[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
ASSESSING THE VA IT LANDSCAPE: PROGRESS AND CHALLENGES
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, FEBRUARY 7, 2017
__________
Serial No. 115-1
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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C O N T E N T S
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Tuesday, February 7, 2017
Page
Assessing The VA IT Landscape: Progress And Challenges........... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Timothy J. Walz, Ranking Member........................ 2
WITNESSES
Mr. Rob C. Thomas, II, Acting Assistant Secretary for Information
and Technology and Chief Information Officer, Office of
Information and Technology, U.S. Department of Veterans Affairs 4
Prepared Statement........................................... 34
Accompanied by:
Jennifer S. Lee, M.D., Deputy Under Secretary for Health for
Policy and Services, Veterans Health Administration
Mr. Bradley Houston, Director, Office of Business
Integration, Veterans Benefits Administration
Mr. David A. Powner, Director, IT Management Issues, U.S.
Government Accountability Office............................... 6
Prepared Statement........................................... 39
STATEMENTS FOR THE RECORD
Blinded Veterans Association..................................... 51
Disabled American Veterans....................................... 53
The American Legion.............................................. 57
Veterans of Foreign Wars......................................... 59
ASSESSING THE VA IT LANDSCAPE: PROGRESS AND CHALLENGES
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Tuesday, February 7, 2017
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. David P. Roe
[Chairman of the Committee] presiding.
Present: Representatives Roe, Coffman, Wenstrup, Radewagen,
Bost, Poliquin, Dunn, Arrington, Higgins, Bergman, Gonzalez-
Colon, Walz, Takano, Brownley, and Kuster.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The hearing will come to order.
I want to welcome everyone to today's hearing, and I know we
have a lot of Members in different hearings. There are a lot of
meetings going on this morning.
We will begin the 115th Congress by examining IT because it
is so important to everything VA does and everything we all
hope to accomplish as part of the department's transformation.
From delivering timely care to veterans, to ensuring that
medical records follow the patient, to making benefit decisions
accurately, modern IT systems are essential.
This year and next are pivotal because the department has
major decisions to make about how to modernize its systems. VA
is also beginning several projects they have attempted with
poor results in the past and now is the last chance to get them
right.
Let us start with VistA, the electronic health records
system that performs so many other administrative functions.
The Choice Act independent assessment in 2015 was an invaluable
study of VistA. It explained the weaknesses and complexities
that have accumulated in the system over the last 20 years and
recommended that VA send Congress a comprehensive cost benefit
analysis of keeping VistA or changing course. Then in 2016 the
Commission on Care recommended VA retire VistA in favor of a
commercial off the shelf software. However, the VistA Evolution
program was already well underway when these recommendations
were issued. VistA Evolution attempts to catch the system up
and put it on a stable course for the future. It is the third
major attempt to modernize VistA in the past decade. Retaining
or replacing VistA is a make or break decision for VA. It must
be made deliberately and objectively. While the department
provided some cost benefit analysis before and after the
independent assessment, it was never as thorough as intended.
Senior officials have testified to this Committee and said
elsewhere that they accept the Commission on Care
recommendation. But what does that mean in practice? And that
has become less and less clear. VistA Evolution is now in its
fourth of five years, and I understand the desire to finish it.
VA must judge it realistically against concrete goals and if it
falls short moving the goal posts is unacceptable.
Another key system is the electronic health management
platform, or eHMP, which is also part of VistA Evolution and
due next year. This is supposed to settle the medical record
interoperability issue with DoD once and for all. After
changing course so many times over the years and then putting
an interim solution in place, VA has a great deal riding on
eHMP. I look forward to hearing about the plan to finish it.
VHA also still badly needs a modern scheduling system and both
sides of the aisle are united to make sure it finally gets done
this year. The Faster Care for Veterans Act puts commercial
self-scheduling software in competition with VA's VistA self-
scheduling project and sets high standards for both of them. If
either one of them cannot meet the standards it must be
eliminated. VA announced in the media that the VistA project
called VAR, V-A-R, would be rolled out in January. Since that
did not occur the Committee would like to know what happened.
Rounding out the list, last year this Committee highlighted
upgrades to the system used to process community provider
claims that had not been implemented. There has been some
progress but the situation is far from perfect. Similarly, the
Veterans Benefits Management System has advanced at great cost
but still cannot handle appeals or all types of claims.
Further, after two previous attempts VA is again trying to
replace its antiquated financial systems. This time the plan is
to adopt an existing system used by the Agriculture Department
rather than build it. This is very encouraging but it is a
complicated, delicate project.
Congress recognizes the depth of technology needed by VA.
To that end we have increased the IT appropriations more than
seven percent on average throughout the last five years. All of
these programs and others we will address today must use tax
dollars responsibly. That is why the Inspector General report
released last week on the failed cloud service broker contract
is so troubling.
Unnecessary data centers are a big problem that devour VA's
budget. These contracts were an effort to push the department
into the cloud and make headway in consolidating the data
centers. But the $5.3 million was wasted and nothing useful
produced. That $5.3 million could pay for so many other things,
for instance 70 entry level nurses in Johnson City, Tennessee.
Every account in the budget affects every other account and we
have to start thinking that way.
I will now yield to my friend, Ranking Member Walz, for his
opening remarks.
OPENING STATEMENT OF TIMOTHY J. WALZ, RANKING MEMBER
Mr. Walz. Thank you, Chairman Roe, and I want to thank all
of you for being here today, and I appreciate the collaboration
of the Chairman of understanding we are coming out of the block
in this Congress. This is our first hearing in here and there
is a reason for that. IT is the fundamental piece that ties all
of the aspects of VA together.
Mr. Thomas, I appreciate you being here. I couldn't resist
the maybe overused cliche' that Groundhog Day was last week.
You are the fourth person since I have been here to sit there
telling us when we are going to update the records. I know it's
with a commitment and a vision and a belief that is going to
happen, but I think as many of us talked technology it has not.
I get that about information technology. Thinking back to
myself, was it a bad buy when I bought that Macintosh II that
was soon replaced by the next one, the GS? Which was soon
replaced by the new iMac, which was soon replaced by this? It
happens. Technology moves quickly. Investments that are made,
especially enterprise-wide investments, that is why I think
that long range vision needs to be in place. VA has a history
of doing this right at times, with VistA and electronic medical
record. I often say I represent the Mayo Clinic and they have
talked about that. But I have used that since I have been there
for now over ten years. The technology has moved beyond that.
VistA is no longer the state of the art. VistA is no longer
maybe in some cases able to do all the things that we need it
to do.
So I think for all of us, our VSOs, certainly the GAO
report, you heard the Chairman on this, there is a real desire
to get this right. I challenge my colleagues sitting up here
is, we need to lay the challenge and say in this Congress we
are going to get there. So just the things that we are going to
focus on today, on the Commission of Care and our VSOs have
called for the purchase of a commercial electronic health
record. I want to explore that some, of where we are going. I
think, we thought the VA was moving in that direction last
summer. It does not appear like that now. That troubles me in
terms of long range vision. Also sitting over on the HAS
Committee last year of watching DoD in their purchase of an
electronic medical record, I know it is more complex and I do
not want to oversimplify. I think the question I am going to
ask and I am sure some of my colleagues are going to ask is,
why do we not have the same one? Why are we not sharing on
that? And why are we not thinking about what is necessary in
the future to make that happen?
VA remains on that high risk list because of it. We do have
to modernize the infrastructure. Dr. Roe is right. We need to
be strong stewards of the taxpayer dollars. We understand it
costs money. I would add also that we have got a lot of
qualified people out there, veterans themselves, that can add
to our capacity in the IT field. I also recognize, though, you
are not exempt from the hiring freeze. So even if we get you
the money to upgrade your infrastructure we cannot necessary
put the people in there to do that. That is going to be
addressed kind of holistically as we do that.
The next point, and I would just say as I hope to hear
today from this is, I have often said we cannot talk VA health
care, even VA in general, in a vacuum outside of the general
public. If we are going to talk about choice programs and
community-based care and fee for service, the inability to
communicate amongst the VA and those private sector entities
that in many cases are not as far along as VA is, how are we
going to think strategically of what this infrastructure looks
like to allow safe, secure, and smart transfer of data between
the VA and those private sector hospitals? How are we going to
work with them to make sure that interoperability is there, not
just between DoD and VA, but between DoD, VA, and the private
sector where our veterans are receiving care especially in
rural areas.
I am interested to hear on this. I know it is a challenging
job, Mr. Thomas. I appreciate you being there and with your
team. But as I said, again, I think from my perspective on this
is we are going to have to lay down the line in this Congress
that are we going to get to that enterprise wide infrastructure
that gets us moving where our folks, because you will hear the
testimony from the VSOs, our veterans are getting to the point
where they are frustrated. And it starts, whether it is
scheduling, whether it is transfer of the electronic medical
record, whether it is benefits payments, whether it is
smoothing out how we do G.I. Bill, all those things fall under
the umbrella of IT. So I look forward to the testimony and I
thank the Chairman for the hearing. I yield back.
The Chairman. I thank the gentleman for yielding. I ask
that all Members waive their opening remarks as per this
Committee's custom. And with that, I invite our first and only
panel who are at the witness table.
On the panel we have Mr. Rob Thomas, Acting Assistant
Secretary for Information and Technology and the Chief
Information Officer for the Department of Veterans Affairs.
