    [Senate Hearing 114-788]
    [From the U.S. Government Publishing Office]

         MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
                      APPROPRIATIONS FOR FISCAL YEAR 2017

                                  ----------

                            WEDNESDAY, JULY 13, 2016

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:31 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Mark Kirk (chairman) presiding.
        Present: Senators Kirk, Hoeven, Boozman, Capito, Cassidy,
    Tester, and Udall.

                         DEPARTMENT OF VETERANS AFFAIRS

    STATEMENT OF HON. LAVERNE H. COUNCIL, ASSISTANT
                SECRETARY FOR INFORMATION AND TECHNOLOGY
                AND CHIEF INFORMATION OFFICER
    ACCOMPANIED BY:
            DAVID W. WALTMAN, CHIEF INFORMATION STRATEGY OFFICER, VETERANS
                HEALTH ADMINISTRATION
            DR. JONATHAN R. NEBEKER, DEPUTY CHIEF MEDICAL INFORMATION
                OFFICER, VETERANS HEALTH ADMINISTRATION

                     OPENING STATEMENT OF SENATOR MARK KIRK

        Senator Kirk. This hearing is to review the Department's
    health record and progress towards full interoperability with
    the Department of Defense (DOD).
        Last year for the first time, the GAO put veterans'
    healthcare on its high risk list for programs that are likely
    to experience fraud, waste, abuse, and mismanagement. The
    Government Accountability Office (GAO) cited information
    technology challenges, one of the five reasons why veterans'
    healthcare was on this list.
        I want to share with you my vision for going forward here,
    that we are aiming for. Whenever a soldier, sailor, airman
    leaves Active Duty and becomes a veteran, we should have a 100-
    percent seamless transmission of their health records to the
    VA.
        Here is a data point. We have about 250,000 servicemembers
    leave the DOD and become veterans every year. That works out to
    about 700 per day, a data flow which is well within the
    possibility of everybody to cover.
        We want to make sure there is a seamless continuity of
    care. I have a friend now who is navigating the Department of
    Veterans Affairs (VA) disability system, she was deployed in
    Iraq, and had 38 separate combat events, and wanted to make
    sure all of those are documented and transferred and are in her
    disability petition.
        Number two, we should also use the combined size of the DOD
    and VA in the marketplace to establish a worldwide standard for
    health medical records, encompassing 22 million people. I
    figure about 2 million come from DOD and 25 million come from
    VA. To have that 27 million people all as a core of people
    covered by one electronic health record (EHR) standard, all
    open source code would allow us to make sure that the industry
    now has one Federal standard.
        The rock candy mountain here is to make sure the system is
    covering so many patients that the industry follows, and we
    make sure the medical record industry is established along the
    lines of a U.S. Code and U.S. standards.
        In my State of Illinois, we have Motorola that made the
    Android System all open source code. Luckily for them, it was
    the right decision. The marketplace developed 70,000 apps for
    the Android system to make it the most flexible and user
    friendly in the world. We want to make sure that open source
    environment allows us to create medical records for people with
    U.S. standards.
        I think we are on our way towards a several billion dollar
    industry now based on this work between DOD and VA.
        I just talked yesterday with the leading company that is in
    this space. They told me when I talked with Judy Faulkner who
    is one of the founders of a company called Epic that now
    employs 5,000 people in Tammy Baldwin's State--they cover a
    vast number of the patients' medical records in my State of
    Illinois.
        She said there are really exciting things in this field to
    gather all those data and do analytics on that. She was
    particularly excited about Epic's sepsis analytics, which she
    said could be traced to the saving of 54,000 lives, patients
    who are liable for sepsis.
        Using these analytics, we could reach a new 22nd century
    level of care for veterans. I want to make sure analytics are a
    deep part of this electronic healthcare revolution that we have
    for VA and DOD.
        Let me turn it over to my good friend, Mr. Tester.

                        STATEMENT OF SENATOR JON TESTER

        Senator Tester. Thank you, Mr. Chairman. Thank you for your
    leadership on this subcommittee. We very much appreciate it.
    Thank you, Secretary Council, and Ms. Melvin, and Dr. Thompson
    for being here today for this hearing, I appreciate the work
    you do.
        We all know and we agree that accountability of VA is
    critically important, whether we are talking about delivering
    quality and timely care or whether we are talking about IT
    initiatives such as electronic health records and scheduling
    systems. We live in the 21st century, and our IT systems should
    reflect that.
        I do look forward to hearing from you about the progress
    made and the challenges involved with VistA, electronic health
    record systems, and other key IT programs. We are obviously
    very interested in the direction VA is heading in terms of
    modernizing VistA, and whether we are talking about going to a
    commercial off-the-shelf system or developing a hybrid of the
    two. Whatever decision is made, we will have long-ranging
    ramifications not only for the VA and veterans but also for the
    American taxpayer who will have to foot this bill.
        Although we are focused on electronic health records, we
    realize that EHR is only one component of a much broader IT
    modernization effort and conversation. Electronic record
    sharing is a great asset for both clinicians and patients, but
    only if the veteran can get an appointment in the first place,
    and that remains a huge challenge for many veterans in my State
    and across this country.
        In fact, scheduling difficulties are the top complaint that
    I hear from folks in Montana, and I hear a lot of them. I can
    tell you that the current system is not going to cut it, so I
    am concerned that the current medical appointment scheduling
    system plan is on hold, if it is not the right plan, then it
    should be revised or replaced, but it cannot be put on the back
    burner. We need to fix it. We need to fix it today.
        So, I look forward to hearing about how the VA is working
    to devise and implement a better plan, and when that will
    happen. Cybersecurity is another urgent priority. As the VA's
    IT system has to provide for greater interoperability among VA
    providers, private sector providers, and the Department of
    Defense, cybersecurity must also evolve and adapt.
        The challenges facing the VA are formidable, and they are
    only going to become more complicated with time.
        I am also a member of the Senate Veterans' Affairs
    Committee, and I am proud that Committee has advanced
    legislation, the Veterans First Act, that includes a lot of
    critical provisions to empower the VA to better serve our
    veterans. As we all know, that bill is being held up, just the
    latest example of Senate dysfunction. Nonetheless, Congress can
    actually be a constructive partner in this effort.
        As the pressure grows on the VA to provide seamless medical
    record sharing and scheduling, I fully expect you to keep us
    apprised of your efforts and your challenges. That line of
    communication is critical as we move forward, and it is
    critical today.
        Again, I want to thank you for your service, and I look
    forward to hearing your testimony. Once again, thank you, Mr.
    Chairman.
        Senator Kirk. Thank you. We want to welcome our witnesses
    here. We have Valerie Melvin, the Director of Information
    Management and Technology Resources Issues at the Government
    Accountability Office; and Dr. Lauren Thompson, Director of the
    DOD/VA Interagency Program Office in the Department of Defense;
    and the Honorable LaVerne Council, with the Department of
    Veterans Affairs, the VA's Chief Information Officer. We also
    have Mr. David Waltman and Dr. Jonathan Nebeker, both with the
    Veterans Health Administration (VHA).
        Let's proceed and have Ms. Council begin.

                  SUMMARY STATEMENT OF HON. LAVERNE H. COUNCIL

        Ms. Council. Chairman Kirk, Ranking Member Tester,
    distinguished subcommittee members, thank you for the
    opportunity to discuss how the Office of Information and
    Technology (OI&T) is transforming technology that we deliver to
    support our veterans.
        I am joined today by Mr. David Waltman, who is VHA's Chief
    Information Strategy Officer, and Dr. Jonathan Nebeker, VHA's
    Deputy Chief Medical Informatics Officer.
        As described in our media review, we have shifted our focus
    to outcomes versus activity by emphasizing transparency,
    accountability, innovation, and team work. We are building on
    the legacy of VHA innovations and maintaining a united
    partnership between medicine and technology. Through
    implementation of a prioritized set of strategic initiatives
    across our now, near, and future time horizons, we are focused
    on providing a consistent high quality experience to our users
    and veterans.
        We are evolving into a dynamic proactive posture. We are
    leaning forward, simplifying and standardizing our
    infrastructure through buy first and Cloud-based delivery
    models, utilizing Cloud-based technology will allow us to buy
    IT services while consolidating our infrastructure and driving
    the market to facilitate innovation.
        Through implementation of our new strategic sourcing
    function, we will be poised to take advantage of a wealth of
    innovation that already exists in the marketplace to reduce
    development overhead costs and speed delivery of services to
    our veterans.
        For the first time, we have IT portfolios in place for all
    administrations. We have filled all of our new IT account
    managers or ITAM positions. The ITAMs keep us connected to our
    partners and ensure that we are meeting their needs.
        I am proud to report that over the last year, VA's OI&T's
    rating was upgraded from 19th to 5th, out of 24 Federal
    agencies, in the recently released OMB Benchmarks for IT
    Customer Satisfaction.
        We have made strong headway toward modernizing how the VA
    does business but we are also recognizing that change is not
    easy and modernization is not a one time act. It requires a
    relentless focus on execution and constant emphasis on
    impactful outcomes.
        In addition, we are transforming OI&T's leadership team,
    with 74 percent of OI&T's executive leadership being in new
    roles or they are new to the agency.
        We are on track with our plans to close 100 percent of the
    Office of Inspector General's (OIG's) 2015 recommendations by
    the end of 2017, of our Federal Information Security
    Modernization Act (FISMA) material weakness, and in July 2015,
    VA had 267,000 accounts with elevated privileges, which allows
    special access to VA systems. We have reduced that number of
    accounts by 95.5 percent, exceeding all original expectations.
        To reduce complexity and manage access, we are
    standardizing our device policy to no more than two devices,
    such as a Smartphone and laptop for each staff member. Since
    March 2015, our team has identified, corrected and remediated
    21 million critical and high vulnerabilities utilizing Nexus
    monthly scans and enterprise patching.
        We have developed an IT/non-IT policy to ensure IT dollars
    are spent appropriately. We have reduced the number of
    applications by 500 percent, closing off any potential path for
    attackers. We have our quality and compliance function, and we
    are finalizing our governance, structure and strategic sourcing
    function.
        OI&T is committed to safeguarding our veterans'
    information, and tools, technology, and people of the highest
    caliber are required. We have increased our cybersecurity
    funding to $370 million, and I would like to thank this
    subcommittee for helping us to fully resource our cybersecurity
    capability for the very first time.
        We recognize that effective cybersecurity requires
    vigilance and a security conscious culture. We take security
    risks seriously. We are addressing all key FISMA findings, and
    we are prioritizing our efforts to close the most critical
    risks first.
        We know that a veteran's complete health history is
    critical to providing seamless, high-quality integrated care
    and benefits. We are happy to say on April 8, we certified an
    interoperative with DOD in accordance with the National Defense
    Authorization Act's (NDAA's) section 713(b)(1), well ahead of
    the December 2016 deadline.
        Last year on July 6, 2015, I was sworn in as the Assistant
    Secretary and CIO of OI&T. After 1 year, I have learned a lot
    about the purpose, passion, and drive it takes to make change
    in a governmental agency. I have also experienced the true grit
    of the people who are dedicated to the mission of serving our
    veterans.
        Mr. Chairman and members of the subcommittee, thank you
    again for the opportunity to discuss our progress with you. I
    look forward to continuing the conversation, and am happy to
    take any questions you might have at this time.
        [The statement follows:]
                 Prepared Statement of Hon. LaVerne H. Council
        Good morning,

