million in VHA funds.''
    So with all that spending, what new capabilities does VistA 
have as a result of this money spent?
    Ms. Council. From 2013 until now, enabling 
interoperability, doing the JLV, putting in what is called 
eHMP, which is our web capability, which is actually a long-
term interoperability, fully interoperable with DoD solution, 
which we're moving to. So the JLV, the Joint Legacy Viewer, is 
part of the solution, eHMP is the web abled which moves you to 
a fully interoperable data set working with DHMSM (Defense 
Health Management Systems Modernization).
    In addition, there have been clinical needs, lab needs, and 
different things like that implemented into VistA. Also 
stabilization. When you look at the sustainment costs, what 
you're really seeing there is the maintenance costs for the 130 
different instances of it, keeping the data centers up, and all 
the equipment related to that. And that's what's in 
sustainment.
    Mr. Lamborn. All right. Dr. Shulkin, if a VA hospital is 
manipulating wait times, as we have seen with some of our OIG 
reports, how is a self-scheduling system like VAR going to put 
a stop to it? In other words, couldn't someone--and I hope this 
would never happen, but, like I say we have seen otherwise--
couldn't someone just change the information in VAR on the back 
end?
    Dr. Shulkin. Your concern is one that we are very, very 
concerned about. We have 25,000 employees doing scheduling 
today. So that's a large system to have everybody doing it 
exactly right all the time.
    There are two things that will help. Number one is VSE, 
this is the new scheduling system, and makes the likelihood of 
committing scheduling errors that we have been seeing less 
likely, because it's a--instead of that DOS system, it's a much 
more intuitive system that actually hard codes some of these 
decisions so you can't change them as easily.
    The other is VAR, which is where the patient will schedule 
directly, would be very hard to change the data. Once the 
veteran--it's like a transaction in your bank account, you 
know, once the veteran pushes the button, it schedules it and 
it records it with an electronic, you know, digital print. So 
it would be much less likely that there'd be individual 
manipulations.
    Mr. Lamborn. Okay. Thank you. Mr. Chairman, thanks for 
having this hearing. I yield back.
    Mr. Coffman. Thank you, Mr. Lamborn.
    Mr. O'Rourke, you are now recognized for five minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman. Secretary Shulkin, I 
really appreciated your opening comments and the harkening back 
to the spirit of innovation and leadership that allowed the VA 
to develop VistA and the Nation's first electronic health 
record in the first place. And in answer to some of my 
colleagues' questions, taking the long view on how we establish 
a base and a platform from which we can do great things again. 
I think that is the spirit that we need to approach this with.
    And I know it is a real challenge because there are some 
basic questions of competency right now in the VA that are 
totally legitimate, and I think many of us and our constituents 
want to make sure that we at least reach competency but that 
cannot, be the goal, I mean, it has got to be excellence.
    And I think in whatever the VA evolves into over the next 
10, 20 years, the ability to schedule and expertly manage the 
patient's medical information, share it between the VA and DoD, 
and then VA and community providers, is critical.
    And so I just want to make sure that we are approaching 
these challenges the same they did 40 years ago, let's find out 
whatever they were drinking back then and make sure we order a 
case of that for you and your team, approach this with that 
same vision towards innovating in medicine globally.
    I mean, that is the VA's rightful role, and that is what we 
should expect for our veterans. And I really think your vision 
that you outlined with us in October, which focuses the VA on 
where it can truly excel, and then leverages capacity and 
competencies in the community that complement what the VA does 
is the way to get there. I think that allows you to focus on 
what you can do really well.
    So, I wanted to make that statement to just compliment you 
on your approach. And really, my only concern is that you just 
started in July, and if conventional wisdom holds, you will 
leave at the end of this administration. It is my sincere wish, 
and I will do everything I can to make it happen, that our next 
President keeps this team in place so that we have the 
continuity and consistency to carry this out. I think that is 
really important.
    What are the near-term milestones--and I know you have 
answered this question in different ways from different 
colleagues--what are the near-term milestones that will lay to 
rest any concerns we have about competency, and then also about 
executing a long-term vision that is going to allow the VA to 
develop excellence in this field? What should we be looking for 
in the next seven to eight months?
    Dr. Shulkin. Thank you, Congressman, for your comments.
    Let me just make one historical correction to this. The 
truth is, the history of innovation with the EMR in VA was 
actually that the administration did everything they could to 
stop EMR. It was actually done by the people in the field who 
had to hide their efforts until an Under Secretary, Ken Kizer, 
actually said you're allowed to bring this out of the basement 
into the field.
    So we're trying not to make that mistake. We're trying to 
actually innovate and to help the field actually give us the 
feedback so that we can do what you're asking us to do.
    Mr. O'Rourke. That is great.
    Dr. Shulkin. I think the short-term objectives that we have 
are really to focus on the veterans' needs. This is why when 
we're rolling out the VistA scheduling evolution, when we're 
rolling out the VAR, the self-scheduling application, our 
evaluation criteria are asking veterans did we meet their 
needs.
    And so those are the short-term goals, and we should have 
this information very, very soon, this summer. As we're rolling 
out both VSE and VAR, we are doing constant evaluations asking 
our veterans are their needs being met in terms of access.
    Mr. O'Rourke. So the milestone measurement is determined by 
the veterans themselves?
    Dr. Shulkin. Yes.
    Mr. O'Rourke. And it is not the VA directly asking, or is 
it, that, or is there a third party whom we can trust that has 
got an objective distance from the VA to make sure that we are 
really getting the unvarnished truth about the success of this? 
That would be my preference.
    Dr. Shulkin. Yeah. Yeah. Yeah. And it's a little bit of 
both. The way that we're asking our veterans is actually 
several ways. One is, we use a standardized Federal government 
survey that is, in the government, called a CAHPS survey, which 
is done by every health care institution, that is done by a 
third party. So we hire a third party to administer that.
    We also ask our veterans when they come to appointments, 
there's a kiosk, so we actually, in the kiosk ask them, how 
satisfied are you with the ability to get this appointment when 
you needed it? So they're entering that data.
    Mr. O'Rourke. And I will just say this real quickly as I 
wrap up. I think it is critical that we ask those veterans not 
physically in the VA because there are many who could not get 
an appointment, and we want to know about their experience just 
as much or maybe more so than we do about those who could get 
in.
    And as you have heard me say countless times, especially 
when it comes to mental health because of the connection to 
veteran suicide, got to make sure that we know about their 
experience in being able to get an appointment, and then the VA 
honoring that appointment.
    Dr. Shulkin. And we generally get that feedback from you.
    Mr. O'Rourke. Thank you.
    Dr. Shulkin. Yeah.
    Mr. O'Rourke. I will yield back to the Chair. Thank you for 
your answers.
    Mr. Coffman. Thank you, Mr. O'Rourke.
    Ms. Walorski, you are now recognized for five minutes.
    Ms. Walorski. Thank you, Mr. Chairman. Dr. Shulkin, you had 
already addressed, I think twice, on VSE and VAR the cost--the 
initial rollout cost and that kind of thing. Do you know what 
the lifestyle costs are to run those two programs?
    Dr. Shulkin. The sustainment costs?
    Ms. Walorski. Yeah.
    Dr. Shulkin. I don't know that.
    Mr. Constantian. Well, there are no marginal additional 
sustainment costs in VSE. VSE is an augmentation of the VistA 
scheduling package, so the same funds that would go toward the 
support of the VistA scheduling package will be sufficient to 
support the enhanced VistA scheduling package with the VSE 
enhancements.
    Ms. Walorski. Okay. And, you know, I am kind of asking that 
question because I am sitting here listening to this, I am 
cautiously optimistic, and I appreciate what your team has 
done, I really do, because I think you have taken great steps 
forward.
    And to kind of just echo some of the questions my 
colleagues had. You know, I haven't been here long, but in the 
four years that I have been here this issue with IT seems to be 
the one that continues to bounce back with some of the best 
efforts that have gone forward, and best trials, and then seems 
to bounce back, and all of a sudden--I will never forget the 
hearing where, you know, the VA was a billion dollars short and 
you needed that to go in the future.
    So I am cautiously optimistic, but I--Ms. Council, in your 
written testimony, you say that ``The JLV provides limited VA 
to DoD medical records sharing compared to the eHMP,'' you are 
working on now. Is it true in order to make eHMP work, you have 
to get rid of VistA's old user interface and implement a new 
one that integrates with the 'Net--with the Internet?
    Ms. Council. You actually have to integrate it into the 
Web. And so you have to go through one at a time and lay that 
in--
    Ms. Walorski. So you don't need to get rid of the old VistA 
program?
    Ms. Council. No, it actually can still live.
    Ms. Walorski. Okay. And then my final question, I think you 
may have answered this is, Ms. Council, OIT is strongly 
advocating Agile Software Development and Project Management, 
what specifically is OIT doing different now? VA's been talking 
about its leadership in Agile among agencies since 2014.
    Ms. Council. Yeah. I'm excited about this. One of things 
that you should have received was the VIP Process, which is now 
standing up, that is our Enterprise Portfolio Management 
Office. That is our intake process. So if you look at PMAS and 
you compare it to what we're doing now with full Agile and VIP, 
we reduced the time that we were spending in document 
preparation by 88 percent.
    We went from 55 documents to 6 plus available to operate. 
We are in a full Agile capability which means that you're 
following the 80/20 rule, which we will be able to produce in 
70 percent faster time with better quality. We have the intake 
process which allows us to assess the business case. And if 
something does not have a viable business case, it will not get 
done.
    Ms. Walorski. I don't want to interrupt, but let me just 
ask you this. So I really do think your presence to this 
conversation has been incredible. I really think you have 
brought this so much farther, so much quicker, than some of the 
folks have in the past. And so I really appreciate what you 
have done and how open you have been with our Committee.
    And I guess, you know, from my perspective, and you know, 
we---I really want this to work--
    Ms. Council. Uh-huh.
    Ms. Walorski [continued]. You know, I want the calls that 
we get in our office to decrease. I want our veterans to 
actually find a seamless, smooth transition, and I want this to 
work, you know, just as much as they do. And I am concerned, 
you know, as we talk about, you know, another rollout, another 
this, another that, and to echo what Congressman O'Rourke just 
said, is there a plan in place, given the political realities 
of how this continuity often gets interrupted, is there a plan 
now, for example, that says no matter who is behind this seat, 
this is what is going to happen? That actually is a plan in 
place that really is not going to be changed in another, you 
know, another development program with another, you know, 20 
million dollars or whatever? Is this going forward regardless?
    Ms. Council. Yes, that was the main purpose of how the 
strategy was defined, because that was my biggest concern. I 
didn't want to spend the effort, either, and not see the team 
continue. So, you know, we've added an additional 11 new 
leaders within OI&T. We've added seven new senior leaders who 
will be out into the field.
    Ms. Walorski. And let me just ask you about those leaders.
    Ms. Council. Yeah.
    Ms. Walorski. Are those leaders competent in the private 
sector, competent folks like when you came in, and you come in 
with all those competency and expert--are these the same kind 
of 11, or are these people that are just elevated inside the 
VA?
    Ms. Council. No, these people are coming from outside in 
private industry as well as from other agencies. They're highly 
rated and we are very competitive. I am excited to say that 
when we look at, even our--actually, Dr. Constantian here is an 
account manager for VHA and that's why he's here. There are now 
standing account managers within OIT that didn't exist before, 
so that we actually have a head to head relationship with our 
business partners and having aggressive conversation about the 
work that we're doing, and how we're spending our dollars.
    Ms. Walorski. I appreciate it. I am out of time. And I 
appreciate it, Mr. Chairman. I yield back.
    Mr. Coffman. Dr. Ruiz, you are now recognized for five 
minutes.
    Mr. Ruiz. Thank you, thank you. Last year in testimony to 
this Committee, Secretary McDonald said the following regarding 
the VA's accomplishment, quote, ``We were the ones that 
discovered that aspirin was important for heart disease, first 
liver transplant, first implantable pacemaker. Last year, two 
VA doctors invented the shingles vaccine. That research is 
important for the American people, and I didn't even mention 
PTS or TBI or prosthetics, things we are known for.''