Welcome, Mr. Thomas. He is accompanied by Dr. Jennifer Lee,
Deputy Under Secretary for Health Policy and Services
representing VHA; and Mr. Brad Houston, Director of the VBA
Office of Business Integration. We also have Mr. David Powner,
the Director of IT Management Issues for GAO. I now ask the
witnesses to stand and raise your right hand.
[Witnesses sworn.]
The Chairman. Please be seated and let the record reflect
that all witnesses have answered in the affirmative. Mr.
Thomas, you are now recognized for five minutes.
STATEMENT OF ROB C. THOMAS
Mr. Thomas. Chairman Roe, Ranking Member Walz, Members of
the Committee, thank you for inviting me to speak with you
about our major information technology modernization projects
at the VA. I am accompanied by Dr. Jennifer Lee, the Deputy
Under Secretary for Health for Policy and Services for the
Veterans Health Administration; and Brad Houston, the Director
of the Veterans Benefit Administration Office of Business
Process Integration.
As the Acting Assistant Secretary and CIO for VA, I oversee
the development and sustainment of every IT system that
supports the Department of Veterans Affairs. I have the
distinct privilege of working side by side with colleagues like
Dr. Lee and Mr. Houston to ensure that the care, services, and
benefits we deliver our Nation's veterans are backed by the
best technology. Now I could share with you the number of
systems and the number of bits and bytes we process each day.
But the most important statistic I can share with you is that
59 percent of our 8,000 person IT workforce are veterans.
I am proud to be a part of that 59 percent. As a grandson
of World War II veterans, son of a veteran, nephew to four
veterans, and a veteran myself, my responsibility to serve is
an honor and a blessing. In 2015 I was living in St.
Petersburg, Florida. I had just accepted a VA position there. I
had no plans to come back to Washington, D.C. As a native of a
small town of 225 people in Western Montana, D.C. is a long way
from home. I had already retired from the Air National Guard,
served as the Chief Information Officer for a Federal agency,
and served as the Deputy CIO for the Department of the Air
Force. The job in St. Petersburg came with sunshine and a
simple focus: improve the veteran experience. Shortly
thereafter I received a call from our former VA CIO. She asked
me to come back to D.C. to redefine our approach and to ensure
that everything we delivered in IT had a clear path and clear
value.
Since that time we embarked on a complete transformation of
the organization and we continue to execute against our
enterprise strategy. We focused on programs and projects that
deliver value and outcomes to our veterans by slashing numerous
processes' steps and artifacts to streamline our services. In
September of 2016 our new Enterprise Program Management Office
was established. We transitioned over 200 projects from the old
system to a new agile process. This transition delivered an on
time delivery rate with an estimated 85 percent cost avoidance
since 2015. The enterprise cyber strategy reduced elevated
privileges by 95 percent, remediated 23 million critical and
high vulnerabilities, and removed 95 percent of prohibited
software.
We are exchanging more health information with DoD than at
any time in the department's history. Our VBA claims are no
longer paper. The Veterans Benefit Management System, or VBMS,
has helped drastically reduce the disability claims inventory.
Our Federal Information Technology Acquisition Reform Act, or
FITARA score, moved from a C to a B plus in less than a year.
VA was one of only three government agencies to receive this
rating and is the largest and most complex to do so. We went
from 19th to fifth in the OMB customer service survey, the only
Federal organization to advance. We have proved out the concept
of a cloud based digital health platform that includes holistic
improvements to health care operations, reduced wait times, and
improving the veteran's experience.
Our Nation's veterans have a force of thousands of IT
experts looking out for their needs. It is a team working
tirelessly day in and day out to modernize the full veteran
technology landscape. It is a team focused on action and
discipline to ensure a shift from homegrown separate entities
to a fully integrated modernized environment capable of
operating as a cutting edge enterprise. It is a team intent on
becoming a world class organization that provides a seamless
unified veteran experience through the delivery of state of the
art technology. They are well on their way to doing so and I am
honored to lead them.
Mr. Chairman, I am happy to answer any questions. Thank
you.
[The prepared statement of Rob C. Thomas Beth McCoy appears
in the Appendix]
The Chairman. Thank you very much, Mr. Thomas, for your
testimony. And now, Mr. Powner, you are recognized for five
minutes.
STATEMENT OF DAVID A. POWNER
Mr. Powner. Chairman Roe, Ranking Member Walz, and Members
of the Committee, thank you for inviting GAO to testify on VA's
IT acquisitions and operations. Technology can help make major
improvements so that ultimately our veterans will face shorter
wait times to schedule needed care, receive higher quality
care, and have their claims processed quicker and more
accurately.
VA spends billions on IT annually and does not have a great
track record for delivering new capabilities. The department
will spend nearly $4.5 billion on IT this year. That makes them
the fourth highest IT spender in the government, behind DoD,
HHS, and DHS. Of the $4.5 billion, only about $500 million goes
towards developing or acquiring new systems. The remaining goes
primarily towards operational systems, many of which are old,
inefficient, and difficult to maintain.
Every two years at the start of the new Congress, GAO
issues a high risk report highlighting areas most in need of
congressional oversight. In 2015 we added two new areas,
managing VA health care and managing IT acquisitions and
operations, which both highlighted concerns with VA's IT
management, including past failures where hundreds of millions
of dollars were wasted. Next week the Comptroller General will
be testifying on our 2017 update and these two areas will
prominently remain on the list of about 30 high risk areas.
This morning I'd like to briefly discuss five areas where
this Committee's continued oversight is greatly needed. Three
areas are major acquisitions associated with electronic health
records, scheduling, and claims processing, and two other areas
address aging legacy systems and inefficient data centers.
Starting with electronic health records, it is well known
that interoperability is needed between VA and DoD and that in
2013 a plan was abandoned to pursue a single approach. In GAO's
view this is duplicative and we see no evidence that separate
approaches will be cheaper or quicker. DoD is pursuing a
commercial solution while VA is attempting to modernize its 30-
plus year old VistA system. VA is now considering a commercial
electronic health record. This uncertainty is not acceptable
and a decision needs to be made. VA needs to let go of VistA
and go with the commercial solution. Further, we see no
justification for VA and DoD pursuing separate systems.
Turning to the scheduling system, the history with
modernizing this system to address long wait times and errors
is best characterized as a failure. This project was terminated
in 2009 after spending $127 million over a nine-year period.
Eight years later, this 30-plus year old system still needs to
be upgraded. Similar to the EHR situation there is uncertainty
with the approach forward and a decision needs to be made
between enhancing the current system or going with a commercial
product. To its credit, I'd like to add that the department has
pilots underway looking at commercial products. Again, buying
instead of building is the way to go.
The final acquisition I'd like to discuss is VBMS, which is
the system that processes disability claims among others. This
upgrade was needed to reduce the backlog of claims and to
process appeals better. This system was partially deployed in
2013 and continues to be enhanced. The good news with VBMS is
that the records are almost entirely automated, eliminated the
inefficient paper. However this system was to be completed in
2015. What is needed is a firm completion date and better
transparency as to exactly what changes are being made to
enhance disability claims and appeals processing. Our
understanding is that this year $75 million is to be spent on
developing this system further.
With these three critical acquisitions congressional
oversight is essential to ensure that several decisions are
made quickly and that progress on all three is better than in
the past. Our veterans need these upgrades and I would suggest
frequent reporting to this Committee on progress. We at GAO can
assist in this oversight in whatever manner is necessary, Mr.
Chairman.
Now I'd like to address the issue of old systems and
infrastructure and how VA needs to decommission these systems
and consolidate data centers to free up modernization funds. We
already discussed the 30-plus year old VistA and scheduling
systems. Last year we reported on the government's oldest
systems and VA has two systems that are over 50 years old. One
is a personnel and accounting system, another is associated
with claims processing. These are expensive and difficult to
maintain and pose security risks.
Finally data center consolidation. Since 2010 Federal
agencies have been consolidating data centers to address unused
capacity. Government wide over 4,300 centers have been closed
of the 10,000 data centers the Federal government has and
collectively we saved $2.8 billion government wide. VA has done
very little in this area, only closing 30 of its 391 centers
and saving only about $19 million.
Mr. Chairman, this concludes my statement. I look forward
to your questions.
[The prepared statement of David A. Powner appears in the
Appendix]
The Chairman. Thank you very much. The written statements
of those who have just provided oral testimony will be entered
into the hearing record. Now I will yield myself five minutes
to begin questioning.
First I would like to start off with Mr. Thomas. And I know
that we are spending $4 billion or $4.5 billion or so each year
on technology, which is a marked increase and obviously needed.
I read in the report that 86 percent of the money we are
spending on IT is used for just maintaining the current system.
If we put an off the shelf, as the Commission on Care
recommended, if that were adopted, and I realize all the
hazards and difficulty in doing that, how much of that would,
how much would you need to maintain a new system? In other
words, what percent of that budget, instead of 86 percent?
Would it be half the budget? A fourth the budget? Or how much
to maintain a brand new system? Just like maintaining a new car
usually is pretty inexpensive.
Mr. Thomas. Chairman, I do not have an exact number on
that. But we definitely agree that our numbers are out of
kilter from industry. You would like to see 60 percent or so in
maintenance and 40 percent in development. As has been
communicated we are running an 85 to 90 percent in sustainment.
We have to shrink that footprint. We have to shrink that
sustainment. And we do have a legacy modernization effort now
that we have stood up to go after those sustainment dollars to
reduce that footprint. It would have to be, to your specific
question, I would have to know exactly which system we were
looking at and which ones we were replacing in order to give
you an exact number.