        Chairman Kirk, Ranking Member Tester, distinguished members of the
    subcommittee, 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 provide
    the best possible service to our VA business partners and our Nation's
    veterans. I will also discuss scheduling, medical record sharing, and
    cyber security initiatives at the Department.
        In order to successfully carry out these major IT initiatives and
    the department's consolidation of community care programs, 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.
        I am joined by Mr. David Waltman, VHA's Chief Information Strategy
    Officer, and Dr. Jonathan Nebeker, VHA's Deputy Chief Medical
    Informatics Officer.
        The Veterans Health Administration (VHA) and the Office of
    Information & Technology (OI&T) are essential partners in delivering
    quality service to our veterans. Meeting the demands of 21st century
    veterans requires an interconnected system of systems, based on a
    single platform, which supports an electronic health record (EHR) as
    one of several components.
        IT plays a critical role in enabling care for our Nation's
    veterans. VA's current EHR modernization efforts focus on delivering
    the tools for clinicians to provide more comprehensive, patient-
    centered care and will support VA's progress to a digital health
    platform.
        We have made substantial progress in delivering new capabilities
    leveraging VistA, the VA Health System's EHR, while also strategizing
    for our future needs. Our efforts to modernize the VA's EHR and our
    plans for the digital health platform are not mutually exclusive. The
    success of the digital health platform is not dependent on any
    particular EHR.
                        vista evolution/interoperability
    Current State of VistA Evolution
        VistA Evolution is the joint VHA and OI&T program for improving the
    efficiency and quality of veterans' healthcare 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 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 healthcare 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 IT Development funds to build critical
    capabilities into VistA since fiscal year 2014, when Congress first
    provided specific funding for the VistA Evolution program. In addition,
    VA has obligated $151 million in IT Sustainment funds and $110 million
    in VHA funds for VistA Evolution. 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
        We know that a veteran's complete health history is critical to
    providing seamless, high-quality integrated 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, on April 8, 2016, we jointly certified, to the House and Senate
    Committees on Appropriations, Armed Services, and Veterans' Affairs
    that we have met the interoperability requirement of the fiscal year
    2014 National Defense Authorization Act (NDAA) Section 713(b)(1). We
    have not stopped our modernization efforts, as we envision further
    enhancements that we know are necessary for greater efficiency.
        For front-line healthcare teams, the two most exciting products
    from VistA Evolution are the Joint Legacy Viewer (JLV) and the
    Enterprise Health Management Platform (eHMP). JLV is a clinical
    application that provides an integrated, chronological display of
    health data from VA and DOD providers in a common data viewer. VA and
    DOD clinicians can use JLV to access, on demand, the health records of
    veterans and Active Duty and Reserve servicemembers. JLV provides a
    patient-centric, rather than facility-centric view of health records in
    near real time. Veterans Benefits Administration (VBA) offices have
    access to JLV and can use it to expedite claims in certain situations.
        As of July 7, 2016, JLV had more than 198,000 authorized users in
    VA and DOD together, including 158,159 authorized VA users. The team is
    authorizing several thousand new users in VA each week. In VA, more
    than 11,000 VBA personnel are authorized to use JLV to help process
    claims.
        The process for granting access to JLV is both simple and secure.
    JLV allows us to monitor access and usage by capturing logins, records
    viewed, activities by users, and transactions per hour. In the interest
    of privacy, security, and safety, JLV is restricted to healthcare
    providers and benefits administrators. Beneficiaries cannot access JLV,
    but this in no way affects their rights to copies of their health
    records upon request. We simultaneously maintain tight controls over
    the system and ensure efficient access to clinicians and benefits
    administrators who need it to do their jobs.
        JLV has been a critical step in connecting VA and DOD health
    systems, but it is a read-only application. Building on the
    interoperability infrastructure supporting JLV, the Enterprise Health
    Management Platform (eHMP) will ultimately replace our current read-
    write point of care application. The current application, called the
    Computerized Patient Record System, or CPRS, has been in use since
    1996. CPRS served VA for many years as an industry leading point of
    care tool for providers, but it has many limitations for modern care
    delivery.
        eHMP will overcome these limitations, and provide a modern web
    application and clinical data services platform to support veteran-
    centric, team-based, quality driven care. eHMP will also natively
    support interoperability between VA, DOD and community health partners.
    We are deploying an initial read only version of eHMP now, and will
    begin deploying eHMP version 2.0 with write-back capabilities in the
    second quarter of fiscal year 2017. Clinicians will be able to write
    notes and order laboratory and radiology tests in version 2.0. eHMP 2.0
    will also support tasking for team-based management and communication
    with improved tracking to ensure follow through on tasks.
        Veterans will benefit from eHMP in several ways. For example, eHMP
    will provide a complete view of a veteran's health history from all
    available VA, DOD and community provider sources of information. This
    will help providers develop a more complete picture of a veteran's
    history, enabling better treatment decisions.
        The veteran's voice will also be front and center in eHMP.
    Veterans' goals and preferences for care will become part of the
    information all providers see. eHMP will also provide a feature
    dedicated to recording and maintaining a veteran's service history,
    including duty locations and what type of work they performed during
    their service. This information could then be used in proactively
    identifying veterans who may be at risk for certain health issues, or
    eligible for medical care based on locations or times in which they
    served.
        Veterans will also benefit from VA care teams who can work together
    more efficiently and effectively using the care coordination and task
    management tools eHMP will provide. For example, if a veteran is
    referred for a particular test or consultation with a specialist,
    workflow management tools in eHMP will ensure the right activities have
    taken place in advance of the referral. This will help reduce wasted or
    unneeded appointments, save time for both veterans and providers. In
    turn, if providers are more efficient, they are able to serve more
    veterans, which will have an overall positive impact on veteran access
    to care. All of these efforts align with the goals outlined by the
    Federal Health Information Technology Strategic Plan 2015--2020 and
    Connecting Health and Care for a Nation: A Shared Nationwide
    Interoperability Roadmap, produced by the Office of the National
    Coordinator for Health Information Technology (ONC) in collaboration
    with VA, DOD and other partners.

        Upon completion, eHMP will support the following capabilities:

      --Veteran-centric healthcare.--eHMP will allow clinicians to tailor
            care plans to specific clinical goals and help veterans achieve
            their healthcare goals.
      --Team-based healthcare.--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 healthcare.--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.--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, our efforts to improve information systems are 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, healthcare 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
    in fiscal year 2018 will not be the ``end'' of VA's EHR modernization.
    VA has always intended to continue modernizing VA's EHR, beyond VistA
    4, with more modern and flexible components.
        Technology and clinical capabilities must consistently evolve to
    meet the growing needs of our veterans. The VistA Evolution program is
    just that--an evolving capability that is an invaluable part, but not
    the end of VA's EHR modernization.
    Digital Health Platform
        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 VistA 4 will deliver in fiscal year 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.
        The VA healthcare system must keep the veteran experience at its
    core and incorporate effective clinical management, hospital operations
    capability, and predictive analytics. We do not have all of this today
    with VistA.
        To prepare for this new era in connected care, 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.
        The EHR is the central component of the digital health platform.
    However, an EHR by itself does not have all of the capabilities
    required to manage care in the community, respond to the changing needs
    of the veteran population, support clinical management, and provide the
    best overall veteran experience with the VA healthcare system.
        We have conducted a business case outlining our vision for the
    digital health platform. Our goal is to have a modern and integrated
    healthcare system that would incorporate best-in-class technologies and
    standards to give it the look, feel, and capabilities users have come
    to expect in the private sector.
        The digital health platform will be agile, and will leverage
    international open-source standards such as the Fast Healthcare
    Interoperability Resources (FHIR) framework.
        FHIR converts granular health data points into standardized data
    formats already well known to healthcare IT application developers. The
    main goal of FHIR is to simplify implementation without sacrificing
    information integrity. VA is working with standards organizations and
    industry partners to further refine FHIR to allow the level of
    interoperability necessary for the functionality described above.
        Health Level 7 International (HL7), a not-for-profit American
    National Standards Institute (ANSI)-certified standards developing
    organization, developed FHIR. HL7 has produced healthcare data exchange
    and information modeling standards since its founding in 1987. Emerging
    industry practices and lessons learned from previous standards
    frameworks informed HL7's development of FHIR.
        The digital health platform will be a system of systems. It is not
    dependent on any particular EHR, and VA can integrate new or existing
    resources into the system without sacrificing data interoperability.
    One of the digital health platform's defining features will be system-
    wide cloud integration, a marked improvement over the more than 130
    instances of VistA that we have today.
        OI&T and VHA have agreed upon a strategy to guide the formal
    planning of modernizing VA healthcare delivery beyond the conclusion of
    VistA 4 in fiscal year 2018. Our vision calls for a digital health
    platform that will go beyond EHR modernization to create a better
    overall experience for the veteran throughout the continuum of care. We
    continue to work closely with VHA to formulate our approach and apply
    the rigor of formalized program planning, and will keep this
    subcommittee updated as the process unfolds.
                                   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 testing VAR at two facilities. We
    have been testing VSE at 10 locations, and are in the training phase
    for national deployment of VSE.
        VAR is a new veteran facing capability allowing veterans to
    directly 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.
        We are testing VAR at two facilities in the VA New England Health
    System (Veterans Integrated Service Network (VISN) 1)--the VA
    Connecticut Healthcare System (West Haven) and the VA Boston Healthcare
    System (Jamaica Plain).
        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 10 VSE Initial Operational Capability sites are:

         1.  Charles George VA Medical Center in Asheville, North Carolina
         2.  West Palm Beach VA Medical Center in West Palm Beach, Florida
         3.  Chillicothe VA Medical Center in Chillicothe, Ohio
         4.  VA Hudson Valley Health Care System in New York
         5.  Louis Stokes Cleveland VA Medical Center in Cleveland, Ohio
         6.  VA New York Harbor Health Care System in New York, New York
         7.  VA Salt Lake City Health Care System in Utah
         8.  VA Southern Arizona Health Care System in Tucson, Arizona
         9.  James H. Quillen VA Medical Center in Mountain Home, Tennessee
        10.  Washington, DC VA Medical Center in Washington, DC

        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, the Medical Appointment Scheduling System (MASS) project
    includes additional features that add complexity, leading us to put
    MASS on a strategic hold while our team ensures that we meet all
    requirements without undue processing difficulties. VA will carefully
    measure the results of the VSE pilot to determine the best use of
    resources that will meet veteran needs. VA is working hard to ensure
    that every technological tool and improvement makes judicious use of
    taxpayer dollars while providing solutions that support today's
    veterans' needs.
                       enterprise cybersecurity strategy
        OI&T is facing the ever-growing cyber threat head on--we are
    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.
        In order to achieve and maintain the highest level of security, we
    need the active participation of everyone who accesses VA systems. We
    are providing comprehensive education to ensure that all VA employees
    remain vigilant. We have updated our National Rules of Behavior and our
    annual security training, and we are emphasizing continuous engagement
    with our employees. Information security poses constant challenges, and
    it is only through continuous reinforcement that our employees can
    support us in this battle.
        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. 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 healthcare,
    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.
    In the fiscal year 2017 budget request, VA ha increased requested
    spending on security to $370 million, fully funding and fully
    resourcing our security capability for the first time. We are committed
    to eliminating our material weakness in fiscal year 2017, and these
    funds are enabling those efforts. In addition, VA is investing over $50
    million to create a data-management backbone. I want to thank this
    subcommittee for fully funding the President's request in this area.
           it transformation and enterprise program management office
        OI&T is transforming. Persistent internal challenges exist in
    delivering IT services, and external pressures have compelled 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.
        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 (FITARA)
    requirements.

        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 streamlines IT
    product release activities and increases the speed of delivering high-
    quality, secure capabilities to veterans. VIP is revolutionary because
    it utilizes a single release process--designed to eliminate redundancy
    in review, approval, and communications--that all VA organizations will
    follow by the end of 2016. These releases are scheduled on a 3-month
    cadence--an improvement over the previous 6-month standard--and allow
    greatly needed IT services to be delivered to veterans more frequently.
        VIP reduces overhead and is more efficient and cost effective than
    PMAS. VIP's 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 7, 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.
                                   conclusion
        VA is at a historic crossroad and will need to make bold reforms
    that will shape how we deliver IT services and healthcare 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.
        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 my testimony, and I am happy to answer your
    questions.

        Senator Kirk. Thank you. We will hear from Valerie Melvin,
    Director, Information Management and Technology Resources
    Issues, U.S. Government Accountability Office.

                        GOVERNMENT ACCOUNTABILITY OFFICE

    STATEMENT OF VALERIE C. MELVIN, DIRECTOR, INFORMATION
                MANAGEMENT AND TECHNOLOGY RESOURCES ISSUES
        Ms. Melvin. Good morning, Chairman Kirk, Ranking Member
    Tester, and members of the subcommittee. Thank you for inviting
    me to testify today. VA's electronic health records system,
    VistA, is essential to the healthcare of veterans, and the
    Department has been taking steps over many years toward
    modernizing the system.
        Also, for almost two decades, it has been working with DOD
    to advance electronic health record interoperability between
    their systems. However, while the Department has made progress
    in these efforts, significant IT challenges have contributed to
    our designating VA's healthcare as high risk, as you mentioned
    earlier.
        At your request, my testimony today summarizes key findings
    and concerns about the Department's efforts based on previous
    reports that we have issued and VA's actions in response to our
    recommendations.
        With regard to electronic health record interoperability,
    we have consistently pointed to a troubled path toward
    achieving this capability. Since 1998, VA has undertaken a
    patchwork of initiatives with DOD to increase health
    information exchange between their systems. These efforts have
    yielded increasing amounts of standardized health data, and
    made an integrated view of the data available to clinicians.
        Nevertheless, a modernized VA electronic health record
    system that is fully interoperable with DOD's system is still
    years away.
        In 2011, VA and DOD announced that they would develop one
    integrated system to replace both Departments' separate
    systems, and thus sidestep many of their previous challenges to
    achieving interoperability. However, after 2 years and
    approximately $564 million reportedly spent, the Departments
    abandoned this plan, saying separate systems with interoperable
    capabilities between them could be achieved faster and at less
    overall cost.
        Yet, as VA and DOD have proceeded on separate paths, we
    have continued to highlight three primary concerns with their
    approach. First, the Departments have lacked outcome-oriented
    goals and metrics to clearly define what they aim to achieve
    from their interoperability efforts. Thus, an important
    question remains as to when VA intends to define the extent of
    interoperability it needs to provide the highest quality of
    patient care, and when the Department intends to achieve this
    with DOD.
        VA concurred with our recommendation that it develop such
    goals and metrics, and subsequently said it is defining an
    approach for identifying health outcome-oriented metrics and
    baseline measurements.
        Second, VA's plan to modernize VistA raises concerns about
    duplication with DOD's system acquisition. The Departments have
    identified 10 areas in which they have common healthcare
    business needs, and a study has identified over 97 percent of
    inpatient requirements for electronic health record systems as
    being common to both Departments.
        Further, despite our recommending that it do so, VA has yet
    to substantiate its claim that modernizing VistA, together with
    DOD acquiring a new system, can be achieved faster and at less
    cost than a single joint system. Thus, an important question
    that remains as to how VA and DOD can continue to justify the
    need for separate systems.
        Finally, while VA has begun implementing VistA
    modernization plans, it is doing so amid uncertainty about its
    approach. A recent independent assessment of its health IT
    raised questions about the lack of any clear advances in the
    Department's efforts over the past decade, and recommended that
    VA assess its alternatives for delivering modernized
    capabilities.
        Nevertheless, the Under Secretary for Health has maintained
    that the Department is following through with plans to complete
    a modernized system in fiscal year 2018, while the CIO has
    indicated that VA is reconsidering how best to meet its needs.
        Thus, with regard to VA's electronic health record
    interoperability and system modernization efforts, uncertainty
    and important questions remain about what the Department is
    prepared to accomplish, in what timeframes, and at what costs.
        This concludes my oral statement. I would be pleased to
    respond to your questions.
        [The statement follows:]
                    Prepared Statement of Valerie C. Melvin

                                 GAO HIGHLIGHTS

        Highlights of GAO-16-807T, a testimony before the Subcommittee on
    Military Construction, Veterans Affairs, and Related Agencies,
    Committee on Appropriations, U.S. Senate.