    So, Ms. Council and Dr. Shulkin, please explain why the VA 
is unable to develop or acquire the technology possessed by 
most modern health care systems and required to efficiently 
share health records and schedule appointments, yet can 
continue to make such progress in other areas of the 
Department. What are your logistical and political barriers?
    Dr. Shulkin. We appreciate the question and the recognition 
of VA's track record of innovation. VA is a leader in 
electronic medical records. There is no system that has the 
extensive experience with EHR than VA. I will tell you, I've 
spent my life practicing in the private sector. I've now 
practiced in the VA system. It's my first time using the EHR. 
And our clinicians really like the VistA EHR. What Ms. Council 
is saying is, and I think what Congresswoman Brownley was 
getting at is, the world has changed a lot. And is this 40-
year-old EHR going to be the system that VA should stick with 
for the next 20 years? And that's where Ms. Council is saying 
we owe it to veterans and to all of you to make sure that we 
believe that's the right answer, and that's where I--
    Mr. Ruiz. I think you got to be careful with that notion, 
because health care information, diseases, recordkeeping 
changes, and it is flexible, so you can't make a guarantee that 
what we have now is going to last 15 years, because we don't 
want it to last 15 years. We want it to change with the ever 
needs of the patients and the community. And so you have got 
to, you know, manage some expectations that the information we 
get changes. So I don't, you know--if you say you are going to 
pick one, and then you are going to keep that same one for the 
next 15 years, then you are setting yourself up for failure. 
And you are also going to keep an archaic, 20 years from now, 
system in place just because you have committed to that.
    Dr. Shulkin. I think we're--I may not have been articulate 
enough, I think we're agreeing with that--
    Mr. Ruiz. Okay.
    Dr. Shulkin [continued]. --which is saying today, VistA is 
actually 130 separate VistA systems, and new technology puts 
stuff in the cloud and makes it a singular system so you can be 
more agile and change it.
    Mr. Ruiz. And I think one of the most important things you 
can do other than creating a more modern, flexible system that 
matches the needs of the patients and the doctors where you 
practice, in order to provide the best care, is to make it 
interoperable with the private sector, and in the private 
sector they are having difficulties in doing that themselves--
    Dr. Shulkin. Right.
    Mr. Ruiz [continued]. --so it would be helpful if you could 
lead the charge to make sure that you do that, because, if I am 
an emergency physician, and I see a patient that is a veteran, 
and I can't get the last CAT scan to compare their abdominal 
CAT scan or I can't get their latest EKG, then I am limited in 
the decisions that require resources that I can make and more 
than not, because I care about the patient, I tend--you know, I 
will not take the risk for the patient, and I will do what I 
need to ensure that the patient is going to be healthy. And 
that means more cost, simply because I can't access a CAT scan 
or an EKG from another institution.
    Ms. Council. Exactly. And so, Congressman, we assessed the 
solution that we've laid out, the one system, actually does 
that in the cloud using software as a service. It builds 
around, I have mentioned earlier, the FHIR concept, which is 
Fast Health Interoperability Resources, which allows you to 
pull those resources together, use that information, and 
redeploy it back out.
    Mr. Ruiz. With the private sector, not within--
    Ms. Council. Wholly with the private sector, and we believe 
that the VA should be the leader in this, as the largest health 
integrator, and actually drive that forward on an HL7 platform.
    Mr. Ruiz. Thank you. I yield back my time.
    Mr. Coffman. Thank you, Dr. Ruiz.
    Mr. Huelskamp, you are now recognized for five minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman. Chairman, I 
appreciate this joint hearing on this topic, and I apologize 
for my tardiness.
    I want to follow-up on just a few things, and I apologize 
if they have been covered before. But the strategic hold on the 
MASS system, can you describe that for me, if you haven't 
already for the full Committee, and I was kind of curious what 
a strategic hold is versus a non-strategic hold?
    Dr. Shulkin. I'd be glad to do that briefly, Congressman. 
We do have a contract with MASS and we could execute that at 
any point. We've decided since we have a system that's 
currently available, VSE, VistA Scheduling Enhancement, that is 
being rolled out as we speak to VAs, to roll that out because 
it's in the best decisions right now since it's available to 
veterans, and to taxpayers to do that. We will have that done 
over the summer and be able to evaluate did the VistA 
Scheduling Evolution meet the needs of veterans, and if not, 
then we'll proceed with a pilot for MASS, which would be a ten-
month pilot at three sites at a cost of $152 million.
    Mr. Huelskamp. So what have you spent on MASS already, and 
that is all on hold, and that--
    Dr. Shulkin. Yes.
    Mr. Huelskamp [continued]. --if it doesn't go forward, we 
would lose all that--
    Dr. Shulkin. Yes, $11.8 million to date on MASS, already. 
The VistA Scheduling Enhancement total cost is 6.4 million.
    Mr. Huelskamp. Yeah, and VistA, that is--you talk about 
rolling it out, it is still just pilot, correct? We are not 
rolling anything out, we are still testing it, beta testing it?
    Dr. Shulkin. Yes. Today, it's actually being used in two 
sites, in Asheville, North Carolina, and Salt Lake City. I have 
the user evaluations which I reviewed last night, which are 
tremendous in terms of its receptivity. It's planned to roll 
out to 11 more, or 11 total VAs by the end of this month or 
within six weeks, and then the national rollout.
    Mr. Huelskamp. You mentioned Salt Lake City. I am looking 
at the testimony, I don't see that on the list of the--
    Dr. Shulkin. Yeah.
    Mr. Huelskamp [continued]. --the VSE IOC sites?
    Dr. Shulkin. Yeah, I'll be glad to share--actually last 
night, I have it on me, I'll be glad to share the user feedback 
from Salt Lake City.
    Mr. Huelskamp. Okay. How seriously did you consider a 
commercial alternative to the contract, which apparently 
strategic hold could be abandoning that work and doing it with 
VistA? Strategically, what did you consider on the commercial 
side, and I know Zocdoc was mentioned, I haven't used that. I 
was looking at it preparing for this hearing, but describe the 
process by which you decided not to use any commercial 
alternatives.
    Dr. Shulkin. Well, MASS is a commercial alternative. It's 
made by the Epic Company, which is a leader in health 
information systems. It was selected through a competitive 
process, and we do have an IDIQ contract with them that we 
could execute at any point.
    Mr. Huelskamp. It is an operating system?
    Dr. Shulkin. Oh, yes.
    Mr. Huelskamp. And so you spent how many dollars just to--
    Dr. Shulkin. Eleven point eight million.
    Mr. Huelskamp. Did you ever use it as a pilot program--
    Dr. Shulkin. No.
    Mr. Huelskamp [continued]. --or at least try it?
    Dr. Shulkin. Nope, the pilot program would be $152 million 
to implement because of all the interfaces and the spreads, so 
that's the decision which we're facing right now. We decided, 
you called it a strategic hold, is that it's in the best 
interest of taxpayers before we proceed with the $152 million, 
to see if VSE, which is in the field now being rolled out, 
meets the needs of veterans. If not, we can proceed with MASS.
    Mr. Huelskamp. Still, maybe you can follow-up with 
something later if--went down the MASS road for a while and 
then apparently have abandoned it. Strategic hold is your name, 
not mine, and I am just trying to figure out how we got there. 
Now we are back on something that has, you know, been around 
for decades, and trying to make that work.
    Another question, and more directly, or I guess more 
broadly on this, does anything in the Choice legislation or 
other current statutes require you to set up a system in which 
a contract or a third party or somebody other than the veteran 
can make their own appointment?
    Ms. Council. Not that I'm aware of.
    Dr. Shulkin. I'm not aware of that in the legislation.
    Mr. Huelskamp. So you are free to do that?
    Dr. Shulkin. Yes.
    Mr. Huelskamp. And that is what bothers me more broadly, I 
think we are still--what I am seeing is just kind of this 
attempt at pushing through a model which doesn't work, in my 
opinion, in the 21st century. Maybe it works for a few folks. 
But it is also, for instance, we have got another system out 
there with many of the veterans who are in other systems. Many 
of them are in Medicare, and this is not the Medicare system at 
all. We don't require you to go through Medicare to make an 
appointment, but somehow it looks like the track is still push 
veterans through this system. Can you describe a little bit 
more why we still think we have got to push it through a system 
rather than letting, you know, something like a commercial term 
where you don't have to call the VA, you don't have to work 
through the contractor, you call the hospital and do like you 
do for Medicare.
    Again, these veterans, many of them, go through the 
Medicare system. That was one of the concerns that the cost 
would be so great of Choice because folks would, yeah, abandon 
Medicare or other options because the VA system would work so 
well, and not quite happen that way. So but just, more 
description of that, I am concerned about still trying to put 
us in the same old model from 30 or 40 years ago, which I don't 
think fits our needs of veterans in this century.
    Dr. Shulkin. Yeah. VA has a long history of using care in 
the community for veterans. We've been doing this for a long 
time. You used to have a system, I think like you were 
describing, where veterans would seek care in the community, 
and we would go and schedule it, very similar to the way that 
you schedule with Medicare. The Choice legislation did 
require--
    Mr. Huelskamp. If I interrupt, with Medicare, they don't 
schedule the appointment, do they?
    Dr. Shulkin. No, and so I think what you're describing now, 
where we're seeing so many complaints is the veteran needs to 
go to the TPA to access Choice. And so that has added a level 
of complexity. And this is where we've submitted legislation 
for your consideration to try to simplify and streamline these 
care in the community programs. Because we agree with you, it's 
too complex today.
    Mr. Huelskamp. Yeah, that is why I asked first and this 
is--do we need any legislative changes to allow the veteran to 
make their choice directly, and I don't think so. But I 
appreciate that. With that, Mr. Chairman, I yield back.
    Mr. Coffman. Thank you, Mr. Huelskamp.
    Mr. Takano, you are now recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Is it Dr. Shulkin? There are some aspects to the legacy 
VistA system that you definitely want to see preserved and 
continued; am I understanding that correctly?
    Dr. Shulkin. I think there are many, many good things about 
the VistA system and VistA Evolution, which is the newer sort 
of what we call eHMP, it's the web-based version; it also has 
many, many great features. I think at the same time, what Ms. 
Council is saying is, is that she wants to make sure, and we're 
going to do this together, that this is the appropriate 
technology for the future of VA.
    Mr. Takano. And you are going through that evaluation 
process now?
    Dr. Shulkin. Yes.
    Ms. Council. Yes.
    Mr. Takano. Okay. You know, I mean, I heard about the 130 
separate systems, you are going to use the cloud, and try to 
get it all sorted together. And you are also looking at 
possibly a major replacement, or not. You are sort of trying to 
figure all of that out; is that correct?
    Ms. Council. We actually have defined a new technical 
digital health platform for VHA. It's currently being looked at 
by the users, and I am currently looking for an ability to 
build the prototype, so that we can show it to you, but also, 
so that the users can play with it. It leverages EHR as a 
health record and does not have all that complexity that VistA 
has in it, and so we're agnostic as to which VHR, but it also 
is in the cloud, it's highly agile, and it's highly 
interoperable with care in the community, the DoD, and anyone 
else that we'd have to engage with on behalf of the veteran.
    Mr. Takano. So that leads me to this next question. Dr. 
Shulkin, in your testimony you mentioned much of what, is it 
Dr. Council, or is it Ms. Council?
    Ms. Council. It is sometimes, it depends on whatever you 
want--
    Mr. Takano. That the VA plans to expand partnership with 
health information exchanges that are outside the VA--
    Dr. Shulkin. Uh-huh.
    Mr. Takano [continued]. --or HIEs to improve access to 
health information between the VA and community providers. I 
want to mention that we have a very, very successful HIE in the 
Inland Empire, the region of California that I represent and 
Dr. Ruiz represents, and we, actually by the end of the year, 
expect that health information exchange to include all of our 
hospitals in our region, a three million population strong, and 
we even--in other parts of southern California, other parts of 
California rather than start their own HIEs are actually 
leveraging off the work that our HIE has done. I understand it 
supports nine million patient files.
    Dr. Shulkin. Uh-huh.
    Mr. Takano. And by the end of the year, it will include all 
the hospitals by the end of the year. How has the outreach to 
HIEs gone, and what challenges do you face as you look to form 
partnerships with HIEs such as the one I just described?
    Dr. Shulkin. Right. I completely agree with you, 
Congressman. When I was running hospitals prior to taking this 
position, I was participating in functional HIEs. So VA wants 
to be part of these regional HIEs. We currently are partners 
with 71 today, 71 HIEs active throughout the country. That's 
where it does impact 475,000 veterans today, where we're 