The Chairman. Certainly, I agree with that. The question, I
guess what I was looking for, the number is significant. And
however much that is, that could actually go into paying for a
new system instead of maintaining an antiquated system. Do you
agree or disagree with the statement that VistA lacks the tools
and the extensive analytics capabilities of a modern commercial
EHR? Do you agree or disagree with that?
Mr. Thomas. I agree with you, Chairman.
The Chairman. Well then we, then why are we proceeding
down, and I know you are not, Mr. Thomas. You have been given a
job to do. But why would VA continue down that road when
basically DoD swallowed the bitter pill and they are in the
process, and I know, I have implemented an electronic health
record system. It is not easy going from paper, transporting
from where you are now to a new system would be an enormous
undertaking. I certainly understand that. But my fear is, I
have been sitting here now for eight years and listening to how
it is going to get better and so forth. And I realize there are
a lot of good, smart people out there that are working on this.
It is obviously not easy. But there are great commercial off
the shelf products that can do scheduling, that can do billing.
I was reading where I think it is TriCare and Medicare pay
their claims at 99 percent in 30 days. VA is 60-something
percent in 30 days and we are losing our providers. They are
dropping off and that is hurting our chance to reform the
Choice program. Because if you do not have network providers
out there in the private sector you cannot do the Choice
program. So the fact that VA does not have the technology to
pay its bills is actually hurting our mission of health care.
So I think, another question I have on the benefits side it
was estimated that the life cycle costs would be about $579
million and a year later it is $1.1 billion. That doubled in a
year. So I think we have been sort of burned with that. We have
seen what happened out in Denver and other things VA has done
in house. So maybe we should look at off the shelf. And I know
this is not your cause. Your job is to try to make the system
work. I understand that and I appreciate your team's hard work.
Another question I have on VBMS, how often is that system
down, not functioning? And how much lost productivity is that,
when people cannot access the records or anything?
Mr. Thomas. Chairman, I do not have a specific number on
the downtime. I will tell you that we do quarterly releases to
make sure that the system is performing and doing what the
benefits folks need to have. Those tools are extremely
important for eligibility and benefits. But I do not have a
specific number on the downtime over the past 12 months. But I
can get back to you with that.
The Chairman. I would appreciate that. Because I think that
obviously delays the claims being completed. What are the
success criteria for VistA 4 and eHMP? And I don't mean just
the back end technological improvements. What are the new
things clinicians are going to be able to do, such as in care
coordination, information sharing, they cannot do now? And I
will, I am going to gavel myself down. My time has expired. And
if we have a second round I would appreciate the answer. I now
yield to Mr. Walz for five minutes.
Mr. Walz. Thank you, Mr. Chairman. Back to this issue of
legacy costs that we were, it is my understanding DoD spends
about 95 percent of their IT budget on managing legacy costs
and that was one of the main reasons they gave publicly for
moving to a commercial program for them. And so I think that
the question Dr. Roe brought up is very interesting. Again,
without gross generalization that used car that is sucking up
money every single month and is undependable, it is not
delivering what it is supposed to do, versus one that is under
warranty, is better, again, I know it is much more complex than
that. But I think that analysis.
So that brings me to this. We need to know those numbers.
And the independent assessment recommended that VA conduct a
cost benefit analysis among commercial EHRs, open source EHRs,
and the continued development of VA's own custom in house EHR.
This report, they were to report this analysis to Congress by
the end of 2016. Has this been done?
Mr. Thomas. Ranking Member, we did complete the business
case analysis. We completed it at the end of December. We have
that. We would be happy to come back and talk to your team
about that. But we do have the business case.
Mr. Walz. Do you feel, Mr. Thomas, that data, and I do not
know what it showed, but do you not think that would be an
important consideration on decision-making points? What that
shows in there in terms of cost versus those different routes?
Mr. Thomas. Yes, absolutely. I totally agree.
Mr. Walz. Are there commercial sources in your opinion, or
maybe some of the experts with you, that would support VHA the
way we need it to?
Mr. Thomas. Absolutely. I mean, it is going to be my goal
and my charge that we go commercial to the greatest extent
possible. Because we have not had a great track record on
developing software. It has been delayed. We have seen the
delays. And it is going to be my goal to go commercial to the
greatest extent possible.
Mr. Walz. I think if the data leads us there, and I think
many of us up here it has led us there, I get the feeling that
people who sat in your position before agreed with that, too. I
think Dr. Roe brought up an interesting point, he is probably
right about this, unfortunately it does not appear like it is
going to be your call. My suggestion to our colleagues is I
think it needs to be our call, with the money, with the
taxpayers, if we are getting the right data in this. If the
experts are telling me this is the right way to go, if the data
and analysis shows that, and we are simply choosing to go
legacy routes because of unknown reasons, that is when we need
to step in and say, no, we are going to pursue this. Which
leads me to the next one.
GAO believes it does not have the assurance from the VA and
DoD are pursuing the most effective solution. And Mr. Powner, I
appreciate your candidness on this, that they are not doing it.
I have talked until I am blue in the face about seamless
transition. I sat in those hearings over in HAS last year where
one of the reasons they gave us over there is that, well, the
VA system will not operate on submarines. Perhaps not. I do not
know that for a fact. But the issue there being is that we have
such unique needs in DoD versus VA that there is no possible
way we could design an electronic health record that would have
interoperability. It simply did not address the issue of pay,
benefits, all the other things that could be interoperable. Is
there any progress in our mind, Mr. Powner, that we are moving
towards my 201 file can seamlessly shift over to either VBA or
VHA without any glitches? Do you think that is happening? Or
could it?
Mr. Powner. No, not at all. I----
Mr. Walz. Okay. So we hear about all the information they
are sharing back and forth. We hear about all the
communications that are starting to happen. But none of that
matters to the veteran. What I care about is, I go into VA and
they have everything there that I do not have to go back home
and dig in a shoe box for, you know, whatever it is that was
given to me paper format.
Mr. Powner. Look, it is well documented there is a lot of
commonality across the two departments and agencies. Yeah,
there are some unique requirements. But what, the problem with
the Federal government is they are so reluctant, not just VA
but other pockets in the government, to buy commercial products
and change antiquated business practices. Buy commercial
product and change the business practices. That is why DoD's
estimate is so high because it is primarily going to change the
business practices. So that is buy one, and change the business
practices. And if we have a few one-offs on ships or whatever
it is then we have one-offs. But you can work around the one-
offs if you have an 80 or 90 percent solution for the two
departments.
Mr. Walz. And it is, and I can tell you this Committee, and
I am very careful, again, I keep coming back to the term. I do
not want to oversimplify something that is very complex. It is
not as easy as people want it to say on all this. I have to
tell you, I cannot talk to a veteran and justify why we are
going to spend countless dollars for two systems that may not
communicate, that do not improve the veteran experience, that
do not make it more secure, and do not guard taxpayer dollars.
So I am at the point now where I encourage my colleagues on
this is we need to demand an interoperability. We need to have
one system. We need to buy it if it works there. Then we need
to be responsible to make sure it is implemented. And ten more
years of it, I cannot stand it.
The Chairman. Thank you, Mr. Walz. Chairman Bost, you are
recognized for five minutes.
Mr. Bost. Thank you, Mr. Chairman. And if I can, and if the
Committee will tolerate me, going back to the Ranking Member's,
just so you know it is very hard to explain to the general
public why it is that we cannot take our records from DoD and
go right into being a retired veteran, and that same medical
record cannot be transferred. That is very difficult to explain
to the public. Now I know it is hard to get done, and I know
that the military and we in the military have always worked
that way. Because remember the computers were turning up
whenever I got out of the military and I still have the blue
microfiche. Now I have to have find a microfiche reader to be
able to see my records, which you cannot hardly find those
anymore by the way. That being just an opening statement. That
is not where I want to go with the question.
I would like to, if I can, question Mr. Houston with the
VBMS. You know, our last numbers we have shown that the total
cost of the VBMS was about $1.3 billion from January, 2015. How
much of that the department has spent on developing the VBMS to
date? Where are we at, as far as the numbers are concerned?
Mr. Houston. Congressman, the development cost is about
$500 million. The remainder of that cost is testing, quality
assurance, and then the operating costs for running the system,
and then the cost of loading the system.
Mr. Bost. Okay. Well the estimated cost from what I
understand it was $579.2 million, but that was in 2009, is that
correct?
Mr. Houston. Sir, I am not sure where that number is from.
Mr. Bost. Okay.
Mr. Houston. But we did not spend $579 million in 2009.
Mr. Bost. Okay. So the real question I have is, is does the
VBMS have the capacity to process pension claims?
Mr. Houston. Congressman, it currently stores all records
for pension claims. It makes payments for some of the pension
claims. This year we will finish the processing so that it will
be able to pay all pension claims through the VBMS system.
Mr. Bost. So it will be done by the end of this year?
Mr. Houston. Yes, sir.
Mr. Bost. Well if that is to say, now from start to finish?
Mr. Houston. Yes, sir.
Mr. Bost. Okay.
Mr. Houston. In addition to the payment of the claim, we
have integrated incoming pension claims into our central intake
system as well. So it will be start to finish, Congressman.
Mr. Bost. Okay. How much of a priority has this been with,
through your agency?
Mr. Houston. Congressman, I am new to the VBMS team.
However, pension processing has been right behind the backlog
as far as the priority for the systems development.