                             Why GAO Did This Study

        VA operates one of the Nation's largest healthcare systems, serving
    millions of veterans each year. For almost two decades, the department
    has undertaken a patchwork of initiatives with DOD to increase
    interoperability between their respective electronic health record
    systems. During much of this time, VA has also been planning to
    modernize its system. While the department has made progress in these
    efforts, it has also faced significant information technology
    challenges that contributed to GAO's designation of VA healthcare as a
    high risk area.
        This statement summarizes GAO's August 2015 report (GAO-15-530) on
    VA's efforts to achieve interoperability with DOD's electronic health
    records system. It also summarizes key content from GAO's reports on
    duplication, overlap, and fragmentation of Federal Government programs.
    Lastly, this statement provides updated information on VA's actions in
    response to GAO's recommendation calling for an interoperability and
    electronic health record system plan.

                              What GAO Recommends

        In prior reports, GAO has made numerous recommendations to VA to
    improve the modernization of its IT systems. Among other things, GAO
    has recommended that VA address challenges associated with
    interoperability, develop goals and metrics to determine the extent to
    which the modernized systems are achieving interoperability, and
    address shortcomings with planning. VA generally agreed with GAO's
    recommendations.
        View GAO-16-807T. For more information, contact Valerie C. Melvin
    at (202) 512-6304 melvinv@gao.gov.

                           ELECTRONIC HEALTH RECORDS

    VA's Efforts Raise Concerns about Interoperability Goals and Measures,
                     Duplication with DOD, and Future Plans

                                 what gao found
        Even as the Department of Veterans Affairs (VA) has undertaken
    numerous initiatives with the Department of Defense (DOD) that were
    intended to advance the ability of the two departments to share
    electronic health records, the departments have not identified outcome-
    oriented goals and metrics to clearly define what they aim to achieve
    from their interoperability efforts. In an August 2015 report, GAO
    recommended that the two departments establish a timeframe for
    identifying outcome-oriented metrics, define related goals as a basis
    for determining the extent to which the departments' systems are
    achieving interoperability, and update their guidance accordingly.
    Since that time, VA has established a performance architecture program
    that has begun to define an approach for identifying outcome-oriented
    metrics focused on health outcomes in selected clinical areas and has
    begun to establish baseline measurements. GAO is continuing to monitor
    VA's and DOD's efforts to define metrics and report on the
    interoperability results achieved between the departments.
        Following an unsuccessful attempt to develop a joint system with
    DOD, VA switched tactics and moved forward with an effort to modernize
    its current system separately from DOD's planned acquisition of a
    commercially available electronic health record system. The department
    took this course of action even though, in May 2010, it identified 10
    areas of healthcare business needs in common with those of DOD.
    Further, the results of a 2008 study pointed out that more than 97
    percent of inpatient requirements for electronic health record systems
    are common to both departments. GAO noted that the departments' plans
    to separately modernize their systems were duplicative and recommended
    that their decisions should be justified by comparing the costs and
    schedules of alternate approaches. The departments agreed with GAO's
    recommendations and stated that their initial comparison indicated that
    separate systems would be more cost effective. However, the departments
    have not provided a comparison of the estimated costs of their current
    and previous approaches. Further, both departments developed schedules
    that indicated their separate modernization efforts will not be
    completed until after the 2017 planned completion date for the previous
    joint system approach.
        VA has developed a number of plans to support its development of
    its electronic health record system, called VistA, including a plan for
    interoperability and a road map describing functional capabilities to
    be deployed through fiscal year 2018. According to the road map, the
    first set of capabilities was delivered by the end of September 2014
    and included a foundation for future functionality, such as an enhanced
    graphical user interface and enterprise messaging infrastructure.
    However, a recent independent assessment of health information
    technology (IT) at VA reported that lengthy delays in modernizing VistA
    had resulted in the system becoming outdated. Further, this study
    questioned whether the modernization program can overcome a variety of
    risks and technical issues that have plagued prior VA initiatives of
    similar size and complexity. Although VA's Under Secretary for Health
    has asserted that the department will complete the VistA Evolution
    program in fiscal year 2018, the Chief Information Officer has
    indicated that the department is reconsidering how best to meet its
    future electronic health record system needs.
                                     ______

        Chairman Kirk, Ranking Member Tester, and members of the
    subcommittee:

        Thank you for inviting me to testify at today's hearing on the
    Department of Veterans Affairs' (VA) electronic health record system--
    the Veterans Health Information Systems and Technology Architecture
    (VistA)--and the department's progress toward achieving
    interoperability with the Department of Defense (DOD). For almost two
    decades, VA has been working with DOD to advance electronic health
    record interoperability between their systems, in an attempt to achieve
    the seamless sharing of healthcare data and make patient data more
    readily available to healthcare providers, reduce medical errors, and
    streamline administrative functions. Also, for much of this same time
    period, VA has been planning and taking steps toward the modernization
    of its electronic health record system, with the intent of ensuring
    that the department can effectively deliver care for the millions of
    veterans and others that it serves.
        Since 2001, we have issued a number of reports that addressed VA's
    progress, in conjunction with DOD, toward achieving interoperable
    electronic health records between their separate systems,\1\ as well as
    its project with DOD to jointly develop a shared electronic health
    record system.\2\ In addition, we have reported on actions that VA has
    taken with regard to modernizing its electronic health record
    system.\3\ While the department has made progress in these efforts, it
    has also faced significant information technology challenges that
    contributed to our designation of VA healthcare as a high risk area.\4\
    ---------------------------------------------------------------------------
        \1\ GAO, Electronic Health Records: Outcome-Oriented Metrics and
    Goals Needed to Gauge DOD's and VA's Progress in Achieving
    Interoperability, GAO-15-530 (Washington, D.C.: Aug. 13, 2015);
    Opportunities to Reduce Potential Duplication in Government Programs,
    Save Tax Dollars, and Enhance Revenue, GAO-11-318SP (Washington, D.C.:
    Mar. 1, 2011); Electronic Health Records: DOD and VA Should Remove
    Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-
    265 (Washington, D.C.: Feb. 2, 2011); Electronic Health Records: DOD
    and VA Interoperability Efforts are Ongoing; Program Office Needs to
    Implement Recommended Improvements, GAO-10-332 (Washington, D.C.: Jan.
    28, 2010); Electronic Health Records: DOD and VA Have Increased Their
    Sharing of Health Information, but More Work Remains, GAO-08-954,
    (Washington, D.C.: July 28, 2008); and Computer-Based Patient Records:
    Better Planning and Oversight By VA, DOD, and IHS Would Enhance Health
    Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001).
        \2\ GAO, Electronic Health Records: VA and DOD Need to Support Cost
    and Schedule Claims, Develop Interoperability Plans, and Improve
    Collaboration, GAO-14-302 (Washington, D.C.: Feb. 27, 2014).
        \3\ GAO, Veterans Affairs: Health Information System Far from
    Complete; Improved Project Planning and Oversight Needed, GAO-08-805
    (Washington, D.C.: Jun. 30, 2008).
        \4\ GAO, High Risk Series: An Update, GAO-15-290 (Washington, D.C.:
    Feb. 11, 2015).
    ---------------------------------------------------------------------------
        At your invitation, my testimony today summarizes our key findings
    and concerns from this overall body of work. Specifically, in
    developing this testimony, we relied on our previous reports, as well
    as information that we obtained and reviewed on VA's actions in
    response to our previous recommendations. The reports cited throughout
    this statement include detailed information on the scope and
    methodology for our reviews.
        The work upon which this statement is based was conducted in
    accordance with generally accepted government auditing standards. Those
    standards require that we plan and perform the audit to obtain
    sufficient, appropriate evidence to provide a reasonable basis for our
    findings and conclusions based on our audit objectives. We believe that
    the evidence obtained provides a reasonable basis for our findings and
    conclusions based on our audit objectives.

                                   Background

        VA operates one of the largest healthcare systems in America,
    providing care to millions of veterans and their families each year.
    The department's health information system--VistA--serves an essential
    role in helping the department to fulfill its healthcare delivery
    mission. Specifically, VistA is an integrated medical information
    system that was developed in-house by the department's clinicians and
    information technology (IT) personnel, and has been in operation since
    the early 1980s.\5\ The system consists of 104 separate computer
    applications, including 56 health provider applications; 19 management
    and financial applications; 8 registration, enrollment, and eligibility
    applications; 5 health data applications; and 3 information and
    education applications. Within VistA, an application called the
    Computerized Patient Record System enables the department to create and
    manage an individual electronic health record for each VA patient.
    ---------------------------------------------------------------------------
        \5\ VistA began operation in 1983 as the Decentralized Hospital
    Computer Program. In 1996, the name of the system was changed to VistA.
    ---------------------------------------------------------------------------
        Electronic health records are particularly crucial for optimizing
    the healthcare provided to veterans, many of whom may have health
    records residing at multiple medical facilities within and outside the
    United States. Taking these steps toward interoperability--that is,
    collecting, storing, retrieving, and transferring veterans' health
    records electronically--is significant to improving the quality and
    efficiency of care. One of the goals of interoperability is to ensure
    that patients' electronic health information is available from provider
    to provider, regardless of where it originated or resides.
        Since 1998, VA has undertaken a patchwork of initiatives with DOD
    to allow the departments' health information systems to exchange
    information and increase interoperability.\6\ Among others, these have
    included initiatives to share viewable data in the two departments'
    existing (legacy) systems, link and share computable data between the
    departments' updated heath data repositories, and jointly develop a
    single integrated system that would be used by both departments. Table
    1 summarizes a number of these key initiatives.
    ---------------------------------------------------------------------------
        \6\ DOD uses a separate electronic health record system, the Armed
    Forces Health Longitudinal Technology Application, which consists of
    multiple legacy medical information systems developed from customized
    commercial software applications.

    TABLE 1: HISTORY OF THE DEPARTMENTS OF VETERANS AFFAIRS' AND DEFENSE'S ELECTRONIC HEALTH RECORD INTEROPERABILITY
                                                       INITIATIVES
    ----------------------------------------------------------------------------------------------------------------
                   Initiative                          Year begun                         Description
    ----------------------------------------------------------------------------------------------------------------
    Government Computer-Based Patient Record  1998.......................  This interface was expected to compile
                                                                            requested patient health information in
                                                                            a temporary, ``virtual'' record that
                                                                            could be displayed on a user's computer
                                                                            screen.
    Federal Health Information Exchange.....  2002.......................  The Government Computer-Based Patient
                                                                            Record initiative was narrowed in scope
                                                                            to focus on enabling the Department of
                                                                            Defense (DOD) to electronically transfer
                                                                            service members' health information to
                                                                            the Department of Veterans Affairs (VA)
                                                                            upon their separation from active duty.
                                                                            The resulting initiative, completed in
                                                                            2004, was renamed the Federal Health
                                                                            Information Exchange. This capability is
                                                                            currently used by the departments to
                                                                            transfer data from DOD to VA.
    Bidirectional Health Information          2004.......................  This capability provides clinicians at
     Exchange.                                                              both departments with viewable access to
                                                                            records on shared patients. It is
                                                                            currently used by VA and DOD to view
                                                                            data stored in both departments' heath
                                                                            information systems.
    Clinical Data Repository/Health Data      2004.......................  This interface links DOD's Clinical Data
     Repository Initiative.                                                 Repository and VA's Health Data
                                                                            Repository to achieve a two-way exchange
                                                                            of health information.
    Virtual Lifetime Electronic Record......  2009.......................  To streamline the transition of
                                                                            electronic medical, benefits, and
                                                                            administrative information between the
                                                                            departments, this initiative enabled
                                                                            access to electronic records for service
                                                                            members as they transition from military
                                                                            to veteran status and throughout their
                                                                            lives. It also expands the departments'
                                                                            health information-sharing capabilities
                                                                            by enabling access to private-sector
                                                                            health data.
    Joint Federal Health Care Center........  2010.......................  The Captain James A. Lovell Federal
                                                                            Health Care Center was a 5-year
                                                                            demonstration project to integrate DOD
                                                                            and VA facilities in the North Chicago,
                                                                            Illinois, area. It is the first
                                                                            integrated Federal healthcare center for
                                                                            use by beneficiaries of both
                                                                            departments, with an integrated DOD-VA
                                                                            workforce, a joint funding source, and a
                                                                            single line of governance.
    ----------------------------------------------------------------------------------------------------------------
    Source: GAO summary of prior work and department documentation  GAO-16-807T.