exchanging records with 713 hospitals as part of these 71 
community partnerships. So we want to expand that. It's the 
future, and it's the only way that you're going to make 
community care and VA care work as an integrated network.
    Mr. Takano. And what is your timeline for that? What is 
your timeline to get that done?
    Dr. Shulkin. It goes region by region, because as I said, 
some regions are really pushing it and others are a little bit 
slower to get there. But part of what we're doing with the 
revised care in the community program that Representative 
Huelskamp asked about, we are using the 421 million dollars to 
accelerate a VA portal into these HIEs.
    Mr. Takano. And how--of the 77 that you already are doing 
partnerships with--
    Dr. Shulkin. Uh-huh.
    Mr. Takano [continued]. --how meaningful is the 
interoperability?
    Dr. Shulkin. It's an exchange of documentation, an exchange 
of lab information, medical record information, it's what HIEs 
do. I mean, there's no--you don't enter new data into it, it's 
really read-only capabilities.
    Mr. Takano. Okay. Thank you, Mr. Chairman. I yield back.
    Mr. Coffman. Thank you, Mr. Takano.
    Dr. Shulkin, using VAR, can the veterans actually see a 
calendar for available appointment slots?
    Dr. Shulkin. Yes, Mr. Chairman. In relatively limited 
today, primary care and mental health. But they can see what 
appointments are available to them so they select what's best 
for them.
    Mr. Coffman. And what happens if the veteran requests say, 
three dates that are not available? What would occur in the 
system?
    Dr. Shulkin. I assume that if it's not working for them, 
because I would call that not working, I'd be frustrated. They 
have to pick up the phone and call.
    But Alan, do you have a better answer?
    Mr. Constantian. If the three dates they selected with the 
VAR system were not available, they'd have to either pick up 
the phone, as Dr. Shulkin said, or make a subsequent request.
    Mr. Coffman. So let me just say something. I think we are 
coming full circle on this, that we instituted a Choice Program 
because of problems in the VA scheduling system. Secretary 
McDonald was in Denver, Colorado last weekend, and his 
statement about the so-called quote-unquote scandal was that it 
was merely a lack of training of VA appointment personnel. I 
differ with that. I think it was fundamentally due to 
corruption, that they had manipulated the system in creating a 
secret list in order to get cash bonuses. And, you know, there 
is not even an acknowledgment of that. I think only six people 
out of what was a systemic problem were held accountable, that 
were responsible.
    And so, I am very concerned about turning the--going full 
circle and giving it back to the people that created this 
problem, that caused us to enact the Choice Program. And where 
we have programs like Medicaid, Medicare, TRICARE, that, don't 
require that and so I just want to state my reservation about 
this. I think there are some other things that are being worked 
on that are very important. Obviously, I had a discussion about 
cyber security yesterday, and I was very disappointed in the 
answer that I received on that. But I just have--I think there 
is a cultural problem here that has not been resolved.
    And, let's see. Ms. Brownley? You are now recognized for 
five minutes.
    Ms. Brownley. Thank you, Mr. Chairman. I appreciate it.
    I just wanted to follow-up on my line of questioning 
earlier with regards to, you know, the core VistA system, and 
it is my understanding that the independent assessment 
recommended the VA conduct a cost-benefit analysis between a 
commercial, off the shelf product and/or continuing the use of 
the VistA health record currently in use. So is the VA 
currently undergoing that, or what are we doing?
    Ms. Council. We actually--
    Ms. Brownley. It sounds like you are thinking a lot about 
it--
    Ms. Council. No, we actually have done the business case. 
The business case analysis was done last fall. Based upon that, 
we decided that the right thing to do is lay out the new 
digital health platform, because that's really what's needed 
for the future.
    Ms. Brownley. Uh-huh.
    Ms. Council. If VHA is going to provide health care in the 
future and today, it needs to move into a digital platform, and 
that's what we have laid out. We're building the view for it, 
so people can see what we're talking about, and Dr. Shulkin is 
looking at it from a functional point of view and the user.
    Ms. Brownley. So when you say you have done a business 
analysis, that is not really a cost-benefit analysis, is it, 
or--
    Ms. Council. The business case is a cost-benefit analysis--
    Ms. Brownley. Okay.
    Ms. Council [continued]. --looking at the overall long-term 
ability to maintain it, what it would take if we wanted to 
change it, how could we get it onto an architecture that is 
more agreeable and agile so they can move and change as health 
care is changing.
    Ms. Brownley. Uh-huh.
    Ms. Council. Also, how would we work with the care in the 
community, but fundamentally four core things need to be in a 
health care system. You need to have clinical management, you 
need to have hospital operations capability, you also need to 
have the veteran experience core to what we offer, and you have 
to have predictive analytics. We do not have that today with 
VistA, and so we decided to pull and build the new digital 
health platform to address it after reviewing that business 
case last fall.
    Ms. Brownley. Okay. Very good. And, you know, I would like 
to know more about the digital health platform and all of the 
different possibilities in terms of how it can support veterans 
and their needs.
    I know I mentioned this to you in my office yesterday, and 
one of my frustrations, and I think probably all of us who sit 
here on the dais, their frustration is that we never--in terms 
of accountability, we never seem to have an agreed-upon matrix 
of what we are looking for, and let's just talk about 
scheduling and wait times is one of those metrics.
    And so I'm just hoping that as we proceed in this system, 
that we all can agree on what we are looking for, and how we 
can hold you accountable and ourselves accountable for making 
sure that we are meeting the appropriate needs that we are 
looking for, because I think sometimes we have--you may be 
looking at something, and but we are looking for something 
else, and those two issues never seem to meet.
    Ms. Council. And that's a core backbone of the new 
development, because you need analytics. That's what you really 
want to understand: how well things are performing, how well 
are we responding, and frankly, how well the diagnoses and what 
we decide to do for the veteran's actually working for that 
veteran. That is core to this system and it doesn't require 
human interface to get that information.
    Ms. Brownley. Well, and I think we need to have that 
discussion about what those--you know, what are we going to get 
from those analytics, and so that we all have sort of a common 
understanding of it.
    And just one last, very quick question, you know I don't 
want to dwell on this, but we obviously have spent millions and 
billions of dollars on trying to make an IT system that works. 
And I guess my question is, of those millions and billions of 
dollars that we have spent, was any of that money, in essence 
sort of worthwhile in terms of what you are building on and 
trying to come to today?
    Dr. Shulkin. Yeah. First of all, you know, seeing patients 
in the system and using VistA, the country should be proud that 
we developed this system. Doesn't mean that it's going to be 
the system for the future, but it's working today, millions of 
veterans' lives depend upon it, and it helps VA provide better 
quality than the private sector in many, many measures that's 
consistently published in the best journals in America.
    Secondly, VSE, which is the, I'm sorry, VistA Evolution, 
which is where this 510 million went to over the last couple 
years, is actually now being launched. April 5th it went into 
five sites. So you're finally seeing, with all these years in 
development, all that money, it's actually now, just this 
April, being put into the system. It's going to be a major 
advance. So whether all of it was necessary, whether it could 
have been done more efficiently, I'm sure that it could have 
been done more efficiently, but absolutely not a waste, 
Congresswoman. It's here now.
    Ms. Brownley. Thank you very much and thank you all for 
your testimony. I yield back.
    Mr. Coffman. Thank you, Ms. Brownley, Ranking Member 
Brownley.
    Dr. Benishek, you are now recognized for five minutes.
    Mr. Benishek. Thank you, Mr. Chairman.
    I have got just a few more questions about where I was when 
I was asking the questions last time, and the DoD, VA 
interoperability now, so there was 55,000 VA people who are 
able to access both DoD and VA records of veterans. We are not 
sure the amount of veterans that they are actually able to 
access. Are these health--I wasn't sure because I think maybe 
you answered them in different ways--are these health 
professionals that have access to this, or are these veteran 
benefit people that have access?
    Dr. Shulkin. Both. Both.
    Mr. Benishek. Both. So then what percentage of this and how 
many people are we talking about. 55,000, is that what 
percentage of that, is that ten percent of the system or--
    Dr. Shulkin. Well, of health professionals. You know, it 
may be as low as 20, 25 percent of the system.
    Mr. Benishek. All right. Okay. That is kind of where I was 
going there.
    Dr. Shulkin. Yeah.
    Mr. Benishek. So there is some definite work to be done 
there.
    Dr. Shulkin. Absolutely. Training, yes.
    Mr. Benishek. So it is basically a training issue then, you 
think?
    Dr. Shulkin. It's primarily a training issue. You have to--
it's not easy, at least not easy for me. You have to leave, you 
have to go out of a system--
    Mr. Benishek. So by December you think we will have that 
better then, I mean, full up to speed then--
    Dr. Shulkin. Yeah.
    Mr. Benishek [continued]. --Ms. Council?
    Ms. Council. Yeah, it's an integration issue with VistA, 
and that's one of the reasons we need to get to a new digital 
health platform. Everything's separate, and that is the root of 
the issue.
    Mr. Benishek. I want to ask another question, now this is 
still about this self-scheduling thing. So in the 
consolidation, we are not going to rely on the third party 
people to do the scheduling, or we don't know that yet? See, I 
have a problem if a veteran calls, I need an appointment, they 
get the appointment and then the eligibility and everything is 
figured out later? How is that going to actually work, Dr. 
Shulkin?
    Dr. Shulkin. Yeah. We know the current system isn't working 
the way it should for veterans. No disagreement there. So what 
we have proposed is a new streamlined system. We have actually 
released this week a draft RFP to the industry to seek industry 
partners who could help us do this better. We believe we're 
going--VA can't do this alone. I hear the skepticism. I don't 
think we're trying to say that we should be doing this alone. 
So we are seeking--and the RFP will be released, a full one, 
later on this spring with a selection in the fall, for partners 
to help us do this better, because frankly this is what many 
managed care plans and other companies are doing much better 
than we are right now.
    Mr. Benishek. All right. Okay.
    Let me ask you another question now. There is this Fee 
Based Claim System, that is involved with paying providers in 
the community, and apparently the VA has this auto-adjudication 
update possibility to speed this along. Do you intend to make 
that happen, or, this is a problem with the payment issue?
    Ms. Council. Yes, we do.
    Mr. Benishek. What is the story there?
    Ms. Council. Yes, we do. As part of the integration for 
community and care includes eligibility, referral 
authorizations, provider payments and customer service being 
tied into one service, so we can see that seamlessly, because 
it can't be done choppy like it is right now. Right now it's 
very human labor intensive.
    Mr. Benishek. Is that something that is going to happen 
soon, or you have to wait until the whole integration is done, 
or, can it just be done now?
    Ms. Council. No, I think what we needed were the 
requirements coming in from the business partners which we now 
have. We can make the changes and then upload that system.
    Mr. Benishek. All right. Well, I have just got a few more 
minutes here, so I am just going to comment. And this has been 
an ongoing issue, and, you know, I appreciate your working on 
all these things. But it seems to me that in the private 
sector, many of this IT stuff is, you know, the problems are 
solved and then the system is improved on a constant basis 
rather than trying to develop a huge comprehensive fix. And 
then, you know, by the time the fix is actually figured out, it 
is obsolete, you know, so why isn't that more the way that we 
are doing this than what seems to be happening here?
    Ms. Council. That is actually the way it should work. We 
have 365 data centers within the VA, 130 instances of VistA, 
and 834 custom systems. In addition, they're spread out across 
the 1,500 health systems, and it was built as it went. It looks 
nothing like what you would see in private industry, and 
fundamentally, what we're laying out is a digital health 
platform that will get us there. I hundred percent agree with 
you, you don't have to get a hundred percent of the solution in 
place to start. You could start with 20, 30, 40 percent and 
just get better over time. But that requires a standard 
platform, it requires one instance, one solution, and a process 
that everybody uses, and that was not how the VA was built.
    Mr. Benishek. All right. I am out of time. Thank you, Mr. 
Chairman.
    Mr. Coffman. Thank you, Dr. Benishek. And thank you to our 
witnesses, you are now excused.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous materials. Without objection, so ordered. I would 
like to once again thank all of our witnesses and our audience 
members for joining us in today's discussion. With that, this 
hearing is adjourned.