Mr. Bost. Okay. The reason why I am asking these questions
and the concerns I have is each one of us in our office, and
one of my busiest members of my staff is a veteran himself that
processes these claims. And the process and the length of time
that it takes is so devastating to our veterans. And many
become frustrated and they just throw their hands up and quit,
and that is not what we want them to do. We want that
opportunity for them to receive their claim due them, if due
them, okay? Now that does not mean we want fraud or anything
like that. But those that are truly due the benefits, we need
to be able to process them as quickly as possible. And in this
electronic age, there is no reason why we should have to wait
as long as we do and why it actually takes an act of Congress
to try to push through some of those that are very, very clear
and the concerns that we have. So my hope is that you are
continuing to work on the system to get it to where it works as
fast as possible, at the point that the private sector feels it
should move.
Mr. Houston. Congressman, that is absolutely correct. And
you mentioned end to end. I think more important than just end
to end is automation. End to end processing with our same
humans has the same constraint. And pension claims are math.
And one of the things about moving them into central intake is
to extract the numbers they wrote into data so that we can do
automated decision-making or accelerated decision-making
through the use of automation. And that is part of why we need
to continue to invest in that system.
Mr. Bost. Okay. Thank you and I yield back.
The Chairman. I thank the gentleman for yielding. Mr.
Takano, you are recognized for five minutes.
Mr. Takano. Thank you, Mr. Chairman. Anyone on the panel
might answer this question. Does interoperability between DoD
systems and the VA systems depend on using the same vendor? In
other words, is VA, if we are going to move toward
interoperability, are we in a position where we are going to
have to be forced to, say, adopt the Cerner system because DoD
has purchased it first?
Mr. Thomas. You will recall last year my former boss
LaVerne Council came over and talked to you about the digital
health platform. We went down that proof of concept during the
summer and into the fall. And what we did prove out in that is
that we can have full interoperability with the Cerner EHR with
the FHIR, which is the Fast Healthcare Interoperability
Resources. It is the industry leading standard. So we would not
have to be on the same commercial EHR and we could have that
interoperability you are asking about.
Mr. Takano. So if we were to go, make a commercial decision
to go fully commercial, we would still have an option to look
at different providers and take bids or evaluate who might
offer the best value in terms of a contract?
Mr. Thomas. Yes, Congressman, that is the plan.
Mr. Takano. Do you generally agree with the idea that who
owns a patient's data should be the patient him or herself? You
are nodding yes. Is it, is it the case in the private sector
that there is complete portability of data in most cases? Is
that something we are arriving at? Or are there impediments to
that?
Dr. Lee. Congressman Takano, I can speak to that. So as a
practicing emergency room physician I have worked in many
different health systems in the private sector and now at VA
and also in DoD. And the interoperability or portability of
records is a challenge in many of our systems. We are getting
better but it is still a challenge.
Mr. Takano. Is there a proprietary interest among private
health care providers to really not be fully portable because
they want to keep that information to have some sort of
economic advantage? In other words, that data is valuable in
terms of being able to not share, that really they are not
fully on board with that, the patient has a full ability to
have that data be portable.
Dr. Lee. I personally believe that is often the case.
Mr. Takano. Has not been the case? Okay----
Dr. Lee. That that is often the case.
Mr. Takano [continued]. You think that is often, that is
the case?
Dr. Lee. Yes. Yes.
Mr. Takano. So here is my question in terms of our
potential of going fully on Choice, is we have VA with its
massive data, it is one of the largest health care systems in
the world, looking to interact with a private sector system
that is not going to be fully transparent, not fully on board
with the idea of 100 percent portability. We are trying to
achieve that between the DoD. There is no question I think that
all of us on this Committee want that to happen with DoD and
VA, that we have seen terrible things happen when there is not
that 100 percent portability. But I think there is a question
about whether that portability is something that we will be
able to achieve in interfacing with the private sector.
Let me see what other questions I might have had.
Dr. Lee. Can I speak to that for----
Mr. Takano. Please, go ahead.
Dr. Lee [continued]. So you are absolutely correct. We need
to improve our health information exchange with the community.
Because now, over 30 percent of our care is actually purchased
in the community. And so health information exchange is not
only, and interoperability is not only critical with DoD but
with our community partners.
The way that we are going about doing that is through the
eHealth Exchange, getting our community partners to sign on to
the Health Information Exchange. And over time we have improved
significantly in the amount of information exchange we are
doing. So right now we have over 88 community partners, that
represents 815 hospitals, over 430 federally qualified health
centers, 150 nursing homes, over 8,400 pharmacies, and over
14,000 clinics. So, and those are health systems like the Mayo
Clinic, Cleveland Clinic, Johns Hopkins, and other major
providers where you can now go, they can see our veterans'
information securely and we can see information about those
patients if they have been in those systems.
Mr. Takano. Dr. Lee, do you think it is an important
principle that we establish with regard to interacting with the
30 percent of our private sector providers that the patient's
medical information is owned by the patient and should be 100
percent portable?
Dr. Lee. I think that is our goal. We want to empower
patients. It is one of our goals in VA is to engage our
patients, our veteran patients in their care. And I think that
would lead to better health.
Mr. Takano. Thank you.
The Chairman. I thank the gentleman for yielding. Just to
comment, the 21st Century Cures Act made strides to make
different commercial EHR systems share information. It imposes
a $1 million penalty for every occurrence of information
blocking. And Dr. Lee, you are absolutely right. One of the
problems you have is being able to share data when you are in
the ER or wherever you may be seeing a patient. I now yield
five minutes to Dr. Dunn.
Mr. Dunn. Thank you, Mr. Chairman. And also let me say
thank you for allowing me to participate on this important
Committee. I am the son of a veteran, a father of a veteran,
and also a veteran myself. So it is very close to my heart.
Mr. Thomas, I understand the VA has yet to resolve some
9,500 outstanding system security risks identified by the IG as
recently as March of last year. They also produced 35
recommendations for improving the VA's information security
programs, six of which were recent and 29 of which came from
previous years. Now the VA is required under the FISMA, the
Federal Information Security Modernization Act, to ensure
effective security controls over your information resources. My
question is do the weakness in your security posture put at
risk any personally identifiable information for your patients
or your workforce?
Mr. Thomas. Thank you. I would say protecting the veterans'
data and the employees' data is job one for me. It is what
keeps me most focused and most concerned. As you communicate,
we have had a number of findings. We have closed three of the
eight findings. We have 35 plans in play right now. We have a
very large focused team. And we plan to close all of those
findings at the end of 2017. So it is a major focus for us.
Mr. Dunn. In `17? Excellent. So is the VA aware of any
breaches in security where personal information was retrieved
by intruders?
Mr. Thomas. I am not aware of any at this time but I can
get back to you. If we have had some I have not been told.
Mr. Dunn. Obviously, we would be curious to know that. And
finally, can you share with the Committee why the VA has had so
much trouble? What is keeping you from better securing this
system? And you spoke to the timeline, so that was my question.
Mr. Thomas. I think VA lacked a coherent strategy on cyber.
I think in 2015 when we came together and developed the
enterprise cyber strategy, delivered that to Congress, we
developed an incredible plan that had a lot of details. It had
900 actions that we needed to take care of in our integrated
master schedule. And we have been going after all of those.
When I came to the VA we had personally identified the PIV
cards that everybody has to use to log on, we were at less than
ten percent when I came to the VA. Leaving FEMA, we were at 99
when I left FEMA. Coming to the VA, we were at ten, we are now
at 85 percent. We have made incredible progress in the last 18
months.
Mr. Dunn. Thank you. Mr. Powner, in your expertise do you
wish to add anything? Elaborate on any of those comments or----
Mr. Powner. No. I would just say on the information
security front, that was IG work not GAO's, but the good news
is there were those vulnerabilities and they are fixing them. I
think the question of the breach is I think another important
bit of information for this Committee would be the number of
times the VA has been attacked, whether there was a breach or
not. Because sometimes you might have a full breach but your
understanding of who is hitting us and at what frequency, that
is, you kind of need to know that, too. And that is very
important.
Mr. Dunn. And can you share those numbers?
Mr. Powner. I don't have that personally. I don't have that
information. We have not done detailed work on it. But that is
clearly something that the Chief Information Security Officer
would have.
Mr. Dunn. Who do you think the actors are? Who is trying to
breach your information?
Mr. Powner. It is all over the board. I mean, I do work, I
do some detailed work on things like on NOAA ground systems for
our weather satellites. They get hit and we did some recent
work on that. And, you know, it's all over the board when you
look at that. And that's why it's important, it's great that
the vulnerabilities are being addressed and that hopefully
there have not been any breaches where PI has been disclosed.
But knowing the frequency of those attacks is very helpful
because it helps us secure better. And we just need to be open
with that because it is continually increasing.
Mr. Dunn. Thank you. We would look forward to seeing those
numbers. Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding. Ms.
Brownley, you are now recognized for five minutes.
Ms. Brownley. Thank you, Mr. Chairman. And I want to
associate myself also with the comments that the Chairman has
made and the Ranking Member as well. And I wanted to ask in
terms of the EHR and where we are, so that we are all on the
same page here in understanding where we are. Who is making
that decision? And when is that decision going to be made in
terms of going to, you know, an off the shelf system or
continuing efforts on the VistA?
Mr. Thomas. Thank you. I am confident we are going to go
commercial. I can't speak for Dr. Shulkin. I hope for a speedy
confirmation so that he can come on and help us work through
that. I can tell you that knowing his background in industry he
has done that and his experience has been a doctor in leading
hospitals in the past. I have worked with him the past 18
months. He is very decisive. And I am looking forward for a
quick confirmation for Dr. Shulkin to come on as the Secretary.