        In addition to the initiatives mentioned in table 1, VA has worked
    in conjunction with DOD to respond to provisions in the National
    Defense Authorization Act for fiscal year 2008,\7\ which required the
    departments to jointly develop and implement fully interoperable
    electronic health record systems or capabilities in 2009. Yet, even as
    the departments undertook numerous interoperability and modernization
    initiatives, they faced significant challenges and slow progress. For
    example, VA's and DOD's success in identifying and implementing joint
    IT solutions has been hindered by an inability to articulate explicit
    plans, goals, and timeframes for meeting their common health IT needs.
    ---------------------------------------------------------------------------
        \7\ Public Law No. 110-181, Sec. 1635, 122 Stat. 3, 460-463 (2008).
    ---------------------------------------------------------------------------
        In March 2011, the secretaries of VA and DOD announced that they
    would develop a new, joint integrated electronic health record system
    (referred to as iEHR). This was intended to replace the departments'
    separate systems with a single common system, thus sidestepping many of
    the challenges they had previously encountered in trying to achieve
    interoperability. However, in February 2013, about 2 years after
    initiating iEHR, the secretaries announced that the departments were
    abandoning plans to develop a joint system, due to concerns about the
    program's cost, schedule, and ability to meet deadlines. The
    Interagency Program Office (IPO), put in place to be accountable for
    VA's and DOD's efforts to achieve interoperability,\8\ reported
    spending about $564 million on iEHR between October 2011 and June 2013.
    ---------------------------------------------------------------------------
        \8\ The National Defense Authorization Act for fiscal year 2008
    called for the departments to set up an interagency program office to
    be a single point of accountability to implement fully interoperable
    electronic health record systems or capabilities by September 30, 2009.
    This office was chartered in January 2009.
    ---------------------------------------------------------------------------
        In light of VA and DOD not implementing a solution that allowed for
    the seamless electronic sharing of healthcare data, the National
    Defense Authorization Act for fiscal year 2014 \9\ included
    requirements pertaining to the implementation, design, and planning for
    interoperability between the departments' electronic health record
    systems. Among other actions, provisions in the act directed each
    department to (1) ensure that all healthcare data contained in their
    systems (VA's VistA and DOD's Armed Forces Health Longitudinal
    Technology Application, referred to as AHLTA) complied with national
    standards and were computable in real time by October 1, 2014; and (2)
    deploy modernized electronic health record software to support
    clinicians while ensuring full standards-based interoperability by
    December 31, 2016.
    ---------------------------------------------------------------------------
        \9\ Public Law No. 113-66, Div. A, Title VII, Sec. 713, 127 Stat.
    672, 794-798 (Dec. 26, 2013).
    ---------------------------------------------------------------------------
        In August 2015, we reported that VA, in conjunction with DOD, had
    engaged in several near-term efforts focused on expanding
    interoperability between their existing electronic health record
    systems. For example, the departments had analyzed data related to 25
    ``domains'' identified by the Interagency Clinical Informatics Board
    and mapped health data in their existing systems to standards
    identified by the IPO. The departments also had expanded the
    functionality of their Joint Legacy Viewer--a tool that allows
    clinicians to view certain healthcare data from both departments in a
    single interface.
        More recently, in April 2016, VA and DOD certified that all
    healthcare data in their systems complied with national standards and
    were computable in real time. However, VA acknowledged that it did not
    expect to complete a number of key activities related to its electronic
    health record system until sometime after the December 31, 2016,
    statutory deadline for deploying modernized electronic health record
    software with interoperability. Specifically, the department stated
    that deployment of a modernized VistA system at all locations and for
    all users is not planned until 2018.

       Together with DOD and the Interagency Program Office, VA Needs to
            Develop Goals and Metrics for Assessing Interoperability

        Even as VA has undertaken numerous initiatives with DOD that were
    intended to advance electronic health record interoperability, a
    significant concern is that these departments have not identified
    outcome-oriented goals and metrics to clearly define what they aim to
    achieve from their interoperability efforts, and the value and benefits
    these efforts are expected to yield. As we have stressed in our prior
    work and guidance,\10\ assessing the performance of a program should
    include measuring its outcomes in terms of the results of products or
    services. In this case, such outcomes could include improvements in the
    quality of healthcare or clinician satisfaction. Establishing outcome-
    oriented goals and metrics is essential to determining whether a
    program is delivering value.
    ---------------------------------------------------------------------------
        \10\ GAO, Electronic Health Record Programs: Participation Has
    Increased, but Action Needed to Achieve Goals, Including Improved
    Quality of Care, GAO-14-207 (Washington, D.C.: March 6, 2014);
    Designing Evaluations: 2012 Revision, GAO-12-208G (Washington, D.C.:
    Jan. 31, 2012); Performance Measurement and Evaluation: Definitions and
    Relationships, GAO-11-646SP (Washington, D.C.: May 2, 2011); and
    Executive Guide: Effectively Implementing the Government Performance
    and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1, 1996).
    ---------------------------------------------------------------------------
        The IPO is responsible for monitoring and reporting on VA's and
    DOD's progress in achieving interoperability and coordinating with the
    departments to ensure that these efforts enhance healthcare services.
    Toward this end, the office issued guidance that identified a variety
    of process-oriented metrics to be tracked, such as the percentage of
    health data domains that have been mapped to national standards. The
    guidance also identified metrics to be reported that relate to tracking
    the amounts of certain types of data being exchanged between the
    departments, using existing capabilities. This would include, for
    example, laboratory reports transferred from DOD to VA via the Federal
    Health Information Exchange and patient queries submitted by providers
    through the Bidirectional Health Information Exchange.
        Nevertheless, in our August 2015 report, we noted that the IPO had
    not specified outcome-oriented metrics and goals that could be used to
    gauge the impact of the interoperable health record capabilities on the
    departments' healthcare services. At that time, the acting director of
    the IPO stated that the office was working to identify metrics that
    would be more meaningful, such as metrics on the quality of a user's
    experience or on improvements in health outcomes. However, the office
    had not established a timeframe for completing the outcome-oriented
    metrics and incorporating them into the office's guidance.
        In the report, we stressed that using an effective outcome-based
    approach could provide the two departments with a more accurate picture
    of their progress toward achieving interoperability, and the value and
    benefits generated. Accordingly, we recommended that the departments,
    working with the IPO, establish a timeframe for identifying outcome-
    oriented metrics; define related goals as a basis for determining the
    extent to which the departments' modernized electronic health record
    systems are achieving interoperability; and update IPO guidance
    accordingly.
        Both departments concurred with our recommendations. Further, since
    that time, VA has established a performance architecture program that
    has begun to define an approach for identifying outcome-oriented
    metrics focused on health outcomes in selected clinical areas, and it
    also has begun to establish baseline measurements. We intend to
    continue monitoring the department's efforts to determine how these
    metrics define and report on the results achieved by interoperability
    between the departments.

      VA's Plan to Modernize VistA Raises Concern about Duplication with
               DOD's Electronic Health Record System Acquisition

        Following the termination of the iEHR initiative, VA moved forward
    with an effort to modernize VistA separately from DOD's planned
    acquisition of a commercially available electronic health record
    system. The department took this course of action even though it has
    many healthcare business needs in common with those of DOD. For
    example, in May 2010, VA (and DOD) issued a report on medical IT to
    Congressional committees that identified 10 areas--inpatient
    documentation, outpatient documentation, pharmacy, laboratory, order
    entry and management, scheduling, imaging and radiology, third-party
    billing, registration, and data sharing--in which the departments have
    common business needs.\11\ Further, the results of a 2008 study pointed
    out that over 97 percent of inpatient requirements for electronic
    health record systems are common to both departments.\12\
    ---------------------------------------------------------------------------
        \11\ Department of Defense and Department of Veterans Affairs Joint
    Executive Council and Health Executive Council, Report to Congress on
    Department of Defense and Department of Veterans Affairs Medical
    Information Technology, required by the explanatory statement
    accompanying Department of Defense Appropriations Act 2010 (Public Law
    111-118).
        \12\ Booz Allen Hamilton, Report on the Analysis of Solutions for a
    Joint DOD-VA Inpatient EHR and Next Steps, Task Order W81XWH-07-F-0353:
    Joint DOD-VA Inpatient Electronic Health Record (EHR) Project Support,
    July 2008.
    ---------------------------------------------------------------------------
        We also issued several prior reports regarding the plans for
    separate systems, in which we noted that the departments did not
    substantiate their claims that VA's VistA modernization, together with
    DOD's acquisition of a new system, would be achieved faster and at less
    cost than developing a single, joint system. Moreover, we noted that
    the departments' plans to modernize their two separate systems were
    duplicative and stressed that their decisions should be justified by
    comparing the costs and schedules of alternate approaches.\13\
    ---------------------------------------------------------------------------
        \13\ GAO, Electronic Health Records: VA and DOD Need to Support
    Cost and Schedule Claims, Develop Interoperability Plans, and Improve
    Collaboration, GAO-14-302 (Washington, D.C.: Feb. 27, 2014). See also
    GAO, 2014 Annual Report: Additional Opportunities to Reduce
    Fragmentation, Overlap, and Duplication and Achieve Other Financial
    Benefits, GAO-14-343SP (Washington, D.C.: Apr. 8, 2014), and 2015
    Annual Report: Additional Opportunities to Reduce Fragmentation,
    Overlap, and Duplication and Achieve Other Financial Benefits, GAO-15-
    404SP (Washington, D.C.: Apr. 14, 2015).
    ---------------------------------------------------------------------------
        We recommended that VA and DOD develop cost and schedule estimates
    that would include all elements of their approach (i.e., modernizing
    both departments' health information systems and establishing
    interoperability between them) and compare them with estimates of the
    cost and schedule for developing a single, integrated system. If the
    planned approach for separate systems was projected to cost more or
    take longer, we recommended that the departments provide a rationale
    for pursuing such an approach.
        VA, as well as DOD, agreed with our recommendations and stated that
    an initial comparison had indicated that the approach involving
    separate systems would be more cost effective. However, as of June
    2016, the departments had not provided us with a comparison of the
    estimated costs of their current and previous approaches. Further, with
    respect to their assertions that separate systems could be achieved
    faster, both departments had developed schedules which indicated that
    their separate modernization efforts are not expected to be completed
    until after the 2017 planned completion date for the previous single-
    system approach.

     VA Has Begun to Implement VistA Modernization Plans amid Uncertainty
     about Its Approach; the Department Is Currently Reconsidering How to
                                    Proceed

        As VA has proceeded with its program to modernize VistA (known as
    VistA Evolution), the department has developed a number of plans to
    support its efforts. These include an interoperability plan and a road
    map describing functional capabilities to be deployed through fiscal
    year 2018. Specifically, these documents describe the department's
    approach for modernizing its existing electronic health record system
    through the VistA Evolution program, while helping to facilitate
    interoperability with DOD's system and the private sector. For example,
    the VA Interoperability Plan, issued in June 2014, describes activities
    intended to improve VistA's technical interoperability,\14\ such as
    standardizing the VistA software across the department to simplify
    sharing data.
    ---------------------------------------------------------------------------
        \14\ Technical interoperability refers to the ability of multiple
    systems to be able to transmit data back and forth.
    ---------------------------------------------------------------------------
        In addition, the VistA 4 Roadmap, last revised in February 2015,
    describes four sets of functional capabilities that are expected to be
    incrementally deployed during fiscal years 2014 through 2018 to
    modernize the VistA system and enhance interoperability. According to
    the road map, the first set of capabilities was delivered by the end of
    September 2014 and included access to the Joint Legacy Viewer and a
    foundation for future functionality, such as an enhanced graphical user
    interface and enterprise messaging infrastructure.
        Another interoperable capability that is expected to be
    incrementally delivered over the course of the VistA modernization
    program is the enterprise health management platform.\15\ The
    department has stated that this platform is expected to provide
    clinicians with a customizable view of a health record that can
    integrate data from VA, DOD, and third-party providers. Also, when
    fully deployed, VA expects the enterprise health management platform to
    replace the Joint Legacy Viewer.
    ---------------------------------------------------------------------------
        \15\ The enterprise health management platform is a graphical user
    interface that is intended to present patient information to support
    medical care to the veteran from a standardized set of information,
    regardless of where the veteran receives care. Clinical information
    captured at the point of care is made available to all authorized
    providers across the enterprise.
    ---------------------------------------------------------------------------
        However, a recent independent assessment of health IT at VA
    reported that lengthy delays in modernizing VistA had resulted in the
    system becoming outdated.\16\ Further, this study questioned whether
    the VistA Evolution program to modernize the electronic health record
    system can overcome a variety of risks and technical issues that have
    plagued prior VA initiatives of similar size and complexity. For
    example, the study raised questions regarding the lack of any clear
    advances made during the past decade and the increasing amount of time
    needed for VA to release new health IT capabilities. Given the concerns
    identified, the study recommended that VA assess the cost versus
    benefits of various alternatives for delivering the modernized
    capabilities, such as commercially available off-the-shelf electronic
    health record systems, open source systems, and the continued
    development of VistA.
    ---------------------------------------------------------------------------
        \16\ Independent Assessment of the Health Care Delivery Systems and
    Management Processes of the Department of Veteran Affairs, Integrated
    Report (Sept. 1, 2015).
    ---------------------------------------------------------------------------
        In speaking about this matter, VA's Under Secretary for Health has
    asserted that the department will follow through on its plans to
    complete the VistA Evolution program in fiscal year 2018. However, the
    Chief Information Officer has also indicated that the department is
    taking a step back in reconsidering how best to meet its electronic
    health record system needs beyond fiscal year 2018. As such, VA's
    approach to addressing its electronic health record system needs
    remains uncertain.
        In summary, VA's approach to pursuing electronic health record
    interoperability with DOD has resulted in an increasing amount of
    standardized health data and has made an integrated view of that data
    available to department clinicians. Nevertheless, a modernized VA
    electronic health record system that is fully interoperable with DOD's
    system is still years away. Thus, important questions remain about when
    VA intends to define the extent of interoperability it needs to provide
    the highest possible quality of care to its patients, as well as how
    and when the department intends to achieve this extent of
    interoperability with DOD. In addition, VA's unsuccessful efforts over
    many years to modernize its VistA system raise concern about how the
    department can continue to justify the development and operation of an
    electronic health record system that is separate from DOD's system,
    even though the departments have common system needs. Finally, VA's
    recent reconsideration of its approach to modernizing VistA raises
    uncertainty about how it intends to accomplish this important endeavor.
        Chairman Kirk, Ranking Member Tester, and members of the
    subcommittee, this concludes my prepared statement. I would be pleased
    to respond to any questions that you may have.

        Senator Kirk. Thank you. Dr. Thompson, we will hear your
    statement.