    [Whereupon, at 11:37 a.m., the Subcommittees were 
adjourned.]

                          A P P E N D I X

                              ----------                              

                Prepared Statement of Dr. David Shulkin
    Good afternoon, Chairman Benishek, Chairman Coffman, Ranking Member 
Brownley, Ranking Member Kuster, and Members of the Subcommittees. 
Thank you for the opportunity to discuss the progress that the 
Department of Veterans Affairs (VA) is making towards modernizing our 
information technology (IT) infrastructure to better serve our VA 
business partners and our Nation's Veterans. We will also discuss 
scheduling, claims processing and adjudication, and medical record 
sharing initiatives at the Department. In order to successfully carry 
out those initiatives and our consolidation of community care programs, 
in addition to the legislative authorities and resources identified in 
our October 30, 2015 report to Congress, VA will need a digital health 
platform and IT solutions that will meet the evolving needs of our 
Veterans, as well as support our streamlined business processes. We are 
accompanied today by Dr. Alan Constantian, Deputy Chief Information 
Officer in the Office of Information Technology (OI&T).

New VA IT Strategic Plan

    OI&T is at a critical inflection point. Persistent internal 
challenges exist in delivering IT services, and external pressures are 
compelling us to change and adapt. Through the MyVA initiative, VA is 
modernizing its culture, processes, and capabilities to put Veterans 
first, and is giving our team the opportunity to make a real difference 
in Veterans' lives. This momentum is driving us to transform OI&T on 
behalf of our partners, our employees, and Veterans.
    With this in mind, VA developed a new IT strategic plan. Our new 
vision is to become a world-class organization that collaborates with 
its business partners to provide a seamless, unified Veteran experience 
through the delivery of state-of-the-art technology. Our guiding 
principles are to be transparent, accountable, innovative, and team-
oriented. To build trust, we are committed to measuring success, 
investing in the capabilities of our employees, and collaborating 
across VA.
    We have created five new key functions to support VA's strategic 
objectives.