Ms. Brownley. And so I understand that, you know, these IT
systems are complicated. The decision-making process should not
be complicated, though. That should be pretty straightforward
and simple, from my perspective. So if we go to an off the
shelf product, when would we do that? And how long will it
take? And do you have a timeline? I mean, it sounds like you
cannot really until a decision has been made. But roughly, how
long would it take if the decision was made today?
Mr. Thomas. Congresswoman, the only thing I could go by is
what timeline DoD has had. We are working very closely with DoD
on how they are doing. I'm going next week up to Fairchild Air
Force Base to the Genesis Cerner EHR ribbon cutting. I do not
have a timeline for you. But I think once the decision is made
we can get back to you with what that timeline would be.
Ms. Brownley. Okay. And the GAO has commented, you know, on
the electronic health records, on scheduling systems, on VBMS.
And it sounds like we are making some progress on VBMS.
Scheduling systems, I am not sure where that is. You know,
again, I think this, the decision-making tree and the timeframe
should be a relatively straightforward one that everybody is
well aware of and understands that we can monitor. So are we
waiting for Mr. Shulkin to come in and everything will be, you
know, decided again? Or is there a timeline that everyone is
following around some of these systems and where we are going
to get the improvements that we need?
Mr. Thomas. So as it relates to scheduling, we talked to
you all last year about access being the top priority of the
agency and that we were going to modify the VistA scheduling
enhancement. We spent $7 million on that. We have a go-no go
decision on putting, delivering that to all of the field. The
go-no go decision is on 10 February. So we are very close to
that date. We had some slip-ups through the year last year and
because of that Dr. Shulkin as the Under Secretary of Health
directed that we move forward with MASS, which is an epic
commercial solution. We kicked that off in January. We went
through critical decision one on January 19th and we are moving
forward with the commercial scheduling capability and Boise,
Idaho is the pilot.
Ms. Brownley. Thank you. I just hope, Mr. Chairman, as we
proceed this cycle that these timeframes that we have and drop
dead dates that we can stay sort of apprised. That just we have
a sort of almost like a cheat sheet of all these different
systems, you know, what the timeline is going to be, where the
decisions are, so that we can really monitor them. Because as
you said in your opening comments, it always feels like the
goal posts are moving and I cannot keep track of the movement
on those goal posts because it is testified in one Committee
that says this, and then we go to, you know, to the next
meeting, and then it said, oh, well we had some delays. Well,
okay, so we had delays. How are we being informed? You know
what is the new timeline? So I just, I hope really that we can
do that and get there.
To the GAO, I am just wondering if you were following the
DoD implementation of electronic records and are you sort of
watching the success, if you will, as it rolls out? The
interoperability with community health services as well?
Mr. Powner. Yeah, we are monitoring that at a high level
and we will keep you apprised on how that is going.
Ms. Brownley. And, I mean, so far are you seeing good
results?
Mr. Powner. It is very early.
Ms. Brownley. It is very early.
Mr. Powner. It is very early. One comment on the goal post
moving, if I could suggest, I do work for many Committees in
the Congress on these IT issues. I think it would be very
valuable if you guys had a quarterly update on all these
systems. One on electronic health records, one on scheduling,
one on VBMS. We could establish the baseline and we could get
quarterly updates and we can assist you with those updates
coming from the department. And then we would have very clear
transparency on what progress is being made or if it is not
being made, and if the goal posts change. And we would love to
assist you in that oversight if you want to do that.
The Chairman. Your time has expired. I think that is a
great idea. I ask unanimous consent to allow General Bergman,
who has got to be at another hearing in about five minutes,
since I retired as a Major and he is a Three-Star General I
hope I do not hear any objection to that. So if you would go
ahead, General Bergman? Fire away. Yes, sir. I am an 04. You
are----
Mr. Bergman. I had better pay attention here, or listen to
the question. Mr. Powner, your testimony states that the VA
operates approximately 240 information systems. Of that 240,
how many are major, how many are minor? Or are there, is there
a third category?
Mr. Powner. I don't have an exact number of majors and
minors. I will say this, VA has to report on the IT dashboard
on what is called major investments. The problem is with their
major investments, some of those investments have multiple
systems rolled up underneath that. Most of what they do there
is major, major operational systems and major systems that are
in acquisition. I think the big thing going forward when you
look at their split on their IT spend is each year the amount
of money they spend on development continues to lessen, while
the amount of money they spend on their operational systems and
salaries increases. So we are below $500 million on this $4.5
billion and that is really what we need to kind of reverse that
trend. They are not alone. This is a problem across the Federal
government. But a 10-90 split, close to that, is not where we
would need to be.
Mr. Bergman. Okay. Thank you. Mr. Thomas, how many of those
systems does the VA believe are necessary to really accomplish
the mission?
Mr. Thomas. Congressman, I think the systems we currently
have that are even antiquated are necessary for the mission. I
would probably say that we have five majors. I would consider
VistA a major, VBMS a major, our interoperability is a major,
MASS is a major, and then the newer one is our financial
modernization. Those would be what I would consider the big
five.
Mr. Bergman. Thank you. Again, Mr. Powner, how would you
recommend that the VA go about the modernization of some of
these specific systems to eliminate those maintenance costs
that you referred to and to free up money for new innovation?
Mr. Powner. Yes, so the modernization or development needs
to go hand in hand with the decommissioning of the old systems.
So for instance, the one system I mentioned, BDN, which does
some claims processing, that is tied to some of their
modernization efforts. We need firm decommission dates.
The challenge in the government is we continue to
modernize. And VA does do the right thing on incremental
development. We encourage that. But you need an end game, like
on VBMS, when are you going to be able to deploy VBMS
completely and then when are we going to be able to turn off
this old accounting system, the old claims processing system,
that is 50 years old?
I will add the data center consolidation, there is an
opportunity there not only to modernize and secure our data
better, but to save hundreds of millions of dollars if they got
serious about it. We mentioned DoD, that they have a worse
split on legacy versus new development. But DoD has a great
data center consolidation effort and I think they are planning
to save about $4.5 billion when it is all said and done by
about 2019 on consolidating data centers. VA needs to get in
the same boat with DoD on data center consolidation, because
you can shift inefficient spending into the development bucket.
Mr. Bergman. Thank you. Mr. Thomas, would you like to add
to that at all?
Mr. Thomas. Well I would just completely agree. We have to
shrink our footprint. We have often sided with delivering more
functionality versus shutting down and decommissioning legacy
systems. We are now going after this in an aggressive way. We
actually stood up a team in order to go after sunset dates of
our systems. We have to shrink our footprint. If we do not
shrink our footprint, we do not free up dollars that we can
develop and deliver capabilities to serve the veterans and
improve the employees' experience. We are going after this in a
big way.
Mr. Bergman. Okay. Thank you. Mr. Chairman, I yield back
the rest of my time. Thank you.
The Chairman. Thank you for yielding. Ms. Kuster, you are
recognized for five minutes.
Ms. Kuster. Thank you very much, Mr. Chairman. And I just
want to say to General Bergman, who is the Chair of the
Oversight and Investigations Committee, as you're Ranking I
would look forward to working with you and ask for perhaps from
the chair that we could have those quarterly reports unless
they are coming to the full Committee. I am going into my third
term. This was the very first hearing we had when the class of
2012 came and it is discouraging. It sounds like there has been
some progress, but there is a lot of confusion still. And I do
not understand why we do not get progress reports and why we
only find out about this when we come to these seemingly annual
first hearings. So I would take you up on the GAO's suggestion
that we get quarterly reports.
I think it is a complex area. But we deal with a lot of
complexities in the United States Congress. We deal with a lot
of big budgets and we deal with a lot of IT. And it is
discouraging to me to continue to hear about systems that are
50 years old that pose a security risk that I cannot even
imagine, how many people work in the VA that can do anything on
a 50-year-old system? Were they seven years old when they
started? I mean, how long have they been there? Who can work on
these systems?
Mr. Thomas. Well we have always had transition plans. But
to your point, the available resources for those aging systems
gets smaller every year as people retire and as people
separate. That is what increases that risk. That is what makes
this even more important that we get these legacy systems shut
down.
Ms. Kuster. And these are not minimal systems. Accounting?
This is how we are keeping track of all these tax dollars
across our country? Claims processing, this is why we hear from
veterans who wait years, dozens of years, trying to get their
fair shake on the services and the claims that they are due. So
I just want to join those of us on both sides of the aisle
about our frustration.
I am interested in your testimony that buying instead of
building is the way to go. That at least seems to be some
progress from where we were with the VistA and the Alta and we
want to keep our own and we do not want to look at the other.
But I have got to ask you a question. Because there is a
terminology question that I am concerned about. We hear about
off the shelf, and that I presume is a term of art for a
private proprietary commercial product. But when you use that
going commercial, we recently heard from a VA witness that you
are moving toward developing the digital health platform which
actually is not commercial. That is a public private
partnership, not off the shelf. And my understanding is that
that could take up to 25 years. It does not currently exist. It
would require a substantial effort, I would imagine a
substantial cost. And look you realize, because this is your
goal as well, we are put here to serve the veteran first and
serve the taxpayer at the same time. And I have just got to ask
you, what is it that you are referring to? Are you talking
about going commercial or are you talking about some kind of
public private partnership that would take a long time to
develop?
Mr. Thomas. So when we did the digital health platform, in
that it had VistA as one of the options. But it also had a
number of commercial off the shelf capabilities that went along
with it. For example, customer relationship management out of
the box already, not something that we would have to custom
build. The analytics engine came out of the box and it was
available. So there were commercial products along with our
VistA so it is a hybrid.