                             DEPARTMENT OF DEFENSE

    STATEMENT OF DR. LAUREN THOMPSON, DIRECTOR, DOD/VA
                INTERAGENCY PROGRAM OFFICE
        Dr. Thompson. Chairman Kirk and Ranking Member Tester,
    thank you for the opportunity to address the Subcommittee on
    Military Construction and Veterans Affairs. I am honored to
    represent the Department of Defense and Department of Veterans
    Affairs as Director of the DOD/VA Interagency Program Office,
    or IPO.
        As part of the current strategy to achieve the President's
    goal of electronic health record interoperability and
    modernization, the IPO was re-chartered in 2013 to serve as the
    single point of accountability for identifying, monitoring, and
    improving the health data standards to create seamless
    integration of health data between the DOD, the VA, and private
    healthcare providers.
        Health data interoperability is essential to improving the
    care delivered to our servicemembers, veterans, and their
    beneficiaries. Working closely with the Office of the National
    Coordinator for Health Information Technology (ONC) and
    standards development organizations, the IPO helps identify,
    implement, and map the appropriate national standards
    associated with both Departments' electronic health record
    systems.
        Assisting the Departments with their interoperability and
    modernization milestones, the IPO serves as a central resource
    as DOD and VA develop, adopt, and update a technical framework
    that is clinically driven to align identified standards with
    approved use cases.
        To that end, the IPO monitors industry best practices and
    provides technical guidance to facilitate data interchange
    between the Departments. We also serve as a conduit for the
    Departments' engagement with ONC and standards development
    organizations to facilitate knowledge sharing on a national
    level.
        We have been integrated into ONC's planning for a national
    health IT ecosystem and we are key contributors in the
    development of ONC's nationwide interoperability roadmap that
    seeks to advance nationwide health IT.
        The IPO also plays an important role in monitoring the
    progress that DOD and VA continue to make in enhancing their
    interoperability efforts. Specifically, we have established a
    health data interoperability metrics dashboard to identify
    Department-specific targets for transactional metrics and
    trends.
        In addition to these efforts, last year the Government
    Accountability Office recommended that DOD and VA adopt outcome
    oriented metrics to provide a basis for assessing and reporting
    on the progress of the Departments' interoperability efforts.
    We concurred with GAO's guidance, and I am pleased to report
    that we have made substantial progress addressing the
    recommendations.
        Specifically, we have been working closely with ONC, DOD,
    VA, and other public and private partners to develop outcome
    oriented metrics that not only measure the impact
    interoperability has on healthcare but specifically focuses on
    the impact interoperability has on patients and providers.
        The IPO is fully committed to assisting DOD and VA as they
    continue to enhance health data interoperability between their
    electronic health record systems and the private sector, which
    will serve as the foundation for a patient-centric healthcare
    experience, seamless care transition and improved care for our
    servicemembers, their families, and our veterans.
        Again, thank you for the opportunity today, and I look
    forward to your questions.
        [The statement follows:]
                   Prepared Statement of Dr. Lauren Thompson
        Chairman Kirk and Ranking Member Tester, thank you for the
    opportunity to address the Subcommittee on Military Construction and
    Veterans Affairs. I am honored to represent the Departments of Defense
    and Veterans Affairs as the Director of the DOD/VA Interagency Program
    Office (IPO).
        As part of the current strategy to achieve the President's goal of
    electronic health record interoperability and modernization, the IPO
    was rechartered in 2013 to serve as the single point of accountability
    for identifying, monitoring, and approving the health data standards to
    create seamless, integration of health data between DOD, the VA, and
    private healthcare providers.
        As you know, DOD and VA are two of our Nation's largest healthcare
    systems, and share more health data than any two other major systems.
    Currently, the Departments share more than 1.5 million data elements
    daily, and more than 100,000 DOD and VA clinicians are able to view the
    real-time records of the more than 7 million patients who have received
    care from both Departments.
        Health data interoperability is essential to improving the care
    delivered to our servicemembers, veterans, and their beneficiaries.
    Working closely with the Office of the National Coordinator for Health
    Information Technology (ONC) and Standards Development Organizations,
    the IPO helps identify, implement, and map the appropriate national
    standards associated with both Departments' electronic health record
    systems. These steps are vital and provide the building blocks
    necessary for the Departments to achieve health data interoperability
    as required by the fiscal year 2014 National Defense Authorization Act.
    In fact, earlier this year the Departments met this requirement and
    provided certification to Congress that their systems are interoperable
    with an integrated display of data.
        The IPO is a collaborative entity, comprised of staff from both
    Departments with technical expertise in health data standards and
    information sharing. Assisting the Departments with their
    interoperability and modernization milestones, we serve as a central
    resource as DOD and VA develop, adopt, and update a technical framework
    that is clinically driven to align identified standards with approved
    use cases. To that end, the IPO monitors industry best practices and
    provides technical guidance to facilitate data interchange between the
    Departments. We also serve as a conduit for the Departments' engagement
    with ONC and Standards Development Organizations to facilitate
    knowledge sharing on a national level; we have been integrated into
    ONC's planning for a national health IT ecosystem, and were key
    contributors in the development of ONC's Interoperability Roadmap that
    seeks to advance nationwide IT interoperability.
        The IPO also plays an important role in monitoring the progress
    that DOD and VA continue to make in enhancing their interoperability
    efforts. Specifically, we have established a Health Data
    Interoperability Metrics Dashboard to identify Department-specific
    targets for transactional metrics and trends. We share this and much
    more information with Congress in our quarterly Data Sharing Reports
    and regular briefs with Committee staff. In addition to these efforts,
    last year, the Government Accountability Office (GAO) recommended that
    DOD and VA adopt outcome-oriented metrics to provide a basis for
    assessing and reporting on the progress of the Departments'
    interoperability efforts. We concurred with GAO's guidance and I am
    pleased to report that we have made substantial progress to address
    this recommendation. Specifically we have been working closely with
    ONC, DOD, VA, and other public and private partners to develop outcome-
    oriented metrics that not only measure the impact interoperability has
    on healthcare but specifically focus on the impact interoperability has
    on our patients and providers.
        The field of health data is constantly evolving. For the
    Departments to maintain and enhance the interoperability of their
    electronic health record systems, we must continue our collaboration
    with ONC and industry partners to ensure that DOD and VA map their data
    to the latest national standards, and that ONC and the private sector
    can continue to learn from our experience.
        The IPO is fully committed to assisting DOD and VA as they continue
    to enhance health data interoperability between their electronic health
    record systems and the private sector. Enabling health information
    exchange between EHR systems in DOD, VA, and the private sector will
    serve as the foundation for a patient-centric healthcare experience,
    seamless care transitions, and improved care for our servicemembers,
    their families, and our veterans. As IPO Director, I am happy to answer
    any questions you may have on the IPO and work of DOD and VA to
    identify and adopt health data standards.
        Again, thank you for this opportunity, and I look forward to your
    questions.

        Senator Kirk. Thank you. Let me start with questions. I
    will ask LaVerne, since you have been in office for about a
    year now, and coming out of J&J and Dell Computer, can you give
    me your first impressions when you came into the VA IT
    business?

                        CIO COUNCIL IMPRESSION OF VA IT

        Ms. Council. Thank you for the question. I think one of the
    biggest surprises was the lack of an integrated data management
    capability, which I think is critical to being able to share
    the right information, have the right analytics, and be able to
    disseminate the information out to everyone.
        Also, the number of custom systems, having well over 800
    different applications out, that tends to be a fairly high
    number, and most organizations might have a few but not that
    many, and also the age of those systems was also something that
    was surprising to me.
        In addition, not having a program or project management
    office.

                            OVER 800 VA APPLICATIONS

        Senator Kirk. Let me interrupt you to make a key point.
    What you are telling the committee is you have several hundred
    customization projects underway to current software that would
    make you one of the largest software development operations in
    the country right there at VA, not a core competency for you
    guys.
        Ms. Council. Most of the work is managed by contractors, to
    your point, we have about 218 projects going on right now, and
    the level of customization is a concern because it does make it
    harder to maintain those systems.
        Senator Kirk. Thank you.
        Ms. Council. Thank you.
        Senator Kirk. Over to you.

           INTEROPERABILITY AND ENTERPRISE HEALTH MANAGEMENT PLATFORM

        Senator Tester. Thank you, Mr. Chairman. Thank you all for
    your testimony. Secretary Council, you mentioned in your
    testimony that deployment of the Joint Legacy Viewer (JLV) has
    been a major step towards interoperability. As you well know,
    this is a read-only application, and we know the enterprise
    health management platform (eHMP) will eventually be a
    replacement, and it will bring more capabilities to add to the
    record, I would assume.
        On April 8, you jointly certified with the DOD
    interoperability. Could you tell me, number one, how
    interoperability will be improved as you implement the
    enterprise health management platform?
        Ms. Council. Thank you for the question. I will start and
    then I will pass it over to Mr. Waltman to add some more parts
    to it. Clearly, being able to certify interoperability of the
    JLV was exciting. We have to date 178,000 users of the JLV
    today. We have used it to support about 7 million different
    intentions, and going forward, the eHMP is going to augment it.
    David, if you want to share some information, that would be
    great.
        Mr. Waltman. Thank you, Ms. Council, Senator. The
    enterprise health management platform is a great opportunity
    for us to build on the interoperable information exchange base.
        Senator Tester. I got you. Let me cut right to it, because
    my time is going to be limited. Right now----

                          INTEROPERABILITY DEFINITION

        Senator Kirk. We are getting to the heart of this hearing,
    would you please define ``interoperability'' as you understand
    it from the NDAA?
        Mr. Waltman. Yes, Mr. Chairman. The NDAA required us to
    have an exchange of all health record information between the
    two departments.
        Senator Kirk. I will read to you Webster's definition of
    ``interoperability.'' Interoperability is ``The ability of a
    system to work with and use another system.''
        Mr. Waltman. Understand.
        Senator Kirk. In the case of the Joint Legacy Viewer, which
    is kind of a kludgy Band-Aid that we have. When I talked to
    Cerner, they told me it does not provide the x-ray data of a
    patient, so we would say now welcome to the VA, we have no x-
    ray data on you from all the x-rays, the Navy, the Army, Air
    Force did for you.
        Mr. Waltman. Yes, Mr. Chairman. Agree and understand that
    definition.
        Senator Kirk. I think most members of this committee would
    say that is not interoperable.
        Mr. Waltman. Understand. I think that----

                     JOINT LEGACY VIEWER AND IMAGING ISSUES

        Senator Kirk. What about CAT scans?
        Mr. Waltman. Right. The data that we are exchanging now is
    all of the health record data, which includes 25 domains of
    standardized data where standards exist, so that includes
    progress notes, lab reports. It includes the reports from all
    of those imaging studies.
        As we know, the size of data for the studies themselves is
    exponentially larger than----
        Senator Kirk. If we had a veteran who had a spot on his
    lung indicating cancer, the Joint Legacy Viewer would not share
    that with the VA so VA would not know about that emerging
    cancerous situation, is that correct?
        Mr. Waltman. I think Dr. Nebeker may be able to answer this
    question in a clinically precise way, but I would say there
    would be a radiology report from the study that was done
    identifying the spot, and that report is available today.
        Senator Kirk. This is a narrative thing?
        Mr. Waltman. That is correct.
        Senator Kirk. I am actually talking about the imagery.
        Mr. Waltman. Right.
        Senator Kirk. Most people would think that a medical record
    includes x-rays that they had taken when they were in the
    service.
        Mr. Waltman. Yes, and that is certainly part of the medical
    record, and the report that the radiologist completes after
    such imaging studies are done are what other providers
    typically use to address findings from those reports and follow
    their course of care.
        That said, we are working and in the process now of
    delivering the image viewer component of the Joint Legacy
    Viewer, which will be available in the next release, and now
    the challenge there is to make sure that we have the bandwidth
    and ability to exchange the images when they are needed to be
    exchanged for clinical purposes.
        I think the point was that we wanted to ensure we have
    interoperability and exchange of all the clinically relevant
    information, so Dr. Nebeker, you may want to make a comment
    about images and reports and their relevance.
        Dr. Nebeker. Images are critical to the provision of
    medicine. In most cases the narrative is the most important
    part of that because as people are planning operations or
    leading up to an operation or planning treatment, most of us--I
    am a geriatrician and primary care provider as well as a
    consultant, I usually rely on the interpretation because I am
    not expert in all the various domains of radiology to make
    those types of calls.
        Definitely for many types of operations, it is critical to
    have the images, so we agree with your statement.
        For the interoperability, certification of
    interoperability, there was fairly clear instruction in the
    statute and also in the response, and Ms. Thompson may be able
    to take this on a little bit more, but interoperability is a
    concept. You brought up the dictionary. It is really critical
    to have use cases about what are the problems we are trying to
    solve with interoperability.
        Clinicians, between VA and DOD, jointly developed a number
    of use cases, and the conditions for interoperability were
    meant for those use cases. Ms. Thompson, if you would like to
    elaborate.
        Senator Kirk. This is the only subcommittee that has joint
    jurisdiction of both DOD and VA, so we are the only guys that
    can really ride herd on something like bringing you two
    together, DOD and VA together.
        Senator Tester. I just want to continue real quick. I
    actually am going to be very interested to hear Dr. Cassidy's
    questions on this because you are in the business.
        You were asked a question and your response was what we are
    trying to solve here, what we are trying to solve here is not
    have to rewrite the book again. Quite frankly, where the person
    was hurt, how the person was hurt, the x-rays, the CAT scans,
    all that would be on there so that when a veteran is going to
    get rated, it would be a much easier process, and it would not
    take forever, and it would not be like a very complicated math
    problem. It would be right there.
        The information has to be there. It is interesting that you
    would say the notes are more important than the pictures. I am
    not a doctor, but do you ever do a surgery and not look at
    pictures of the x-rays and that kind of stuff? You just start
    cutting based on notes?
        Dr. Nebeker. Yes, sir, I completely agree that for
    operations the pictures are critical.