    1.The Account Management function establishes a clear, consistent 
process for understanding and meeting the needs of our business 
partners and our customers.
    2.The Enterprise Program Management Office (EPMO) function monitors 
key information to improve project execution and deliver better 
outcomes.
    3.The Data Management function will ensure interoperability with 
our partners and protect Veteran data.
    4.The Strategic Sourcing function will focus on knowledge sharing, 
best practices, and sharing insights on new technologies.
    5.Finally, the Quality and Compliance function enables us to adhere 
to appropriate policies and standards to eliminate material weaknesses.

    Building a strong team and ensuring that the mission continues past 
2016 is vital to OI&T's transformation. IT is a field characterized by 
constant evolution. Veterans have earned the best care and benefits 
available which must be enabled by the best technological solutions and 
be empowered by the most skilled employee base. We must embrace 
creative staffing approaches and incentivize the best and brightest 
talent, both within and beyond the Federal government, to deliver 
world-class solutions.
    However, talent management is not simply attracting the right 
people. It is retaining those with a passion and a commitment to our 
mission by fostering a compelling, rewarding environment. We are 
emphasizing our team's development as a key priority. The goals and 
milestones of our enterprise strategy will cascade throughout the 
team's performance plans at all levels. We are also customizing 
development and education programs, and by the end of 2017, VA will 
develop a meaningful employee career plan - a first in OI&T. Most 
importantly, we are leading talent development from the highest tiers 
of the OI&T team. We are evaluating our leadership approach to ensure 
that we have the right leaders in the right positions. We are infusing 
new perspectives and skills by hiring new talent. OI&T has added 5 
senior leaders in critical roles and will add 11 more in the next 90 
days. This team will realize our strategies and carry out our mission 
now and into the future.
    This transformation will be different because we have the key 
components for success. Over three phases of implementation, OI&T will 
stabilize and streamline core processes and platforms, eliminate 
material weaknesses, and institutionalize a new set of capabilities to 
drive improved outcomes.
                  Enterprise Program Management Office
    EPMO is building our momentum in OI&T's transformation. EPMO hosts 
our biggest IT programs, including the Veterans Health Information 
Systems and Technology Architecture (VistA) Evolution, 
Interoperability, the Veterans Benefits Management System, and Medical 
Appointment Scheduling System (MASS). EPMO also supports the Federal 
Information Technology Acquisition Reform Act requirements.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Fig. 1 - EPMO Organizational Chart

    EPMO ensures alignment of program portfolios to strategic 
objectives and provides visibility and governance into the programs.
    For enterprise initiatives, EPMO helps program and project teams to 
better develop execution plans, monitor progress, and report the status 
of these programs and projects. EPMO enables partnerships with IT 
architects for enterprise collaboration and serves as a program/project 
resource for the delivery of enterprise and cross-functional programs. 
This helps identify Shared Services Enterprise Programs and will help 
plan resource requirements with portfolios and architecture.
    EPMO has already produced results. The Veteran-focused Integration 
Process (VIP) is a project-level based process that replaces the 
Program Management Accountability System (PMAS). VIP establishes a 
single release process with a predictable cadence that all VA 
organizations will follow by the end of 2016. It reduces overhead and 
eliminates redundancy in review, approval, and communication processes. 
These efficiencies include reducing the review process from 10 
independent groups with
    90 people to a single group of 30 people focused on ensuring that 
products meet specified, consistent criteria for release.
    VIP focuses on doing rather than documenting, with a reduction of 
artifacts from more than 50 to just seven, plus the Authority to 
Operate, and the shift from a 6-month to a 3-month delivery cycle. 
Further, as a guarantee to our work, EPMO will ensure that product 
teams stay assigned to their projects for at least 90 days after the 
final deployment.
                   Enterprise Cybersecurity Strategy
    OI&T is facing the ever-growing cyber threat head on. The first 
step in our transformation was addressing enterprise cyber security. We 
delivered an actionable, far-reaching, cybersecurity strategy and 
implementation plan for VA to Congress on September 28, 2015, as 
promised.
    OI&T is committed to protecting all Veteran information and VA data 
and limiting access to only those with the proper authority. This 
commitment requires us to think enterprise-wide about security 
holistically. We have dual responsibility to store and protect Veterans 
records, and our strategy addresses both privacy and security. We 
designed our strategy to counter the spectrum of threat profiles 
through a multi-layered, in-depth defense model enabled through five 
strategic goals.

      Protecting Veteran Information and VA Data: We are 
strongly committed to protecting data. Our data security approach 
emphasizes in-depth defense, with multiple layers of protection around 
all Veteran and VA data.
      Defending VA's Cyberspace Ecosystem: Providing secure and 
resilient VA information systems technology, business applications, 
publically accessible platforms, and shared data networks is central to 
VA's ability to defend VA's cyberspace ecosystem. Addressing technology 
needs and operations that require protection, rapid response protocols, 
and efficient restoration techniques is core to effective defense.
      Protecting VA Infrastructure and Assets: Protecting VA 
infrastructure requires going beyond the VA-owned and VA-operated 
technology and systems within VA facilities to include the boundary 
environments that provide potential access and entry into VA by cyber 
adversaries.
      Enabling Effective Operations: Operating effectively 
within the cyber sphere requires improving governance and 
organizational alignment at enterprise, operational, and tactical 
levels (points of service interactions). This requires VA to integrate 
its cyberspace and security capabilities and outcomes within larger 
governance, business operation, and technology architecture frameworks.
      Recruiting and Retaining a Talented Cybersecurity 
Workforce: Strong cybersecurity requires building a workforce with 
talent in cybersecurity disciplines to implement and maintain the right 
processes, procedures, and tools.

    VA's Enterprise Cybersecurity Strategy is a major step forward in 
VA's commitment to safeguarding Veteran information and VA data within 
a complex environment. The strategy establishes an ambitious yet 
carefully crafted approach to cybersecurity and privacy protections 
that enable VA to execute its mission of providing quality health care, 
benefits, and services to Veterans, while delivering on our promise to 
keep Veteran information and VA data safe and secure.
    In addition, we have a large legacy issue that we need to address. 
VA is increasing our spending on security to $370 million, fully 
funding and fully resourcing our security capability for the first 
time. In addition, we are investing over $50 million to create a data-
management backbone.
                               Scheduling
    We recognize the urgent need for improvement in VA's appointment 
scheduling system. We are evaluating the Veteran Appointment Request 
(VAR) application and the VistA Scheduling Enhancement (VSE) through 
simultaneous pilot programs. We are also testing VAR at 2 facilities 
and VSE at 10 locations.
    VSE updates the legacy command line scheduling application with a 
modern graphical user interface. This capability reduces the time it 
takes schedulers to enter new appointments, and makes it easier to see 
provider availability. VSE provides critical, near-term enhancements, 
including a graphical user interface, aggregated facility views, 
profile scheduling grids, single queues for appointment requests, and 
resource management reporting.
    Our VSE Initial Operational Capability (IOC) sites are:

      Charles George VA Medical Center in Asheville, NC
      West Palm Beach VA Medical Center in Florida
      Chillicothe VA Medical Center in Chillicothe, OH
      VA Hudson Valley Health Care System in New York
      Louis Stokes Cleveland VA Medical Center in Cleveland, OH
      VA New York Harbor Health Care System in New York
      VA Salt Lake City Health Care System in Utah
      VA Southern Arizona Health Care System in Tucson, AZ
      James H. Quillen VA Medical Center in Mountain Home, TN
      Washington, DC VA Medical Center in Washington, DC

    VAR allows Veterans to request primary care and mental health 
appointments as face-to-face, telephone, or video visits by specifying 
three desired appointment dates. The software allows established 
primary care patients to schedule and cancel primary care appointments 
directly with their already-assigned Patient Aligned Care Team 
provider.
    VA schedulers tell us that they need a system focused purely on 
scheduling. VSE and VAR pilots are available now and show positive 
results in meeting the business requirements of our partners. In 
contrast, MASS includes additional features that add complexity, 
leading us to put MASS on a strategic hold while our VA team ensures 
that all requirements are met without undue processing difficulties.
                            VistA Evolution
    VA is committed to the continued success of VistA, our electronic 
health record (EHR).

Current State of VistA Evolution

    VistA Evolution is the joint VHA and OI&T program for improving the 
efficiency and quality of Veterans' health care by modernizing VA's 
health information systems, increasing data interoperability with the 
Department of Defense (DoD) and network care partners, and reducing the 
time it takes to deploy new health information management capabilities. 
We will complete the next iteration of the VistA Evolution Program-
VistA 4-in fiscal year (FY) 2018, in accordance with the VistA Roadmap 
and VistA Lifecycle Cost Estimate. VistA 4 will bring improvements in 
efficiency and interoperability, and will continue VistA's award-
winning legacy of providing a safe, efficient health care platform for 
providers and Veterans.
    VA takes seriously its responsibility as a steward of taxpayer 
money. Our investments in VistA Evolution continue to make our 
Veterans' EHR system more capable and agile. VA has obligated 
approximately $510 million in development funds to build critical 
capabilities into VistA since FY 2014, when Congress first provided 
specific funding for the VistA Evolution program. VA has obligated $151 
million in IT Sustainment funds and $110 million in VHA funds. The VHA 
funding supports the operational resources needed for requirements 
development, functional design, content generation, development, 
training, business process change, and evaluation of health IT systems.
    It is important to note that VistA Evolution funding stretches 
beyond EHR modernization. VistA Evolution funds have enabled critical 
investments in systems and infrastructure, supporting interoperability, 
networking and infrastructure sustainment, continuation of legacy 
systems, and efforts-such as clinical terminology standardization-that 
are critical to the maintenance and deployment of the existing and 
future modernized VistA. This work was critical to maintaining our 
operational capability for VistA. These investments will also deliver 
value for Veterans and VA providers regardless of whether our path 
forward is to continue with VistA, a shift to a commercial EHR platform 
as DoD is doing, or some combination of both.