Ms. Kuster. Can I ask you about scheduling? Because I know
I had a meeting in my office--now this is four years ago--with
a company that I thought was brilliant. They had a scheduling
product that would create efficiencies by taking into account
people who are unlikely to show up to their appointment. They
have a long history, they have travel issues, getting a ride,
you know, any of the number of issues that our veterans deal
with.
And that you put the reliable people in the morning and
just bang, bang, bang, get them done, and the less reliable
people later in the day, and double book. Why isn't something
like that in the works? Because I can't even imagine. We are
talking about the money that we are spending on IT, we are not
even talking about the taxpayer dollars that are being lost
from lost productivity just out the window because people can't
see the doctor, the health care provider, they need. If you
could respond.
Dr. Lee. Congresswoman Kuster, we have to modernize our
scheduling system. It is really a priority for us because it
does impact our ability to perfectly match the capacity of our
providers to the demand and the appointments requested. So, as
you heard from Mr. Thomas, we are moving forward with the
commercial scheduling solution, MASS, that will really
revolutionize the way that we are able to serve veterans.
Ms. Kuster. And my time is up. What is the timeframe on
that so my Subcommittee can keep track of that?
Dr. Lee. So we will have results from the pilot in about 18
months, so it will be summer of 2018. In the meantime, we do
need an interim solution and that is the VistA Scheduling
Enhancement that you heard about. We will have a final answer,
go/no go, by the 10th of February.
Ms. Kuster. I just hope this technology is not obsolete by
the time you get it in place----
The Chairman. Ladies.
Ms. Kuster. --but I admire your efforts, and I hope that--
--
The Chairman. Time has expired. Chairman Arrington, you are
recognized for five minutes.
Mr. Arrington. Chairman Roe, Ranking Member Walz, thank you
for the opportunity to serve on this Committee. I represent
West Texas, 29 counties, 40--over 40,000 veterans. I did not
serve in the military, and so I thank God for the opportunity
to serve those who did serve, and I hope I can make a
contribution here.
I got to say I am very discouraged to hear about the
timeframe of years and the lack of productivity and problem
solving because we are all here to serve the veterans and
provide excellent service, there is nobody that does not want
to do that, no one in this room. And we are also here to be
stewards of the taxpayer monies, and I can't wrap my head
around because we are not trying to send a man to Mars, we are
just trying to provide services in a meaningful way, and a
responsible way, and nothing seems to be working.
Let me jump to my questions, I have so many I will have
follow-up after the hearing. But I hear a lot about symptoms,
whether it is the interoperability or the lack thereof, or the
operating inefficiency, or the security challenges, or the
functionality, I want to try to get at the core problem here.
Instead of looking at the cracks, you know, on the wall, what
is the foundational problem here?
Is it the personnel management and the challenges in
Government to that end? Is it leadership, the lack of
continuity, the lack of support from the top-down over the
years? What do you think the fundamental issues are to the
problems that we are talking about here? I will ask Mr. Thomas
then I will ask Mr. Powner to respond as well, please.
Mr. Thomas. My view, is we lacked a coherent strategy. We
lacked the right processes and procedures. For the past 18
months we have been going through an incredible transformation.
It used to just to develop 10 or 20 lines of code, it required
61 artifacts, a cumbersome bureaucratic process, 58 governance
boards. We now have a small streamlined set of governance
boards, now the artifacts that are required are seven.
We incrementally deliver now every 90 days. The continual,
perpetual development delivery days are gone. We have
transformed. We are showing up differently. We are working much
better with our partners than we ever have before. And we have
made that turnover, now we--that transformation has happened
and now we need to get on with it, which is what we aim to do.
Mr. Arrington. Mr. Powner?
Mr. Powner. I think a couple key things here. Leadership
turnover. Look at the CIO's situation at VA, we get a new CIO
too frequently. And when new folks come in, what do they do? A
new strategy, new thoughts, not enough delivery.
Now, to be fair to VA, I think there's been some delivery,
like I mention, on VBMS, but what we need is I do not--we do
not want to hear another CIO coming in come up with another, we
got a strategy. Right, Rob? We got a strategy, we got
governance, we got processes, now you need to use it and
deliver. That is what needs to occur. But what happens is there
is always this new leadership coming in and they come up with a
new idea and they do not deliver enough.
Mr. Arrington. Are those processes and strategies
memorialized in a strategic plan that we can have and
consistently and repeatedly hold accountable the next group
that comes in if its--if folks are being replaced so often?
Mr. Powner. We actually think they are processes--we have
done in-depth look at processes and governance at VA, pretty
good. Do we have some recommendations? Yeah. But compared to
some other IT shops, pretty good. Okay? And we can be real
critical of those processes. They are pretty good, we just need
to use it now.
Mr. Arrington. Let me jump to another issue. The mention of
the 85 percent of the budget being spent on operating versus
development. How many employees are there in the IT shop there
at the VA?
Mr. Thomas. Eight thousand, Congressman.
Mr. Arrington. Eight thousand. What do you spend as a
percentage of your budget on employees, not development costs
but employees at the agency?
Mr. Thomas. North of a billion dollars.
Mr. Arrington. North of a billion dollars. And have--Mr.
Powner, have we benchmarked those numbers to other departments
and agencies throughout the Federal Government? And is the VA
above, way above, outrageously above?
Mr. Powner. They have a lot more employees than most
department stations. They are one of the largest. So, yeah,
$1.3 billion of their $4.5 billion goes towards salaries. Here
is the issue though. Some of the--like, we had talked about
those old 50-year-old systems and the Cobalt programmers, you
pay a premium after a while when these folks all start
retiring. You either pay a premium to your employees, or you
pay a premium to contractors.
So as you hold onto those old Cobalt base systems that are
50 years old, it is just getting worse every year. Every year
it gets worse.
The Chairman. Gentlemen's time has expired.
I will now like to recognize a very proud New England
Patriots bragging fan, Mr. Poliquin, for five minutes.
Mr. Poliquin. You know, Mr. Chairman, I am very pleased
that you brought that up, and I do not want to chew up a lot of
my time. But you notice, sir, that I am wearing my New England
Patriots necktie on today.
Now this is a very serious topic we are talking about
today, Mr. Chairman, but we have so many sports fans that are
veterans. So this is a great day in America, Mr. Chairman. It
is a great day for the New England Patriots, and I thank all of
our veterans in this country for pushing us over the goal line.
With that said, Mr. Thomas, we all love our veterans, and I
thank you for your service to our country, sir. We just love
our veterans. In Maine Second District, we have about 65,000,
throughout the entire State of Maine about 125,000. And, you
know, I know, Mr. Chairman, that it was George Washington who
first said that we can't expect, we can't expect young men and
women to serve in uniform unless we take care of those who have
already served. Now I am paraphrasing, but that--everyone gets
the point, I am sure.
Mr. Thomas, I am very concerned with the fact that the VA
is such a huge organization designed to do so much good. Three
hundred and forty thousand employees, 144 VA hospitals around
the country, about 1,200 outpatient clinics, and about 300
veteran centers. All designed to help those that we love so
much that have given us our freedom.
However, there has been a spotty track record at best, if I
may, and I am being--trying to be polite. When it comes to
designing these IT systems, and those of us that are involved
in the business community for a while understand that it is
really difficult to design your own system internally and then
customize it, it is very, very expensive. On the other hand, if
you buy something off the shelf, Mr. Chairman, then you are put
in the situation where you might have to adjust it also. And
there's a real temptation to do that.
One of the things that is a concern of mine with the VistA
system is that in all of these outlets across the country, we
have so many of our hospitals and outpatient clinics that have
data, medical records and so forth, clinical information that
are kept on local servers, or on the computers themselves.
This thing, everybody in the world knows what it is. The
data in this machine is kept on a cloud. And if you have it on
a cloud, you can access that data anywhere in the world. So
when I look at one of our great veterans from Lewiston, Maine,
who is maybe traveling down to Florida with his family, or her
family, and has a health problem and goes to a VA facility down
in Florida.
We need to make sure that these records, Mr. Chairman, are
accessible all around the country. And I think the way to do
that is to have one system fully integrated across the VA
network, coast to coast.
Now, I know that you folks are not--and I would like to
turn not to the VistA system, which is more clinical in nature
if I am not mistaken, but more to your financial system that
you are now looking to modernize. And I understand that you
folks are looking towards sharing a system with the Department
of Agriculture, and I am all for sharing. It is a great way to
save money, to give better service to our veterans.
So my question to you, Mr. Thomas, is that what is going to
be the temptation at the VA to customize a system that you are
sharing with AG? And what would that cost if you were to do
that? And wouldn't that put you behind?
Mr. Thomas. I completely agree, Congressman, the whole
track record of the Department of Agriculture already providing
the shared services unlike what you are alluding to where we do
it ground-up. We start developing and it goes on, and on, and
on and we do not deliver, that is not our plan. There are many
customers already with the Department of Agriculture, we are
working that fit-gap analysis right now. And we are not going
to be developing, we are going to be using what they have
already provided to so many of their other customers.
Mr. Poliquin. And if I may, Mr. Thomas. What is that
expected to cost the taxpayers at the VA? What is the VA cost
to sharing a system with AG?
Mr. Thomas. The total cost to date, we are showing it just
a little less than $400 million. We are starting with $40
million this year.
Mr. Poliquin. Four hundred million dollars to share a
system that already exists?
Mr. Thomas. Yes, sir.
Mr. Poliquin. And when do you expect to be fully integrated
with this system? How long is it going to take?
Mr. Thomas. They are still working on the fit-gap analysis.