                        FULL INTEROPERABILITY TIMETABLE

        Senator Tester. Okay, good. The question is when and at
    what point in time are we going to be interoperable to the
    point where the information that the DOD has, and by the way,
    if it is not good information coming to you, you do not have
    good information, but assuming they give you the information,
    you will have all the information on those medical records in
    your hands, when is that going to happen?
        Ms. Council. The image viewer is going into deployment to
    get these images moved into the JLV----
        Senator Tester. When does that happen?
        Ms. Council. September of this year.
        Senator Tester. You will have access to x-rays, CAT scans?
        Ms. Council. Of the records that are in JLV, yes. In
    addition, I think it goes one step further, and the one step
    further is why I think enterprise data management is so
    important. You are both 100 percent correct.
        We have to have seamless movement of that information from
    DOD as far as I am concerned at the Active Duty point of the
    enlisted person, even knowing before they become a veteran, and
    we have to work on that. That is one of the reasons that the
    enterprise level is so important versus just having a pipe that
    is only health.
        Remember, there is much more to the veteran than just their
    healthcare. It is their benefits, it is their ability to use
    our National Cemetery System, it is all the things they have a
    right to, education, and we have to do a much better job of
    creating that seamlessness.
        To your point, the semantic use of that information is that
    information comes one to one, and the veteran does not have
    anything to do to ensure that we have their data. That is the
    most important thing and that is what we are striving for.
        Senator Tester. I have got it. I have been here almost 10
    years now, and I serve on the Senate Veterans' Affairs
    Committee, as does Senator Cassidy, as does Senator Murray and
    others, as well as Senator Boozman.
        The very first meetings that I was at in Senate Veterans'
    Affairs, we talked about interoperability between the DOD and
    VA. That was in 2007. We are 10 years later. We have had
    incredible advances in technology, just flying up through the
    roof. Yet I still have the feeling----

                     JOINT LEGACY VIEWER LACKING ANALYTICS

        Senator Kirk. If the Senator will suspend, I want to add on
    to that. When I talked to Cerner this morning, they talked
    about something that really addresses a key VA priority, which
    is suicide prevention. I understand from the press we had the
    suicide hotline that had not enough responses for people. One
    of my constituents had called in and also committed suicide
    after they called back.
        The exciting thing for what Cerner told me was they had an
    algorithm that could predict suicide likelihood. When I talked
    to Cerner, they said the Joint Legacy Viewer cannot do
    analytics like this.
        David, you are nodding your head. This critical upgrade in
    suicide prevention, they are not capable of doing with this
    Joint Legacy Viewer.
        Senator Tester. You talked about the images coming in in
    September. When do you get to a point where you are satisfied
    with the transfer of information being complete, to deal with
    issues like the chairman said and others?
        Mr. Waltman. Thank you, Senator. I was nodding my head
    because I agree 100 percent, JLV is 100 percent incapable of
    those analytics. JLV, of course, was----

                              ANALYTIC CAPABILITY

        Senator Tester. Okay, I have you. When do we get to a point
    where you are capable of those analytics?
        Mr. Waltman. That is the enterprise health management comes
    in, health management platform, and I will allude to the
    concept of the digital health platform which Ms. Council has
    talked about.
        We need an integrated capability of all the clinical data
    for process management, for managing clinical pathways,
    clinical workflows, integrated with analytics which can use
    algorithms such as described by the chairman, which can predict
    based on the information in the record, based on pathways and
    courses of action available, what interventions should be taken
    and what the processes and care pathway should be.
        Dr. Nebeker can talk in a little bit more detail about
    clinically what that looks like.
        Senator Tester. Do not have to do that. I asked you a
    question, and the question was when are you going to be able to
    do this. I am going to tell you I can filibuster you better
    than you can filibuster me. The question is pretty clear, and
    you are smart people. Tell me when you are going to be able to
    achieve this level. That is it. Is it going to be next year, 5
    years, 10 years, next month?
        Mr. Waltman. 2018.
        Senator Tester. 2018. January 1, 2018?
        Mr. Waltman. The end of fiscal year, so middle of calendar
    year 2018.
        Senator Tester. When we have this hearing on July 15, 2018,
    you are going to be totally interoperable, absolutely there is
    going to be no gaps, the system is going to work?
        Mr. Waltman. I would like to give a yes or no answer to
    that question but I cannot. What I can tell you is that we will
    have the ability to incorporate all of the information between
    the Departments, to use it, process with the type of algorithms
    that are being discussed, but I cannot say that every use case
    that we may have identified for use of interoperable data will
    be used.
        Senator Tester. Thank you. Thank you, Mr. Chairman.
        Senator Kirk. Mrs. Capito.
        Senator Capito. Thank you, Mr. Chairman. I want to thank
    all of you as well. I guess I am going to say I am a bit
    confused because Secretary Council said that on April 8, you
    were certified interoperable. Then Ms. Melvin said that an
    interoperability system is still years away. I think that was
    part of your statement.
        Help me with those--that seems like a direct conflict
    there. Are we talking about the same thing? How do I square
    those two statements?
        Ms. Council. I am going to try to simplify this and talk in
    normal ease versus technical ease.
        Senator Capito. Thank you. I am grateful for that.
        Ms. Council. Let me start with the concept of a system. The
    system, if you want to think about it, the inner workings, the
    system, what all works together. The data is the artifact
    coming out of the system, going into the system, and it
    actually can sit separately from the system--data, system.
        I think Ms. Melvin was referring to an engaged system,
    being on the same system platform, and therefore, assuming
    interoperability would be driven by being on the same system
    platform.

                          SINGLE VA AND DOD EHR SYSTEM

        Senator Capito. What is the objection of having a single
    system, as she mentioned?
        Ms. Council. The reality of a single system, in order for
    you to ensure that you are going to drive the same level of
    data out of that system is that you would have to sit on the
    same instance, time of that system, not just the same name
    system, but the same capabilities, no difference in that
    system.
        Senator Capito. Why can we not do that?
        Ms. Council. The reality is there is no system that can
    support both DOD and VA at the same time, it will not scale.
        Senator Capito. We have Amazon that can scale.
        Ms. Council. At the same time, there is no system that will
    support all the things you have to do, the clinical management
    and the clinical operations at the same time.
        Senator Capito. Ms. Melvin, do you have any comment on
    that?

                             FULL INTEROPERABILITY

        Ms. Melvin. I would start by saying that we are not trying
    to define what an interoperable system is for VA. We have been
    looking at this over the years, and as has been discussed, the
    question has been and what they have been working toward as we
    understand it is a fully interoperable capability.
        When we talk about fully interoperable, we are asking them
    to define what they mean by the data exchange, what has to be
    exchanged, what capabilities and to what extent. Those are
    questions that have not been answered yet in terms of when you
    talk about full interoperability, exactly what is it.
        What kind of performance measures and metrics would you put
    in place to know that you have gotten the full capability when
    you get there.
        Senator Capito. Excuse me. For the discussion on whether
    your x-rays and tests and everything are a part of that, are
    you including that as part of defining what
    ``interoperability'' is?
        Ms. Melvin. Absolutely. It is understanding all of the
    medical information, all of the systems that information would
    have to come through, and what are they doing in the way of the
    exchange capability, how will they know when all of the
    information that they need to ensure that a patient's
    healthcare is fully taken care of, how will they know when they
    have gotten to that point or they have a system that gets to
    that point.
        We did encourage one system, and they in fact had stated
    that one system was the way to go when they went with an
    integrated electronic health record approach in 2011.

                              ONE SEAMLESS SYSTEM

        Senator Kirk. I would say that they are coming up with two
    different systems, and the only government bureaucracy that can
    mandate one system--my preferred outcome would be since LaVerne
    owns about 20 million patients and Dr. Waltman owns about 2
    million patients, that it is only this committee that can
    mandate a VA lead to make sure we have one seamless system.

               PRIVATE PROVIDERS AND HEALTH INFORMATION EXCHANGE

        Senator Capito. In my final 2 minutes, let me ask you, Dr.
    Thompson, because you mentioned private sources, so we have
    just created the Choice card, we now have our veterans going
    out to private providers because of the issue of getting an
    appointment timely, distance, all the things we know exist, and
    this has been going on in the VA system for a while, but we
    have expanded it by the Choice card, how is this going to be
    interoperable with private providers? You have no guarantee.
        I will just give you an example in my State, West Virginia,
    we have a lot of issues with broadband deployment. We just
    started a broadband caucus yesterday, I did, to meet this
    issue. What do you anticipate in this area? That is my final
    question.
        Dr. Thompson. I can speak to DOD, and I would defer to Ms.
    Council to speak for the VA. The DOD participates in what is
    called the eHealth Exchange, which is a public/private
    partnership of both government, including DOD, providers, and
    private sector providers, providing data through health
    information exchange organizations.
        Senator Capito. Would you say your private providers are on
    the same e-records as the DOD?
        Dr. Thompson. For those providers that are participants in
    eHealth Exchange, they do have access to the DOD data.
        Senator Capito. There could be providers that were not on
    the eHealth Exchange?
        Dr. Thompson. Providers who are not presently on the
    eHealth Exchange do not have access to that data.
        Senator Capito. You could have an active military person go
    to a private physician and they could not be on this eHealth
    Exchange, and they would not have that data back at the DOD? Am
    I hearing that correctly?
        Dr. Thompson. That is correct presently. The DOD is moving
    aggressively to increase the number of health information
    exchanges and providers that are participants.
        Senator Capito. This layers on a whole other issue.
    Quickly.
        Ms. Council. We do participate in HIE at the VA with over
    1,500 of those in the United States. What that is is a
    standardized data structure, and that is what I was getting to,
    the data. At the end of the day, that is what you have to have
    to be interoperable, and you need a standard across that.
        Within the United States today, the standard is called
    health information exchange or HIE, and we participate in those
    HIEs as a way to engage that information today.
        Senator Capito. Veterans using the Choice card could go to
    a physician that is not in the health information exchange and
    therefore, their records are not interoperable with you?
        Ms. Council. What we do at the VA is if they go to a doctor
    that is outside of our process, we will reach out to that
    doctor and get that information one way or the other. If we can
    get it electronically, we will get it.
        One of the things about interoperability, and I just think
    it is important to remember, it has a continuum. One part of
    the continuum is non-electronic, which is how we moved things
    before, I hate to say it, but it is paper. The other one is
    called semantics, which is data flowing and data moving and
    talking to each other.
        We are on that continuum constantly, and healthcare has
    been on that continuum constantly, moving to that standard
    called HIE.
        Senator Capito. Thank you.
        Senator Kirk. With everybody's indulgence, I will do a
    brief recess so we can make this vote. If you guys can hang
    loose for a second, since we are paid by the vote here.
        [Recess.]
        Senator Tester. I am going to call the hearing back to
    order. Thank you for your patience. Senator Udall has some very
    important questions, and we will let him go.

                      APPOINTMENT SCHEDULING IMPROVEMENTS

        Senator Udall. Thank you, Senator Tester. Thank you so
    much, and thank you to all the witnesses for being here today,
    we really appreciate your service to the country and service to
    our veterans.
        My first question revolves around the VA scheduling
    scandal. Ms. Council, this question is on scheduling, an issue
    that is critically important to the veterans in my State.
        The VA Office of Inspector General recently released a
    report related to the scheduling scandal from 2014
    substantiating claims that the managers at the VA Medical
    Center in Albuquerque abused scheduling software to manipulate
    metrics and make it appear the wait times were shorter than
    they actually were.
        This is similar to the earlier reports of scheduling
    mismanagement in at least seven other States, including
    Illinois and Arizona.
        The findings of this report confirmed allegations that the
    schedule was rigged to make the center look better. That is
    very troubling. Our veterans have earned the best care we can
    provide, the appointment scandal showed a disturbing disregard
    for health and safety of our heroes.
        I have had a chance to discuss the report with the local
    medical center director in Albuquerque. I appreciate that since
    I raised these concerns the VA has taken several steps to
    improve access to care and reduce wait times. That includes
    extended hour and weekend clinics, same-day primary care
    clinic, hiring additional staff, and expanding the use of
    telemedicine.
        However, I hear from VA employees and from veterans there
    is still much work to do. What steps has the Office of
    Information and Technology taken to eliminate opportunities to
    game the system, and aside from changes in traditional
    management practices and training, are there changes that can
    be made in the software to increase accountability and ensure
    that these work arounds are no longer possible?
        Ms. Council. Thank you, Senator Udall, for the questions
    and the background. We agree with you that this is the most
    important thing, to make sure the veterans have access to the
    care they need.
        To your point, within the VSE product, there is a
    capability to keep people from having to go in and change, it
    tracks any change that could be made, and makes sure we can see
    it.
        In addition, there is a product we call Care Now, which is
    a mobile access for the veteran, which will allow them to
    actually schedule with a doc in real time, in a telemedicine
    way, but on a mobile device. We are working with the doctors
    now to put that into full test.
        It was developed to allow the most capable way for the
    veteran to get help whenever they need it, primarily around
    mental health, but it could also be used for urgent care. It is
    a quite nice interactive system. We look forward to sharing
    that with you as we go forward, but our objective is to make it
    as seamless and as easy for the veteran to engage.
        In addition, their ability to make appointments using a
    mobile device through a system called VAR, which you have also
    heard about, which will allow them to request when they want to
    come in, what date they want to come in, what time, based on
    what is available.
        Trying to put those things in their hands using technology
    is core and key, but we are really excited about this Care Now
    application.
        Senator Udall. Thank you. One of the other things I wanted
    to focus on is Federal information technology management. Many
    of these problems are caused at least in part by legacy IT.
        Ms. Council, I have been working in a bipartisan way with
    Senator Moran, Senator Milkulski and others on the
    Appropriations Committee. We want to improve the oversight of
    how we spend over $80 billion annually on information
    technology across the Federal Government.
        At a hearing following the healthcare.gov Web site debacle,
    we called for OMB to publish a top 10 list for the highest
    priority IT investments across the government. We also called
    for better OMB oversight of these IT projects.
        According to the OMB, three of the Nation's highest
    priority IT projects are at the Veterans Administration. The
    first one, electronic health records/VistA; the medical
    appointment scheduling system (MASS); and third, the Veterans
    Benefit Management System (VBMS).

                     MEDICAL APPOINTMENT SCHEDULING SYSTEM

        Ms. Council, I want to ask specifically about the new
    medical appointment scheduling system, the scheduling
    replacement project was terminated in September 2009 after
    spending an estimated $127 million over 9 years.
        What lessons has the VA learned from the failure of its
    previous scheduling replacement project, which was terminated
    at the cost I just noted?
        Are you using agile or incremental development or best
    Federal acquisition practices for the new medical appointment
    scheduling system, and by what dates will the VA's three
    highest priority IT projects be completed? The three that I
    mentioned there, VistA, MASS, and VBMS.
        Ms. Council. That was three questions, I want to make sure
    I address them properly, sir. Upon arrival in 2015, the
    question of scheduling was on point as what we were going to do
    with that.
        I am going to ask David to share where we are on the
    scheduling process and also why we decided to do some of the
    things we have done, because I think he can give the best feel
    on that because he has been here.