Interoperability Certification

    At VA, we know that a Veteran's complete health history is critical 
to providing seamless, high-quality care and benefits. Interoperability 
is the foundation of this capability as it enables clinicians to 
provide Veterans with the most effective care and makes relevant 
clinical data available at the point of care. Access to accurate 
Veteran information is one of our core responsibilities. The Department 
is happy to report that, thanks to a joint VA and DoD effort, we expect 
that interoperability will be certified with DoD, as defined by the 
2014 National Defense Authorization Act, 8 months ahead of the end of 
the December 2016 deadline.
    For front-line health care teams, the most exciting products from 
VistA Evolution are the Joint Legacy Viewer (JLV) and the Enterprise 
Health Management Platform (eHMP).

Joint Legacy Viewer

    JLV is the basis for achieving interoperability. JLV is a clinical 
application that provides an integrated, chronological display of 
health data from VA, DoD, and community health care partners in a 
common data viewer. It provides a Veteran-centric view of the Veteran's 
health record rather than a facility-centric view. JLV's user base has 
outpaced our projections. As of March 27, 2016, JLV had 55,607 VA 
users, and is adding thousands of new users in VA and DoD every week. 
JLV also provides a near real-time view of DoD and VA health care data 
to benefits administrators, which facilitates the processing of 
Veterans' claims. All Veterans Benefits Administration offices have 
access to JLV and can use it to expedite claims.

Enterprise Health Management Platform

    JLV has been instrumental in connecting the VA and DoD health 
systems, but it does have limitations. We must do more to achieve data 
interoperability. eHMP will expand JLV's capabilities. eHMP is a 
modern, secure, configurable web-based health information platform that 
will expand JLV's capabilities. eHMP is a major cornerstone of building 
VistA into a Generation 3 EHR, building on the capability for 
clinically actionable, patient-centric data pioneered by JLV. By August 
2016, we will have a feed set up from VA to DoD through eHMP and the 
DoD Healthcare Medical System Modernization EHR. As the system matures, 
we will make it available to a broader base of clinicians. We will 
deploy eHMP with expanded capabilities in mid-2017. Clinicians will be 
able to write notes and order laboratory and radiology tests. During 
this deployment, eHMP will support tasking for team-based management 
and communication with improved communication and tracking. Instead of 
a static, ``one-size-fits-all'' desktop view, eHMP will allow 
clinicians to customize their workspaces to treat particular conditions 
more efficiently or best fit their clinical workflows.
    Upon completion, eHMP will support the following capabilities:
      Veteran-centric health care-eHMP will allow clinicians to 
tailor care plans to specific clinical goals and help Veterans achieve 
their health care goals.
      Team-based health care-eHMP will provide an interoperable 
care plan in which clinical care team members, including the patient, 
will understand the goals of care and perform explicit tasks to execute 
the plan. eHMP will also monitor tasks that are not completed as 
specified and escalate them to the appropriate team.
      Quality-driven health care-eHMP will support the 
diffusion of best practices, including evidence-based clinical process 
standardization. eHMP will collect data on how clinicians address 
conditions and power analytics to generate new evidence for better care 
and best practices.
      Improved access to health information-when fully 
deployed, eHMP will allow clinicians to input new data directly into 
the system. eHMP will integrate health data from VA, DoD, and community 
care partners into a customizable interface that provides a holistic 
view of each Veteran's health records.

    Fundamentally, this is about data, not software. Regardless of the 
software platform, we need to be able to access the right data at the 
right time. Health data interoperability with DoD and network providers 
is important-but it is equally important to understand that this is 
just one aspect of having a comprehensive profile to streamline and 
unify the Veteran experience.
    Using eHMP as a tool, health care teams will better understand 
Veterans' needs, coordinate care plans, and optimize care intensity in 
VA and throughout the
                    high-performing network of care.
    Looking to the Future
    Modernization is a process, not an end, and the release of VistA 4 
will not be the ``end'' of VA's EHR modernization. VistA 4 has always 
been scheduled to conclude in FY 2018, but there was always an 
intention to continue modernizing VA's EHR, beyond VistA 4, with more 
modern and flexible components.
    Due to the expansion of care in the community, a rapidly growing 
number of women Veterans, and increased specialty care needs, the need 
for more agility in our EHR has never been greater. We are looking 
beyond what is delivered with VistA 4 in FY 2018, and we are evaluating 
options for the creation of a Digital Health Platform to ensure that we 
have the best strategic approach to modernizing our EHR for the next 25 
years.
    To prepare for this new era in connected health, VA is looking 
beyond the EHR to a digital health platform that can better support 
Veterans throughout the health continuum. These factors drive the need 
for continuous innovation and press us to plan further into the future.
                    Consolidation of Community Care
    On October 30, 2015, VA provided Congress with a plan to 
consolidate all VA's purchased care programs. The plan included some 
aspects of the current Veterans Choice Program (VCP), established by 
section 101 of the Veteran's Choice Act, and incorporated additional 
elements designed to improve the underlying IT infrastructure and 
therefore, the delivery of community care. In this plan, VA identified 
several areas for needed IT solutions and improved IT infrastructure 
including care coordination, claims processing, and medical records 
management.
    Care Coordination: Robust care coordination requires a strong 
health IT platform. VA's future health IT platform will perform the 
following functions: maintenance of care plans; a user-friendly 
interface for Veterans and caregivers to see their information; and 
accurate, timely information for providers. Patient-facing and 
telehealth technologies will allow Veterans to view their health data, 
care plan, and update their health and medical needs. Providers will 
use VA's medical records exchange to support health information 
transactions, and care teams will use the platform to support Veterans 
in their health care experience.
    Claims Processing: VA will pursue simplified processes as it 
implements industry best practices. VA will focus on standardizing 
business rules and logic to support claims processing and improving 
interfaces and coordination with dependent systems (e.g., Eligibility). 
This solution will require a scalable, flexible claims platform that 
supports emerging, value-based care models and streamlines data 
maintenance, storage, and retrieval. This new claims solution will be 
integrated with Veteran Eligibility Systems, Authorization Systems, and 
standardized fee schedules to support auto adjudication. Integration 
with fee schedules will support new payment models and enable better 
tracking and billing integration with other health insurance (OHI). VA 
will also integrate the claims processing system with patient 
information, increasing VA's ability to efficiently bill OHI.
    Medical Records Management: As more Veterans receive care in the 
community, it is increasingly important to develop tools and solutions 
for easy access of health information between VA and community 
providers. To address this issue, VA will adopt a phased plan 
consistent with a systems approach to achieve a solution that is 
secure, efficient, effective, and standards based, using health 
information exchanges (HIEs). In the near-term, VA will focus on 
building upon current infrastructure to improve consistency, 
simplicity, and timeliness of information exchange. In the medium-term 
and long-term, VA plans to deploy a robust health information gateway 
and services, and share most clinical information through HIEs.
    As described previously, we are further implementing the web-based 
JLV to offer a simple, complete, and easy-to-understand view of VA and 
DoD patient data. Second, VA plans to integrate existing exchange 
services to receive and store standards-based electronic documents, 
such as Continuity-of-Care Documents. This reduces the use of paper and 
builds on current VA investments. Third, VA plans to expand 
partnerships with HIEs and use direct secure email protocols. VA plans 
to continue to work with the critical Federal stakeholders to expand 
the usage of national standards for clinical terminology and data 
elements. As VA continues to evaluate the future solutions, VA will 
consider the needs of Veterans, community providers, and VA staff to 
ensure that any solution will support the future delivery of community 
care.
    In the medium- and long-term, VA plans to create an electronic, 
secure, efficient, effective, and standards-based environment in 
compliance with relevant privacy laws affecting Veterans and their 
beneficiaries. VA plans to implement a health information gateway and 
associated services and share most clinical information through HIEs, 
when available. Currently, HIEs reach 40 percent of U.S. hospitals and 
serve approximately one third of the U.S. population.
    Providers will be able to view, append, and share clinical and 
administrative information electronically through a VA health 
information gateway and associated services. Veteran clinical and 
administrative information will then be transferred back to VistA. 
VistA will incorporate an industry-leading information model, 
terminology normalization, knowledge enrichment, and search indexing 
for VA, Federal, and HIE partner sources. Available health information 
will drive enterprise-wide analytics efforts for process improvement.