Ed Murray is the CFO, and he has an executive steering
Committee that I am a member on, they are working the gap-fit
analysis. Once that gap-fit analysis is complete, we will have
a schedule----
Mr. Poliquin. And how long have they----
Mr. Thomas [continued]. --and a timeline.
Mr. Poliquin [continued]. And how long have they been
working to try to find out when this will be done?
Mr. Thomas. It is a recent start with fiscal year 2017. So
we are just getting started, we are just getting rolling.
Mr. Poliquin. I believe my time has expired, Mr. Chairman.
The Chairman. Thank the gentleman for yielding.
Dr. Wenstrup, you are recognized for five minutes.
Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for
being here today. You touched on something before that I would
like to dig into a little bit deeper, which is really this
continuity of leadership and the ever changing roles that you
may have depending upon whoever comes in next.
And so just out of curiosity, I will start with you, Mr.
Powner, when did you come into the VA?
Mr. Powner. Well, I am with GAO, so I have been with----
Mr. Wenstrup. Okay.
Mr. Powner [continued]. --GAO since about 2004.
Mr. Wenstrup. And working on this type of--this entity for
how long?
Mr. Powner. I am actually new to the VA but I have done a
lot of IT work across all Federal departments and agencies for
the last 12 years.
Mr. Wenstrup. Have you ever worked on anything as large as
the VA?
Mr. Powner. Yes. I do a lot of work at IRS on their tax
systems and modernization. Same challenges.
Mr. Wenstrup. Okay. Mr. Thomas, basically the same
question. You have been in your role for how long?
Mr. Thomas. The current role since the administration left,
I have been in this role for less than a month.
Mr. Wenstrup. Okay.
Mr. Thomas. I have been at the VA since 2015. And I have
had a role similar to this when I was in the Deputy CIO for the
Air Force as a deputy to a lieutenant, many Lieutenant Generals
in a row. Five, in fact.
Mr. Wenstrup. But this is probably one of the larger
missions you have had to take on then as far as the size and
scope of what we are embracing here?
Mr. Thomas. Yes, Congressman, that would be true.
Mr. Wenstrup. Okay. So talk about that. And, you know, you
come from the Air Force, there's change of leadership there. So
what kind of things have you seen that have been the determent
to that entity? And how do you feel now with Dr. Shulkin, who
has been here, taking over as the secretary, what do you
anticipate as far as perhaps better continuity or what do you
see as far as that goes? Or are we looking at a whole new
direction?
Mr. Thomas. So last week I gave a public media broadcast
out at television studio to all 8,000 employees. I communicated
that we are going to continue with our strategy, with our plan,
with our framework. I said now that LaVerne Council has gone to
make the big bucks, what changes do I plan to make? I do not
plan to make any change.
That is why she brought me into this role. I was considered
her left flank for the last 18 months, during her entire tenure
I was right there with her, and that is why I am in this role
today to continue on.
Mr. Wenstrup. Okay. I appreciate that. Would anyone care to
just touch in briefly, if you can, for me, like the current
state of access and interaction amongst providers, VA providers
that are outside the walls of the VA, ie., Choice, and those
that are inside the wall? And how is that progressing? And what
are the problems and challenges that you have?
Dr. Lee. Thank you, Congressman. So the Choice Program
continues to evolve and improve. We have made a lot of
progress, although we know there is still a lot more work to be
done.
Last year--well, to date one million veterans have used the
Choice Program to schedule more than six million appointments.
There are more veterans seeking care in the community now than
ever before. And we think that that is great progress because
we want veterans to be able to have choice and options to get
care how they want it, where they want it, when they want it.
We now also partner with over 400,000 community providers.
Mr. Wenstrup. I am talking about the exchange of
information.
Dr. Lee. Sure. The Health Information Exchange, our--we
also have made progress there but, again, more to do. So we use
the national eHealth Exchange, which the Office of the National
Coordinator promoted. And it allows us to exchange, securely,
information between providers, between health systems outside
VA for individual veteran patients.
I have had the experience myself. Again, I mention I am an
ER doctor. I work at the D.C. VA. I actually worked on Saturday
night, and I use some of these tools; Joint Legacy Viewer,
Enterprise Health Management Platform, and others to look up
old records from patients that I took care of. And it was
extremely helpful, and very easy to use from a clinician's
perspective.
Mr. Wenstrup. So that would probably be a good segue here.
So you are in the ER and you get a veteran come through who has
gotten some care outside of the walls of the VA. So how rapidly
are you able to gain access to what has been going on with the
specialists that they see, or whatever?
Dr. Lee. If the providers that they were seeing are
participating in the eHealth Exchange, we can get that
information very rapidly.
Mr. Wenstrup. Are all of the doctors participating in
Choice participating in the eHealth Exchange?
Dr. Lee. I know--I do not know the exact numbers off hand,
Congressman, we can get back to you.
Mr. Wenstrup. But they are not required to, is what you are
saying then?
Dr. Lee. At this point, I am not sure exactly. But we are--
we encourage--we would like more providers, as many providers
as possible, to participate in eHealth Exchange. And that is
where Enterprise Health Management Platform, the EhMP, will
really help us as the clinical providers, because it offers a
easy-to-use search function and it organizes the data in a
better way for us to be able to take care of those patients.
Mr. Wenstrup. Thank you. I yield back.
The Chairman. Gentleman's time has expired. We are going to
have a three minute second round.
I would like to start by just asking Mr. Thomas, and you do
not have to respond right now, or you can. Accessibility for
the visually and sensory impaired is very important. In 2012
OIT issued a memo requiring compliance with Section 508, the
Rehabilitation Act, by January 2013.
It said, ``No software that failed to comply could be
deployed.'' The Committee held a hearing on May 2014 and found
progress was not good. Are all systems and Web sites Section
508 compliant now?
Mr. Thomas. I do not have an answer, Chairman, if they all
are. I will have to get back to you on that. I know we are
really aggressively working that, and I am really confident in
the leader we have overseeing that, and his team.
The Chairman. I think that is extremely important for our
sight impaired veterans, so I would like to get a report on
that.
And then back to Dr. Lee, you were about to answer my
question before I cut myself off, on the success criteria for
VistA IV, and you just mentioned an EHMP. And not just the back
end, but what are the new things that clinicians are going to
be able to do to coordinate care and information they can't do
now?
Dr. Lee. So EhMP is necessary because it helps us meet--it
helps meet some of our unique clinical needs as providers in
VA. So in VA we practice in teams, as you know, and this
platform enables us to work together to send messages and
communicate more easily as a team. So that is one thing.
Another thing it does is better clinical decision support.
So we have tools right in the electronic health record that
help us make decisions about which lab tests to order, which
medications to provide at the point of care. And another
important thing it does is--and this is really critical--is
that it actually works not only with VistA but with commercial
systems. So it provides many options for us, it is not just for
VistA. It can help us to standardize our clinical work
processes as we move to any system in the future.
The Chairman. Mr. Poliquin mentioned this a minute ago, but
I think absolutely getting away from all these servers all over
the place--I know our practice moved to a cloud many years ago
where you can access that information--that is absolutely
critical for the country to have a central repository for
medical information, otherwise it does not do me any good to be
at one hospital ten miles away if I can't get the information
other than just take another history and kind of fly by the
seat of my pants.
A lot of duplication. It is expensive. We order more tests
than we need to order. So I think I would encourage VA to very
rapidly get rid of all that information, all onsite on an
individual computer end of server there onsite and get to a
central cloud based.
I now yield to Mr. Walz, three minutes.
Mr. Walz. Well thank you, Chairman. I am thinking about the
integration and how we move this--but I am reading from your
trade manual, Healthcare IT News, and it says, ``In the latest
example of a world class health system yanking its established
electronic health record in favor of blue chip vendor, Mayo
Clinic is migrating to Epic.''
Here is what it said, ``Epic will deploy a single
integrated EHR and revenue cycle management scheduling system
at the renowned campus. This will replace Mayo's three
currently EHRs and their accounting system, and will be the
foundation for the next several decades of care and delivery at
the world class institution.''
They started exploring in April of 2015 and they have
implemented. And there are few people--they are at 50,000 plus
employees, that scale and that size. My question is, and maybe
it goes to the GAO, is it unrealistic for me and this Committee
to think that we can come to that conclusion, we can decide to
migrate, we can set the working groups in place, and we can
have a drop-dead deadline? Because this institution's spread
around the world in multiple states, 50,000 plus employees,
went from their own proprietary long legacy system, and 18
months made the switch.
Is it possible for us to start getting our mind wrapped
around that?
Mr. Powner. Absolutely. You need a decision, a plan,
action, and I would also say, VA's one of the best at this, go
incremental. You do not need to role out an electronic health
care record initially that does everything. Role it out on a
small scale basis and grow it. They are one of the best
agencies at doing that, they know how to do that.
Mr. Walz. I just feel like I am going to get slow rolled
again, and not get there. I am tempted, and I do not know what
our----
Mr. Powner. That is why----
Mr. Walz [continued]. --Constitutional authority is, I want
a drop-dead date.
Mr. Powner. If you look at this historically, you leave it
up to the departments and agencies, I think it is going to
happen. I think, Congress, with your oversight, whatever you
want to do quarter--or whatever you want to do, but I think if
you need to manage it with a heavy hand to ensure that
deadlines are met.
Mr. Walz. Well, I----
Mr. Powner. (Indiscernible) deadlines are met.