                    THREE HIGH RISK VA DEVELOPMENT PROJECTS

        On the three key projects, however, that you mentioned,
    that was brought to my attention immediately upon arrival, that
    VistA is a 40-year-old system, what we are doing on
    modernization. The MASS project had just kicked in, and it was
    all around the scheduling issue and trying to get this right
    and what we were going to do against that.
        The third area was VMBS, which is handling our claims
    business and how we are going to make that work, and some of
    the underlying parts of it, including the BDN system, which is
    over 50 years old.
        When you ask when all of those are going to get done, the
    reality is you always are in a maintenance mode on any
    sustained application. I would like to say you put them in and
    never see them again, it is not true.
        Applications always cost you, so you are always going to
    have maintenance, you are always going to be doing patching,
    you are always going to try to stay ahead of the cybersecurity
    issues that come with day to day issues on applications.
        As far as being done and the capability, I think the
    reality for us as we talk about EHR and VistA in particular,
    there are new capabilities that have to be added.
        I think the team went forward with an honest and open
    process for trying to decide what those could be, but we all
    know we are not able to move fast enough, and did not move fast
    enough to keep it up to speed where it needs to be, and that is
    why we are talking about a new platform called the digital
    health platform.

                              MASS AND SCHEDULING

        On MASS and scheduling, David, if you would give the
    Senator some of the dates on those.
        Mr. Waltman. Thank you. Senator, the question about MASS
    comes back to what Ms. Council referred to in talking about the
    digital health platform. We made an award of the MASS contract
    last fall.
        That was very soon after Ms. Council and Dr. Shulkin
    arrived, and under their leadership, we had to look at the
    bigger picture and whether VistA in the go forward plan made
    sense.
        Since MASS was to be integrated with VistA, with a specific
    COTS product and had a lot of expense and overhead to do that,
    while determining what our path forward was, the decision was
    made to pause MASS.
        We have worked since then with the VistA scheduling
    enhancements, which Ms. Council mentioned, which allows us to
    do some of the things, auditing, lock down clinical indicated
    data, things like that, and we are currently working to
    complete that and have it deployed and is being piloted in
    three sites right now.
        The answer to when MASS will be completed is there is not a
    completion date determined for that because in the context of
    discussing our EHR way forward and a commercial off-the-shelf
    system, we have to consider whether we need to address
    scheduling in that context or separately.
        Senator Udall. Thank you very much, and thank you for your
    courtesies, Mr. Chairman.
        Senator Kirk. Dr. Cassidy.

                   COMPREHENSIVE DEFINITIONS FOR ALL DATASETS

        Senator Cassidy. First, thank you for that reply, just so
    it is on the record. I learned from you earlier that VistA--VA
    is upgrading the VistA system but will eventually replace it
    with a commercial product.
        I know from staff an RFI has been put out, a request for
    information, to understand what the commercials can do in terms
    of capabilities for the VA. You have mentioned the enterprise,
    just for context.
        My head was turned around just for a little bit. One of the
    issues that has been raised for semantic interoperability is
    comprehensive definitions of all the datasets.
        If we wish the VA system and the DOD system to one, talk
    with one another, and two, talk with providers who are outside
    your system, has the DOD and VA established a common set of
    comprehensive semantic definitions? That is my first question
    to Ms. Thompson, I suppose, and Assistant Secretary Council,
    and maybe Ms. Melvin.
        Ms. Council. I will pass this over to Dr. Thompson.
        Dr. Thompson. Thank you for the question. The IPO's role is
    in working with the DOD and VA for that express purpose. We
    work with the Office of the National Coordinator and standards
    development organizations to determine the health data standard
    that the two Departments should implement in their systems, and
    we work with them presently through a process of mapping to
    those standard definitions to ensure that the systems in place
    in the departments comply with those----
        Senator Cassidy. Yes or no, because that is a lot of
    ``we's.'' Yes or no, you have established a comprehensive set
    of semantic definitions or no, but we are working to do so, and
    are committed to doing so prior to the letting of the contract,
    and these are or are not compatible with those who might be
    outside the system but yet providing for those within?
        Dr. Thompson. Yes, sir, we have established those
    definitions.
        Senator Cassidy. You have established those definitions?
    Thank you. These are common as well with the non-DOD/VA
    providers?
        Dr. Thompson. That is correct.

                APPLICATIONS FOR FUTURE DIGITAL HEALTH PLATFORM

        Senator Cassidy. Secondly, for the DOD, are you all
    requiring--I believe Cerner is your vendor or one of your two
    vendors for your EHR, and do you require them to publish their
    APIs, and do you require they allow plug and play of any future
    app that might be developed that would allow someone to again
    put in their blood pressure monitor at home into the EHR, so I
    guess two questions there.
        One, do you require them to publish the API, and two, do
    you require them to do plug and play, and three, if you do
    require them, do you require them to do it at a reasonable
    cost?
        Dr. Thompson. If I may take those questions for the record,
    that program falls outside of my particular domain. I would
    want to make sure I am providing you with the correct
    information.
        [The information follows:]

        Unrestricted publishing of APIs is not required; however, the
    contract provides for all rights necessary to operate, maintain and
    sustain the EHR system solution; modify interfaces; perform
    cybersecurity and software assurance; and, train on the EHR system
    solution, including disclosure within or outside of the Government as
    necessary to perform these functions.
        The contract contains requirements for the integration of future
    health IT applications or modules, as ordered by the Government once
    any such applications or modules are identified as requirements by the
    functional community. Further, in order to simplify the integration of
    possible future applications, the contract requires adherence to
    modular open system architecture design and development approaches.
        Finally, all negotiations are conducted in accordance with FAR 15.4
    which requires establishing the reasonableness of offered prices.

        Senator Cassidy. The VA, and in your RFP, because I am sure
    you are already thinking about it, again, are you going to
    require whichever vendor wins to publish the API because for
    some, it is not proprietary?
        I have also been told they effectively limit plug and play
    even if somebody comes up with a lower cost app, and they limit
    it by basically charging so much to come up with a custom
    design to allow the plug that they effectively eliminate the
    ability to develop plug and play, so my question there.
        Ms. Council. Our recommendation for a digital health
    platform is that it is all open source and we be able to move
    in and out of the platform.
        Senator Cassidy. Again, they will be required to publish
    their APIs as part of the RFP? I see Dr. Nebeker nodding yes.
        Ms. Council. Yes, that is the expectation of our digital
    platform. We are asking for what is not done today because we
    feel it needs to be open. That is part of how you drive
    innovation, and that will be the best way to ensure that we
    have full interoperability.
        Senator Cassidy. That is good. I have also understood that
    under your current VistA platform that one of the problems is
    that each VISN has done a customization of the VistA program
    for their VISN.
        Indeed, VISN 16 does not necessarily communicate with VISN
    10 because they have both been customized, you can tell they
    are related, but they are first cousins, they are not one and
    the same.
        Ms. Council. Yes, there are 130 plus and distinct instances
    of VistA within the VHA today.
        Senator Cassidy. So, the modernization process, are you
    just going to kind of okay, we have to tolerate that until we
    replace, or are you attempting to reconcile that?
        Ms. Council. I think some of the modernization--I will pass
    this on--I think much of the modernization is to ensure safety,
    health, and the clinical side to assure we are capturing the
    things we need to, just to keep the system whole.
        Also, there is security, things we want to make sure the
    system has the capability to do that might not have been
    thought about 40 years ago. David, if you would like to share
    some of the other modernization efforts.
        Mr. Waltman. Yes, thank you. A key part of the
    modernization work that we are doing now that will continue
    into 2018 with the enterprise health management platform is to
    federate that information from those 130 VistA instances, as we
    just talked about, because you are right----
        Senator Cassidy. ``Federate'' implies to me they are
    allowed to continue to have their own domain.
        Mr. Waltman. Until we move to a COTS solution on the
    digital health platform, there is not an intention to collapse
    all of those instances into one because of time, cost, and
    complexity.
        Senator Kirk. Let me just jump in and have you formally
    define ``federate.''
        Mr. Waltman. ``Federate'' means that we take all of the
    health information from those VistAs and bring it into one
    place so it can be used together. That is what the DHP does.
        It also allows us--we have a software development kit to do
    exactly what you just described, exposing the APIs, people are
    able to write and provide apps into the platform using that
    collected, assembled federated data.

                            DIGITAL HEALTH PLATFORM

        Ms. Council. But to avoid this problem of multiple
    instances in the future, that is the recommendation, a digital
    health platform, that we can keep it on one instance, one
    capability, one solution, and everybody has to come to it. The
    fact is that 130 is what makes it slow, makes it cumbersome,
    makes it take a long time, and it makes it inconsistent.
        To your point, moving to an open architecture that allows
    APIs to come in, allows us to use that information, share it,
    and get it back out and do it in a much more seamless area is
    where we want to go with DHP.
        Senator Cassidy. I am also told that Cerner has DOD, let's
    imagine even that Cerner gets VA, as it turns out now, if you
    have one hospital at Cerner and another hospital with Cerner or
    Epic and Cerner, there is information blocking. Whether it is
    because of technological challenges or because of a proprietary
    instinct is a subject of debate, but nonetheless, it occurs.
        What are you all doing in your RFI or RFP to ensure that we
    will not end up with let's just say technological information
    blocking?

                            OPEN SOURCE APPLICATIONS

        Ms. Council. The recommendation that we are making is that
    is not part of our process, and it will have to be
    interoperable and have to be open source.
        This is an IT recommendation, it is so unusual because we
    are asking for software as a service component, which changes
    the way that works, and we are also saying that we would have
    that level of interoperability, to give you an example, you go
    in and you fill a prescription at Walgreens, and then you go
    and you try to fill that same prescription at Rite Aid, it is
    very hard for you to do it because they have to go get the
    information.
        What we are saying is that would not be the case because
    they are all based on the same information about you, so they
    would each see that prescription.

                       GAO SKEPTICISM ON VA'S ASSERTIONS

        Senator Cassidy. I am taking more time and I apologize, but
    I want to ask one more question. Ms. Melvin, I was so struck by
    your skepticism, so we have heard the vision for the VISNs.
        Nonetheless, it seems as if you are skeptical. Were you
    skeptical about the VistA product, coordinating outside of VA,
    are you skeptical about the VA itself and their vision of a
    commercial product being able to coordinate outside of VA?
        Ms. Melvin. The questions that we raised really deal with
    the fact that we have not seen clear planning across VA and DOD
    relative to what they are trying to achieve.
        Senator Cassidy. Let me ask, would you agree with the
    statement that they have worked out a comprehensive set of
    semantic definitions?
        Ms. Melvin. We understand they have from what they say. We
    are still obtaining information from them. We know they have
    identified some of the standards that they need. We have not
    seen other aspects of what they intend to do in terms of
    putting either the interoperable component together for their
    systems, between VA and DOD, or the planning that is necessary
    for VistA modernization.
        One of the things----
        Senator Cassidy. Can I ask, have they committed to you a
    date on which they will provide that information?
        Ms. Melvin. No, we do not have dates yet.
        Senator Cassidy. That seems like a follow up for our
    committee, that we would also obtain that information because
    that seems like one of the key issues here, correct? I am
    sorry, continue.
        Ms. Melvin. One of the points I would make in going back to
    a statement earlier from Ms. Council where she was saying that
    they have not identified one system that is large enough to fit
    their needs, this is the kind of assertion that we would like
    to see, and that we think it is important for them to have the
    analysis and the transparency as to why a particular
    alternative is not sufficient for their needs.
        It kind of goes to the overall concern that we have in
    terms of analysis, planning, looking at the alternatives, and
    what the departments have in fact done that support where they
    tend to be at this time, and then of course, the specifics for
    what it is they are trying to achieve, and how they will know
    when they get there.
        Senator Cassidy. You have been very generous with your
    time, thank you, Mr. Chairman.
        Senator Kirk. Thank you. Mr. Boozman.

                        VA'S PLANNING FOR THE EHR FUTURE

        Senator Boozman. Thank you, Mr. Chairman. Thank you so much
    for having the hearing. Can somebody respond to Ms. Melvin's
    concern about the clear planning?
        Ms. Council. Yes, I can. She is 100 percent correct in what
    you need to do to provide the kind of background information,
    and one of the things that we have done with this
    recommendation is talk to industry leaders including Gardner
    Medical, very large medical organizations, as well as the KLAS
    Group, which is known as the premiere organization for EHR, and
    they are actually working with us to help us build that
    business case, look at the various options.
        We have a 200-page document which they have gone through
    and explained to us from the industry perspective on what is
    out there in COTS, how well they have been received. They
    talked to over 2,300 providers in these areas about what they
    are developing, so we are leveraging an independent view as to
    what makes sense and what will make sense for us, and why
    certain things do and certain things do not.
        Our objective is by the end of this year we will have a
    business case that the next administration or whomever is there
    has real data based on an independent group to understand
    exactly why we made the decisions we did.

                   ELECTRONIC HEALTH RECORDS AVAILABLE TO JLV

        Senator Boozman. Thank you, Ms. Council. I would like to go
    back to a previous discussion that I did not quite understand.
    You mentioned the image viewer would go on line this September
    for those records that are in the JLV. Which records are not in
    the JLV, and who are you missing?
        Mr. Waltman. Thank you, Senator. All electronic health
    records that have been generated in the VA or since DOD has had
    electronic health records are available and accessible for JLV.
    That includes anything that would be in AHLTA, for example, on
    the DOD side, records from back to----
        Senator Kirk. David, I will interrupt you since you used
    the term ``AHLTA,'' that is the data processing system for DOD.
        Mr. Waltman. Correct.
        Senator Kirk. When I was at Walter Reed, the doctors and
    nurses said that stood for okay, let's all try again.
        Mr. Waltman. I will not comment on that. The point is not
    all records that exist for every veteran are electronic, some
    veterans' records predate the electronic record era. The
    records that are electronic are in JLV. The images are in a
    separate image store in both the DOD and the VA, and that is
    the viewer that is going to allow those to be seen that we are
    speaking of.
        Ms. Council. Lauren, did you have anything you wanted to
    add from a DOD point of view?
        Dr. Thompson. No, I think that was an excellent summary.
    Thank you.