Community Care IT Implementation Strategy

    The New VCP will be implemented through a system of systems 
approach. A system-of-systems approach involves the design, deployment, 
and integration of meta-systems that are themselves composed of complex 
systems, which are integrated to deliver the desired functionality and 
end-to-end user experience. Consistent with this approach, VA will 
begin by understanding the desired experience and required outcomes for 
Veterans, caregivers, VA staff, and community providers. VA will then 
examine all the components necessary to achieve the desired outcomes 
and understand how various component systems will integrate into the 
broader VA health care system and funding environment. To successfully 
implement this system-of-systems approach requires legislative changes, 
resources, and a budget.
    Implementation of the system-of-systems approach will be executed 
through rapid cycle deployment using agile methodologies. This will 
allow VA to fix the most pressing issues with community care today, 
while making continuous updates to promote a learning health system 
that evolves with the needs of the Veteran population. This approach 
enables VA to implement an integrated system design that allows people, 
processes, facilities, equipment, and organizations to deliver high-
quality, high-value care.
    Based on preliminary analysis of Veteran needs and the desired 
Veteran experience, VA has determined that the component systems of the 
New VCP are: 1) Integrated Customer Service Systems; 2) Integrated Care 
Coordination Systems; 3) Integrated Administrative Systems 
(Eligibility, Patient Referral, Authorization, and Billing and 
Reimbursement); 4) High-Performing Network Systems; and 5) Integrated 
Operations Systems (Enterprise Governance, Analytics, and Reporting).
    In order to execute a program of this scope and scale, VA has 
outlined a transition plan consistent with the system-of-systems 
approach to sequence the design, development, and delivery of the New 
VCP. In developing the transition plan, VA considered recommendations 
from stakeholder feedback and the Independent Assessment Report. While 
the transition plan lays out a path forward for the program, the 
complexity of the change will require development of detailed 
implementation plans. In addition, any changes to the New VCP described 
in this plan, as a result of input from Congress or other stakeholders, 
will impact the activities described.
    Transitions of this magnitude take years to design and implement; 
therefore, this plan is organized into three phases.

      Phase I can start immediately and will last 1 year, 
assuming available resources and required legislative and regulatory 
changes. This phase will focus on the development of minimum viable 
systems and processes that can meet critical Veteran needs without 
major changes to supporting technology or organizations.
      In Phase II, also lasting approximately 1 year, VA will 
enhance the changes implemented in Phase I through interfaced systems 
that will appear seamless to Veterans and community providers, but will 
largely continue to employ existing infrastructure and technology.
      Phase III will be a multi-year effort. In Phase III, VA 
will begin deploying an integrated system-of-systems approach that will 
support changes in Phases I and II and enable a seamless experience 
across VA and community care for all stakeholders. VA also will collect 
and analyze data on the progress and performance of the implementation 
to identify opportunities for continuous improvement.

    Through all phases of the transition, VA will build a foundation 
for a health care system that can respond to the evolving needs of 
Veterans and the changing health care landscape at VA and in the 
community.

Phase I: Develop Implementation Plan and Implement Minimum Viable 
    Solutions and Processes

    During Phase I, VA has begun to develop an implementation plan that 
articulates a clear path forward for each system component across the 
three phases. This will include decisions about long-term system 
changes and outcomes of make/buy analyses for clinical and 
administrative technology solutions and network development. Phase I 
will also include the implementation of minimum viable systems and 
processes for the Veteran, community provider, and VA staff experience. 
These systems will focus on improvements that can be executed without 
major changes to organizations or technology.

Phase II: Implement Interfaced Systems and Process Changes

    During Phase II, VA will implement interfaced systems and 
associated processes that will enable a seamless experience for 
Veterans and community providers. Interfaces will employ existing 
resources and technology infrastructure, but will appear integrated to 
end users. VA will need support from Congress to ensure that this 
implementation takes place. Simultaneously, VA will continue to develop 
fully integrated solutions that will be deployed in Phase III.

Phase III: Deploy Integrated Systems, Operate High-Performing Network, 
    and Make Data-Driven Improvements

    During Phase III, VA will begin to deploy integrated systems, 
including process and organization changes that will enable a seamless 
Veteran, community provider, and VA staff experience. These systems 
will build on changes in Phases I and II and will support collection of 
quality, value, and performance data for continuous improvements. 
Similar to Phase II, VA will rely on Congress to support Phase III.

Conclusion

    VA is at a historic crossroad and will need to make bold reforms 
that will shape how we deliver IT services and health care in the 
future, as well as improve the experiences of Veterans, community 
providers, and VA staff. Throughout this transformation, our number one 
priority has and will always be the Veteran-ensuring a safe and secure 
environment for their information and improving their experience is our 
goal.
    Additionally, to make these reforms, as we have discussed in a 
series of hearings on the October 30, 2015, Consolidation of Care 
report, VA will need short- and long-term assistance with legislative 
authorities and resources. Transformation of VA's community care 
program will address gaps in Veterans' access to health care in a 
simple, streamlined, and effective manner. This transformation will 
take into account the interdependent nature of external and internal 
factors involved in VA's health care system.
    As with all issues, VA strongly values the input and support of all 
its stakeholders. We realize the vital role they play in assisting us 
in providing timely, high-quality care to Veterans, and we look forward 
to continued open dialogue.
    This concludes our testimony, and we are prepared to answer any 
questions you or other Members of the Committee may have.

                                 -------
                                 
                       Statements For The Record

                          THE AMERICAN LEGION
    It is no simple task to reform the Information Technology (IT) 
enterprise of an organization the size of the Department of Veterans 
Affairs (VA). Compounding this challenge is the need to mesh reform 
with the larger goal of a national system in which health data flows 
seamlessly and securely, not only between Federal agencies, but between 
public and private health care systems too.
    Chairmen Coffman and Benishek, Ranking Members McLane-Kuster and 
Brownley and distinguished members of the Subcommittees on Oversight 
And Investigations and Health, on behalf of National Commander Dale 
Barnett and The American Legion; the country's largest patriotic 
wartime service organization for veterans, comprising over 2 million 
members and serving every man and woman who has worn the uniform for 
this country; we welcome this opportunity to comment on ``Evaluating VA 
Information Technology.''
    When a patient moves from one health system to another, there's no 
guarantee his or her electronic medical records are compatible with the 
new systems. This is an issue the nation is struggling with, both in 
the private and public sectors. Much attention has been given to the 
issue of examining the Departments of Defense (DOD) and Veterans 
Affairs information technology with an emphasis on the departments' 
efforts to develop and implement an interoperable electronic health 
record (EHR).
    The 2008 National Defense Authorization Act (NDAA) directed DOD and 
VA to jointly develop and implement a ``fully interoperable'' EHR, 
creating an Interagency Program Office to facilitate and coordinate the 
Departments' efforts. In July 2015, DOD awarded a $4.3 billion contract 
to upgrade the Armed Forces Health Longitudinal Technology Application, 
while the VA continues to modernize and evolve its open-source 
platform, the Veterans Health Information Systems and Technology 
Architecture (VISTA). However, problems exist for the EHR platform. The 
EHR program has been listed on the GAO's high risk list for 2015. 
Additionally, recent inspectors general audits of both departments' 
Federal Information Security Management Act compliance identified 
weaknesses and deficiencies in cybersecurity.
    Just last month, The American Legion submitted written testimony to 
the House Subcommittee On Information Technology, Committee On 
Oversight And Government Reform on ``VA Cybersecurity And IT 
Oversight.'' \1\ The hearing examined VA's implementation of the 
Federal Information Security Management Act and Federal Information 
Technology Acquisition Reform Act (FITARA), as well as specific IT 
investments, including the modernization of the VISTA system. \2\
---------------------------------------------------------------------------
    \1\ http://www.legion.org/legislative/testimony/231677/va-
cybersecurity-and-it-oversight
    \2\ https://oversight.house.gov/hearing/va-cybersecurity-and-it-
oversight/
---------------------------------------------------------------------------
    VA is currently engaged in an effort to modernize VISTA. The 
centerpiece of VA's modernization program, referred to as VISTA 
Evolution, is an electronic health record (EHR) that should be 
interoperable with the Department of Defense, as well as private sector 
health care providers. The VA received an overall grade of `C' on the 
Committee's 2015 FITARA Implementation Scorecard, with F's on both Data 
Center Consolidation and IT Portfolio Review Savings. Additionally, the 
VA Office of Inspector General has found repeat ``material weaknesses'' 
in the VA's cybersecurity posture.
    In March of 2013, over a year before the scheduling wait time 
scandal in Phoenix, Arizona would open a wider window of scrutiny onto 
the entire VA healthcare system, The American Legion was raising 
concerns about problems with VA's scheduling software. In a hearing 
before this committee's Oversight and Investigation (O&I) Subcommittee, 
The American Legion sounded the alarm that contrary to reported 
numbers, veterans were waiting far longer for care and ``figures are 
being manipulated by employees to look better, statistics such as VA's 
reported 94 percent of primary care appointments within the proper 
period, mean very little.'' \3\
---------------------------------------------------------------------------
    \3\ Testimony of Roscoe Butler, Waiting for Care: Examining Patient 
Wait Times at VA March 14, 2013
---------------------------------------------------------------------------
    A year after our testimony, VA found itself embroiled in the center 
of a nationwide scandal as concerns that advocates such as The American 
Legion had raised in the past became a staple of nightly news reports. 
At the heart of this scandal was the accusation that, exactly as The 
American Legion had predicted a year previous, figures were being 
manipulated to hide wait times through the use of offline, paper lists 
that avoided the public record of the computer scheduling software and 
its automatic tracking of wait times.
    VA would see massive leadership change over the summer of 2014, but 
would still struggle with an IT plan to fix the problems.
    In 2013 The American Legion noted a large portion of the problem 
was that previous attempts to replace the software had wasted money to 
no result and that there was not plan in place at the time to fix the 
problems. The American Legion stated:

    As we are now a decade into the 21st Century, The American Legion 
believes that VA should also begin implementing 21st Century solutions 
to its problems. In 1998, GAO released a report that highlighted the 
excessive wait times experienced by veterans trying to schedule 
appointments, and recommended that VA replace its VistA scheduling 
system. \4\ To address the scheduling problem, the Veteran's Health 
Administration (VHA) solicited internal proposals from within VA to 
study and replace the VistA Scheduling System, with a Commercial Off-
the-Shelf (COTS) software program. VA selected a system, and about 14 
months into the project they significantly changed the scope of the 
project from a COTS solution to an in-house build of a scheduling 
application. After that, VHA ended up determining that it would not be 
able to implement any of the planned system's capabilities, and after 
spending an estimated $127 million over 9 years, The American Legion 
learned that VHA ended the entire Scheduling Replacement Project in 
September 2009. \5\ We believe that this haphazard approach of fits and 
starts is crippling any hope of progress. It has now been over three 
years since VHA cancelled the Replacement Scheduling Application 
project, and as of today, The American Legion understands that there is 
still no workable solution to fixing VA's outdated and inefficient 
scheduling system.

