[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 [email protected].

                       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.]