                           INDIVIDUAL SERVICE RECORDS

        Senator Boozman. Good, that is helpful. I was pleased to
    hear about the VA's goals with the electronic management
    platform, particularly with the proposed inclusion of the
    veteran's service history to include duty stations and type of
    work they performed during their service, which is really
    important.
        I would like to get a better understanding of how this
    would work in practice. As you know, servicemembers currently
    face a very challenging transition from DOD to the VA.
        When a servicemember separates from their Active Duty, the
    information populating their DD-214 is not automatically made
    available to the VA. It is the veteran's responsibility to make
    sure the VA has the appropriate documentation in order to
    verify their service and eligibility for VA benefits.
        How would eHMP obtain the member's individual service
    record?
        Mr. Waltman. Thank you, Senator. At the present time, the
    military history feature in the HMP is limited to being able to
    have a place for information the veteran provides directly. As
    you said, that is insufficient, and inadequate for seamless
    care.
        It is our desire that with what we have learned about
    clinical record exchange, health information exchange, with
    building JLV, that we will be able to work with our DOD
    colleagues to get the electronic exchange of the service
    history information and be able to feed that directly into the
    platform.
        Ms. Council. I think it is broader than just the
    healthcare. When we look at the totality of the veteran, we are
    looking at the whole veteran dataset, and our enterprise data
    management process is putting that backbone across VHA, VBA,
    NCA, so that way we have the whole look at the veteran, not
    just pieces and parts, and also we want to mitigate the veteran
    having to put information into various data marts as they have
    to do today.
        Senator Boozman. When do you anticipate the platform
    happening?
        Ms. Council. We are beginning that process this year,
    laying out the architecture, bringing in leadership to guide
    that, as well as we have set up a governance council so there
    are data stewards across the organization that will be
    responsible for that data, and veteran data will be owned and
    responsible for our veteran experience team.
        Senator Boozman. One of the problems that we have is making
    sure the servicemember's history and data is accurate. What is
    DOD doing in regard to that? What support would DOD be
    providing?
        Dr. Thompson. If I may, I would like to take that question
    for the record to ensure I provide you with the correct
    information. That falls outside of my immediate domain of
    health data standards.
        [The information follows:]

        Joint Legacy Viewer (JLV) displays servicemember information
    exactly as it's found in the authoritative system (Clinical Data
    Repository (CDR), Composite Health Care System (CHCS), Essentris,
    Theater Medical Data Store (TMDS), etc.). Accuracy is a critical factor
    DOD tests thoroughly before each release. System Integration Testing
    tests patient records in test authoritative data sources like the CDR.
    The testers validate that the data in the disparate data sources
    matches what is displayed in JLV. Further, the operational test report
    also specifies that DMIX has information accuracy.

        Senator Boozman. Good. Thank you, Mr. Chairman. We
    appreciate you all being here. This is certainly something that
    is frustrating in the sense that this has been going on for a
    long time, and as you can tell, there is uniform frustration. I
    know you all are frustrated, too, and working hard to get this
    right.
        Hopefully, we will be able to follow up in the near future
    both in this committee and the Veterans' Committee, DOD, and
    make sure that we are moving in the right direction. Thank you
    very much.
        Senator Kirk. Mr. Hoeven.
        Senator Hoeven. Thank you, Mr. Chairman. Ms. Council, you
    mentioned some of the challenges with your current scheduling
    systems, specifically not having the capabilities to keep up
    with the growing Care in the Community program.
        In North Dakota, where there has been some challenges with
    scheduling Veterans Choice appointments, currently the VA is
    working to implement a pilot project in our State to bring the
    scheduling aspect back to the VA, instead of relying on the
    third-party administrator, which in our case is Health Net.

                       NATIONAL LEVEL IN-HOUSE SCHEDULING

        My questions are does VA have the IT system in place to
    accomplish in-house scheduling on a national level, if not,
    when will we see an updated scheduling system in place that is
    capable of managing Care for the Community appointments for
    Veterans Choice, and what is your near and long-term goal of
    modernizing your current scheduling system?
        Ms. Council. The first part of that question relates to
    Care in the Community, which is led by Dr. Yehia, and we are
    very lock step on that because the Care in Community has a
    bigger issue with the exchange, as I think you well understand,
    Senator, so getting to where we can understand what appointment
    is needed, helping the veteran to make their appointment with
    the doctor, ensuring that the right referrals are happening,
    all the things we are doing using the health interchange that
    we mentioned prior to your arrival.

                               SCHEDULING SYSTEMS

        The scheduling systems, David, I will refer those to you as
    far as making sure we are straight on the timing and
    deployment, but the objective was to put in what is called VSC,
    which is a scheduler that is simpler than what our CPRS system
    is, and I think that was really the core issue around
    scheduling, it was convoluted, very difficult to understand.
        What you are talking about with the veteran in the
    community is how best we make sure we know when they want an
    appointment, and today we are putting in a mobile capability
    called VAR that will allow them to actually request on their
    Smartphone or a call, if they have to, if they are not using
    something electronic, so we could be much more responsive to
    them.
        This is something we are working on daily. As you know,
    Choice has grown, and then figuring out exactly how to get
    these hand shakes clear is something we are very committed to.
    We have to do better. We have a lot more work to do there.
        The Choice program and the scheduling program in general
    are both under engagement, and we are now testing a new
    scheduling capability in dual locations, looking to roll that
    out nationally.
        Senator Hoeven. What are those locations?
        Mr. Waltman. Where that system is being used to see
    patients are at Ashville VA Medical Center, Salt Lake City, and
    Cleveland.

                         SEAMLESS CARE IN THE COMMUNITY

        Senator Hoeven. What I am after, and any one of the three
    of you from VA who want to take a stab at addressing it, under
    the old model, when a veteran wanted care, they called the VA,
    and they either got institutional VA care from a health center
    or community-based outpatient clinic (CBOC), or they got care
    through what was called non-VA healthcare. That was in the
    community.
        For the most part, that system seemed to work, not
    everywhere in the country, but certainly in our part of the
    country that worked pretty well. They were getting their
    appointments and they were getting to the VA or to a local
    private provider if they needed to.
        With the third-party providers in place, that system has
    totally bogged down Veterans Choice, which is creating a real
    problem. That is why we have the pilot project going in North
    Dakota, which will serve North Dakota and Western Minnesota. I
    am very appreciative the VA is doing that, and I am just trying
    to keep it moving along.
        I think somehow nationally we have to get to a more
    seamless process so veterans are not held up from their
    appointments, so they get timely appointments, and so that the
    private providers get paid so they will take those veterans and
    take them in a timely way, and they are not trying to get
    payment out of the veteran then rather than the VA.
        If you could just address how we are going to get there and
    how soon we can get there, I would appreciate it.
        Ms. Council. I will come back to you on some of the
    business issues that are going on with some of the early pay
    and some of the things Dr. Shulkin and his team are doing to
    ensure that people get paid faster and quicker.
        Getting there and completion requires that we must also
    sort of know what the program is going to look like in the
    future. As you know, that is part of the process that is
    currently ongoing.
        We are working very aggressively. We have over 1,500 health
    interchanges in which information is shared with providers. We
    are paying early. We are paying faster. We do not want to have
    that sort of log jam because there has always been a referral
    process within the VA, but as you know with Choice, it requires
    that we step further.
        A date certain for all completion nationally, I do not
    have, but I will come back to you with that.
        [The information follows:]

        The Community Care Scheduling pilot at the Fargo VAMC was initiated
    in September 2016. The Office of Community Care provided routine
    updates to Senator Hoeven's office. On August 31, 2016, the Senator and
    his staff met with VAMC leadership and the Office of Community Care to
    receive a status update on major milestones for the pilot. The key
    milestones included contract modifications to the HealthNet contract,
    union negotiations, process flows and standard operating procedures for
    implementation, and staff training.

        Senator Hoeven. It seems to me that is a real key for your
    data systems, to be able to get----
        Ms. Council. It is.
        Senator Hoeven. Mr. Waltman or Dr. Nebeker.
        Dr. Nebeker. The level of interoperability, this is like a
    wonderful case for interoperability, right, to be able to
    schedule for a veteran to come to us and say hey, look, we
    think we can help you better if you go across the street or
    more locally to your town to get an appointment, let us help
    you get an appointment.
        Technology does exist for this, but we are analyzing the
    maturity of this technology to see if there is
    interoperability. University Health Network has some technology
    for this.
        Also, Boston University was doing a pilot several years ago
    that could do this, and now with North Dakota and Louisiana
    State University, so we are working with these partners to
    assess the maturity and suitability to bring these
    technologies. We look forward to the lessons learned from North
    Dakota.
        Senator Hoeven. Mr. Waltman, anything you want to add?
        Mr. Waltman. Thank you, Doctor, you hit the nail on the
    head there. That is exactly what we are after, and I appreciate
    you saying so. That is what will serve the veteran. It will
    serve them through the VA in the best way possible, but also
    when they need to go to a local provider either for a certain
    capability or just proximity, distance and time, so thank you.
    I think that is exactly right, that is what we need to do. I
    would like to thank all three of you for your work in this
    area.
        Senator Hoeven. Thank you, Mr. Chairman.
        Senator Kirk. Thank you. I will start with my questioning,
    because I am pretty seized with this issue. LaVerne, when we
    met, I want to tell you my tale of woe, because I am so focused
    on this issue.

                               INCEPTION OF VISTA

        Could you please tell the committee when VistA was started,
    what year?
        Ms. Council. I have seen a date from 1973 to 1975, but in
    1975.

                              HEALTHCARE ANALYTICS

        Senator Kirk. I was so concerned about this, I went down to
    the Smithsonian and went to the Innovations Station Exhibit and
    took pictures of computers, like this one, the Altair 880,
    which is considerably younger than all the systems that you
    have. This was the state-of-the-art in 1975, and for $500, I
    can get you one.
        Is it the state of VistA, it is at this level of
    technology? Let me follow up. When we got to the heart of this
    hearing, you certified that you are interoperable based on the
    JLV's existence, and we now know that the JLV does not have x-
    rays or CAT scans, and that is interoperable from your
    viewpoint.
        I would say you could expect some further definition from
    this committee on that point, that we need to move forward on
    this point to make sure there is no net burden on the soldier
    and sailor when they come out of the Service, that we 100
    percent transfer data to the VA, so that VA can see all the
    imagery and everything.
        In the case of my friend who came back from Iraq, all 38
    events in her combat career are included in the record for
    disability adjudication.
        The long term vision that I have, want to make sure that we
    go with a full blown Apple app on the Apps store. I talked to
    Cerner this morning. They said they already have several apps
    through the Apps store. I would like VA--remembering that the
    average age of people coming out of Service is going to be
    about 19, if you are a full blown citizen of the 21st century,
    you will live on this device.
        We are going to have to make sure that there is an app
    right there with full access to their record, including
    imagery, to make sure their clinicians can do the analytics.
        When I got deeper into this, I realized I was going farther
    and farther ahead of my own constituents who may not know what
    analytics does for their healthcare. I would say analytics
    takes us to the next level.
        In the case of being able to predict sepsis or suicide, in
    the case of Epic, they said in the case of sepsis, that was
    54,000 lives that they think were saved by analytics on
    probability of sepsis.
        When I talked to Cerner, they said the Joint Legacy Viewer
    cannot do analytics of the kind to take us to the next level. I
    want to make sure that--only this committee, I think, with
    jurisdiction over military construction and VA, can lean on
    both bureaucracies.
        When I first seized with this issue, I thought let's go
    with a Mark Kirk version, which would be to make all narratives
    Microsoft Word, all images JPEG, so we force the bureaucracy to
    talk to itself and make sure that when you serve the United
    States in uniform, you can make sure that all of the work the
    taxpayers already paid for and your medical record is there for
    the VA.
        Ms. Council. Sir, I think you know from our conversations
    that I concur with you 100 percent, and just to be clear, our
    certification of interoperable with JLV was against NDAA
    section 713(b)(1). It is not to say that it is semantically
    interoperable, it is not.
        Senator Kirk. When you cite that section of the law, it
    does use the word ``interoperable.'' I want to make sure we are
    not in a situation where it depends on what the definition of
    ``is'' is. We have to get away from that kind of thinking.
        Ms. Council. Totally agree. I think you and I also agree on
    the fact that having an open platform that will allow new
    innovation to come to bear, allow us to really use the best and
    the brightest, and also do more around analytics is core and
    key to predictive medicine.
        This is where the organization is moving, probably not
    moving as fast as any of us would like, but certainly we
    understand the value of that, and the value of supporting our
    veterans with the best.
        Senator Kirk. Thank you. I want to go with a full blown
    Apple app and make sure all these 19 year olds when they come
    out, they just hit the application and can see a full blown
    record and can contact VA if they see errors.
        Ms. Council. Yes.
        Senator Kirk. And that we move forward on that basis. You
    will be getting some pretty strong recommendations from this
    subcommittee on that point.

                         ADDITIONAL COMMITTEE QUESTIONS

        Let me move to closing here. I want to thank everybody for
    coming today, and especially my partner, Senator Tester. We
    will leave the record open until the close of next week. Our
    members may submit questions for the record.
        [Clerk's note: No questions were submitted to the
    Department for response subsequent to the hearing.]

                             CONCLUSION OF HEARINGS

        Senator Kirk. We stand adjourned.
        [Whereupon, at 12:10 p.m., Wednesday, April 10, the
    hearings were concluded, and the subcommittee was recessed, to
    reconvene at a time subject to the call of the Chair.]