    \4\ U.S. Medicine Magazine, VA Leadership Lacks Confidence in New 
$145M Patient Scheduling System, May 2009
    \5\ GAO-10-579, Management Improvements Are Essential to VA's 
Second Effort to Replace Its Outpatient Scheduling System, May, 2010
---------------------------------------------------------------------------
    In the summer of 2014 VA announced plans to replace the software, 
going back to the original idea of Commercial Off the Shelf (COTS) 
software to accomplish that end. However, by September reports out of 
VA estimated the COTS plan would not roll out until 2020, over half a 
decade down the road. \6\ VA would ultimately backtrack from this and 
revise that estimate down to 2017; however the move did little to 
ensure confidence in the ability to rectify the very real problems that 
the Phoenix scandal had highlighted.
---------------------------------------------------------------------------
    \6\ No New VA Patient Schedule System Until 2020 - Bob Brewin, 
NEXTGOV September 26, 2014
---------------------------------------------------------------------------
    Recent leadership changes, including the addition of Dr. David 
Shulkin as the Undersecretary for Health and LaVerne Council as VA's 
Assistant Secretary for Information and Technology and Chief 
Information Officer, have been promising moves and The American Legion 
has generally been impressed with the leadership team as they have 
worked to move forward on this issue.
    While briefing VSOs on plans for future integration upgrades, VA 
shared ideas about a plan to move to an online scheduling system where 
veterans could schedule their own appointments. Because our Four 
Pillars include veterans issues as well as issues related to a strong 
national defense, The American Legion is well versed in both VA 
healthcare as well as TRICARE and military healthcare and was able to 
point out the many problems that arose when TRICARE implemented a 
similar scheduling system online.
    Without scheduling personnel to oversee the process, and manage 
appointments, doctors' calendars rapidly overfill, clogging the system 
and making it impossible for patients to find time on the schedule. 
With a scheduling specialist available to determine what the type of 
appointments are and whether there can be multiple patients scheduled 
during certain time periods, the system is reduced to inelegant, brute 
force blocks of time, with little regard to whether doctors and support 
staff could handle different volumes of patients. This is just one 
example of how a strong and transparent partnership between VA and VSO 
stakeholders improves services to veterans.
    We are hopeful that the dialogue with The American Legion and other 
groups will help guide VA moving forward with plans to reform the 
scheduling software. There were serious problems with the way VA had 
gone about business scheduling appointments for veterans. Under the old 
system, while veterans were left out on secret lists, few alarm bells 
were raised inside the system because employees had developed pencil 
and paper workarounds to the computer solutions VA had implemented. It 
took the combined pressure of groups like The American Legion and brave 
whistleblowers within VA who cared deeply about the safety of veterans 
to step forward and identify the problem.
    We are now at a stage where VA is engaging with the very people 
whose membership utilize VA facilities across the country on a daily 
basis and are best in a position to identify problem areas. Hopefully 
VA is listening to these critical stakeholders.

New Veterans Choice Program

    VA's current community care programs still utilize labor-intensive 
business processes that are too reliant upon manual data input, prone 
to errors and processing delays. The current system is a decentralized 
and highly manual process. \7\ The New VCP plan proposes integrating 
most of VA's community care programs into one single program that would 
be seamless, transparent, and beneficial to enrolled veterans. The New 
VCP envisions a three-phased approach to implement these changes to 
support improved health care delivery for enrolled veterans.
---------------------------------------------------------------------------
    \7\ Plan to Consolidate Programs of Department of Veterans Affairs 
to Improve Access to Care - Oct 2015
---------------------------------------------------------------------------
    The first phase will focus on the development of minimum viable 
systems and processes that can meet critical veteran needs without 
major changes to supporting technology or organizations. Phase II will 
consist of implementing interfaced systems and community care process 
changes. Finally, Phase III will include the deployment of integrated 
systems, maintenance and enhancement of the high-performing network, 
data-driven processes, and quality improvements.
    To improve the accuracy of claims and reimbursement processing, the 
2015 Independent Assessment Report recommended that VA employ industry 
standard automated solutions to bill claims for VA medical care 
(revenue) and pay claims for Non-VA Health Care (payment). \8\ VA 
states its New VCP will focus on operational efficiencies, to include 
standardized billing and reimbursement, as well as geographically 
adjusted fee schedules that are tied to Medicare, as deemed 
appropriate. These foci will make it easier and more appealing for 
community health care providers to partner with VA.
---------------------------------------------------------------------------
    \8\ VA Independent Assessment - Sept.2015
---------------------------------------------------------------------------
    The American Legion supports VA developing a 21st Century claims 
and reimbursement processing system that is rules-based, and to the 
extent possible, eliminates as much human intervention as possible. The 
system must eliminate the guess work out of the claims and 
reimbursement process and establish an error-free claims process that 
is responsive to veteran's needs.
    Therefore, we are pleased to see that VA proposes to implement a 
claims solution which is able to auto-adjudicate a high percentage of 
claims, enabling VA to pay community health care providers promptly and 
correctly and to move to a standardized regional fee schedule, to the 
extent practicable for consistency in reimbursement.
    Additionally VA proposes to simplify eligibility criteria so 
veterans can easily determine their options for community care, 
streamline the referral and authorization process to enable more timely 
access to community care, and standardize business processes to 
minimize administrative burden for community providers and VA staff. 
Improvements in how VA processes claims will enable VA to reimburse 
community providers in a timely and efficient fashion.
    The American Legion understands VA's New VCP is a huge undertaking 
and understands the plan will take time to fully implement, 
particularly the IT component required to auto-adjudicate a high 
percentage of claims. However, we do not believe Congress should 
continue to provide VA an open check book without any assurance from VA 
that their IT plan will work. Congress must require VA to not only 
provide an IT plan, but provide some proof that the claim and 
reimbursement system will work. Too often Congress has authorized 
funding in support of process improvement initiatives like CoreFLS, and 
VA's scheduling system, to name a few, without any deliverables, 
resulting in wasted tax payer dollars that can never be recovered. In 
these situations, the ones who are impacted are our nation's veterans 
who are calling out to Congress to fix the system.
    An immediate remedy would be for VA to authorize payment for any 
Non-VA claim immediately upon receipt of a valid bill for health care 
services that a veteran receives. So, we were pleased to hear the 
recent VA announcement that the TPA's are now authorized to begin 
paying any Non-VA health care claim under the VCP without first 
obtaining the veterans medical record from the Non-VA health care 
provider. The American Legion applauds VA for initiating this action. 
This will prevent stories like the November 2015 Miami Herald article 
about Florida hospitals trying to get the Department of Veterans 
Affairs to pay about $134.4 million in outstanding claims for medical 
services they provided to veterans. \9\ If it is determined VA overpaid 
for the care and services, cost recovery should occur after VA has 
verified the care and services provided to veterans receiving that 
health care. Of course, ensuring that records are ultimately returned 
to VA is very important and we look forward to hearing more about how 
VA plans to achieve this.
---------------------------------------------------------------------------
    \9\ Florida Hospitals: VA owes $134 million in unpaid claims: Miami 
Herald; November 17, 2015
---------------------------------------------------------------------------
    Finally, VA's IT systems need to be much more interoperable with 
the private sector, and veterans should be able to access their records 
from any setting. The overarching goal should be for the VA to use 
technology and health information to improve the health and well-being 
of veterans in ways that makes the information accessible when and 
where it matters most.
    VA needs to develop a coordinated IT infrastructure for appointment 
scheduling, coding, billing, claims payment and other core VHA business 
processes, which include the automation of claims payment. This is 
essential to expanding veteran care with community providers. Billing 
and payment systems must be efficient.
    The entire American healthcare economy is struggling to figure out 
ways to develop interoperable electronic healthcare records. If this 
nation is to have truly 21st century healthcare, this concept in both 
the public and private sector is essential. VA can take the lead in 
this field, as they have in so many fields of healthcare in providing 
true innovation. VA healthcare pioneered electronic healthcare records 
with VISTA. VA healthcare pioneered improvements in modern heart 
surgery, in the treatment of Posttraumatic Stress Disorder, and 
integrated care. There should be no reason they should not be 
trailblazers in this arena if properly supported.
                               Conclusion
    The American Legion is deeply committed to working with VA to 
ensure that not only are these IT challenges worked out, but that any 
and all challenges are resolved to help protect the healthcare system 
designed specifically to service the unique needs and challenges of the 
veterans' population. Consistently, veterans speak highly of the high 
quality of care they receive when they can see their VA providers, and 
note how well VA understands their unique sacrifices and military 
culture when they are treating them. Therefore it is doubly important 
that we solve these challenges and make it easier for veterans to 
access the system best suited to treat them.
    The American Legion thanks this committee for the opportunity to 
explain the position of the over 2 million veteran members of this 
organization. For additional information regarding this testimony, 
please contact Mr. Warren J. Goldstein at The American Legion's 
Legislative Division at (202) 861-2700 or [email protected]

                                 [all]