Mr. Walz [continued]. No, and I appreciate that, And to
some of the members who are here, I know you--now I get to tell
the old guy stories. Almost eight years ago, Dr. Roe and I were
exploring this. We went to Iraq and Afghanistan, we went down
to Battalion Aid Station and watched a wounded soldier come off
of a IED hit in Afghanistan.
Watched them open up multiple computers, followed them back
to Bagram where they had multiple computers on, followed them
out to the transport plane on the way back to Landstuhl. Did
not have the capacity to send forward electronically the x-
rays, so they were taped to the chest with a big, you know, do
not lose, on that.
Followed them back to Landstuhl where they arrived, and
then followed them back to here. Then over the years have
watched those patients migrate to the VA with the whole
intention of that was, as you might imagine, that was an
incredibly complicated, complex process that, at times, I have
had folks in my office because of the lack of records. We have
a young man--and Dr. Roe hit on it--lost his sight because we
didn't have timely record exchange. So this is care at the
heart of this, it is not a spreadsheet, it is a diagnostic tool
that we have got to get right. I yield back.
The Chairman. Thank the gentleman for yielding.
Mr. Higgins, you are recognized for three minutes.
Mr. Higgins. Thank you, Mr. Chairman.
It is a question for Mr. Thomas. Regarding the momentum
financial system, sir, how did the VA system get so out of date
while Agriculture's has stayed current? And what plans does the
VA have to ensure the upkeep of this system following its
implementation?
Mr. Thomas. Congressman, I would say that there have been
attempts before, a number of years ago, that have not gone
well. As I stated earlier, the one thing we are not going to do
this time is do a ground-up development effort ourselves. We
are, in fact, going to use the best practices and lessons
learned from, like, for example, GSA is using the Department of
Agriculture shared service. We are going to subscribe to that
and use that instead of developing it in-house.
Mr. Higgins. And in your opinion, this has been the focus
in years past, or is this a newly discovered effort to keep up?
Mr. Thomas. This is definitely a new approach. The last
approach was us bringing in other capabilities and developing
that long development cycle we have discussed before. This is
already using existing shared services that are already being
provided to a number of Government organizations today, and we
are just going to share those lessons learned, and move out,
and make it happen for the VA because we are really antiquated
in accounting and financial at the VA right now.
Mr. Higgins. Thank you, sir.
I yield the balance, Mr. Chair.
The Chairman. I thank the gentleman for yielding.
Chairman Arrington, you are recognized for three minutes.
Mr. Arrington. I think it was you, Mr. Thomas--and, by the
way, thank you guys for your time and your insight--but you
mentioned that you have wanted to go commercial to the greatest
extent possible. There seems to be this inordinate and
unnatural preference to just fix it from within, use the 8,000
employees and the billion dollar budget instead of going off
the shelf.
What is up with that? Why is there the default to this
fixing it from within and this resistance to going
(indiscernible), over the years? You said you are committed to
it now, but there have been lots of years these guys have been
on this Committee and seemingly little progress. So could you
answer that for me?
Mr. Thomas. In my view, Congressman, it is because when
VistA started out it was called Decentralized Hospital Computer
Program, and they hired developers across the Nation and all of
those VMCs, and that has been the VA way, that is not going to
be the VA of the future. We are definitely going to go
commercial, we are going to definitely do software as a
service. We have awarded cloud. We are going to start shrinking
our data centers to get into the cloud. We are going in a
different direction than we have.
Mr. Arrington. So what I am--I hear, that was the VA way.
And I am trying to understand if there is a cultural resistance
here. You have got 8,000 people who are civil service
employees. Is that a challenge, Mr. Powner, that you have got
civil service employees, you have got Government rules, and, in
my opinion as a former Federal employee at the FDIC, it is a
real challenge to get anything done, and it is an
extraordinary, miraculous effort to just get somebody removed
or to downsize because you do not need the employees. How much
of that is a factor in the last several years of not being able
to deliver for the American People?
Mr. Powner. It is a factor. These cultures run deep.
Mr. Arrington. Is it a big factor?
Mr. Powner. Mr. Thomas and I have talked about--yeah. And,
you know, I will give you an example, too, the whole data
center consolidation initiative.
Mr. Chairman, you are absolutely right, we ought to be
going to the cloud, and putting this data in the cloud, and
going to single instances. And most agencies that have done
that have better security, better disaster recovery, and were
better off.
But what happens is we like to have our data right next to
us, and we control it, and see it, and we see the data center.
That is the mentality with a lot of these departments and
agencies, and it has got to stop. That is not the way we move
forward with modern IT.
Mr. Arrington. I will ask it a different way. How much of a
challenge is the Government rules, civil service environment,
to achieving results and excellent service in IT systems and
infrastructure? Big challenge? Tremendous challenge?
Mr. Powner. Oh, it is a challenge, sure, that definitely
contributes.
Mr. Arrington. Real quickly, I have just got a few. What
would be wrong with, given the lack of continuity and
leadership, having a multi-year enterprise architecture plan
audited by the private sector and approved by this Committee,
and then implemented by the VA, but it is on a multi-year
timeframe? Has that ever happened? Why is that a bad idea?
Mr. Powner. I think multi-year strategies are good. I think
I will throw something else, and I think OMB's leadership out
of the White House needs to play a role too. So there is time
like this data center consolidation initiative. It was let out
of the White House since 2010, we ended up putting in law and
the FITARA, Information Technology Act, (indiscernible), in
December of 2014 to continue it, and certain agencies did not
make a lot of progress like VA, and OMB let them get away with
it. That is wrong. OMB should step in and there should be
leadership out of the White House, too, on this.
Mr. Powner. Thank you.
The Chairman. Gentleman's time has expired.
Dr. Wenstrup, you are recognized, three minutes.
Mr. Wenstrup. Thank you, Mr. Chairman. Thank you for those
insights today, it is appreciated.
Dr. Lee, going back to what we were talking about before.
In my practice, you know, we would have patients in our region
going to different hospitals, going through different ERs,
whatever the case may be, and we were able to consolidate and
be able to go online in our offices to access what patient care
they got somewhere else. And it was extremely helpful,
obviously, to us. Again, not repeating tests, things like that.
So you talked about the eHealth Exchange and the ability to
access those types of things. Is it a relatively simple access?
And is it relatively easy to both read and write into it as a
provider? And should every provider that sees a veteran under a
VA system be required to have access to this and use it, in
your opinion?
Dr. Lee. So, Congressman, we have made tremendous progress
in interoperability. The key to that under VistA Evolution was
the Joint Legacy Viewer that actually gives s access to the DoD
records for our patients. Two point five million patient
records have been viewed through the Joint Legacy----
Mr. Wenstrup. I do not men just DoD, but I mean community
care that people are getting today, too.
Dr. Lee. So the Enterprise Health Management Platform
allows a very simple search ability for those types of records.
I have tried it myself, it is easy to use. It helped me taking
care of a patient. Some of these tools, as you said, you need
that data right when you are seeing that patient to be able to
make clinical decisions.
Mr. Wenstrup. But what I am asking is, today in the
community, if someone is getting care in the community, are the
community providers required? Does not sound like they are
required, to be able to use this network. And are they required
to write into it as well so that all of those records are
there?
This is what I am trying to get at. That because people are
going to various places, how easy is it, or are we not
requiring that people are engaged in an information system that
will give you, in the VA emergency room, access to whatever
else they have had done? Because, you know, they say, well, we
do not have that one, you know. Should be requiring everyone to
participate in this? Every provider that sees a veteran?
Dr. Lee. I think that would be the goal. One of our
challenges actually is we need a statutory change to Title 38
of Section 73-32, which this was actually put forth last year
by Congressman O'Rourke on this Committee, the Vet Connect Act
last year. But what one of our barriers in health information
exchange and sharing is that the veteran has to opt in to
sharing of their entire record because of certain protections
that are in Title 38.
What we would like to do is change that to an opt out model
so that we can share, securely, that information with community
providers. That will really help us tremendously in sharing
health information.
Mr. Wenstrup. Yeah. I think if that was just part of
signing in when you say you are going to go to the community
that that is a given. Anyway, thank you. I yield back.
The Chairman. Thank the gentleman for yielding.
Mr. Poliquin, you are recognized for three minutes.
Mr. Poliquin. Thank you very much, Mr. Chair.
Dr. Lee, back in--let's see, I am trying to think when this
was, Dr. Lee. This was--well, several months ago, in any event.
The San Diego Union Tribune came out with an article that said
at some point in time, 6 million veterans would be able to
schedule primary care appointments through one of these little
gizmos. Remember that? But that was back in October, this is
now February. Where does this all stand?
Dr. Lee. So happy to give you an update on that,
Congressman Poliquin. So the Veteran Appointment Request app is
available now at 45 sites, including Togus, actually.
Mr. Poliquin. Thank you.
Dr. Lee. If the veteran goes to--it is Veterans----
Mr. Poliquin. Oldest VA hospital in the Nation.
Dr. Lee. That is right.
Mr. Poliquin. First one.
Dr. Lee. At Togus VA.
Mr. Poliquin. In Maine.
Dr. Lee. If the veteran is seen at Togus VA, they can go to
veteran.mobilehealth.va.gov/veteran-appointment-requests. I
have tried it myself, I have asked veterans who I know to try
it out. You can schedule yourself for a primary care
appointment----
Mr. Poliquin. Okay.
Dr. Lee [continued]. --right on your phone.
Mr. Poliquin. Thank you, Doctor, that is wonderful news.
Now help us out with folks that were not able to record exactly
what you said again. Where do they go to get this----
Dr. Lee. They can go to our----
Mr. Poliquin [continued]. --address?
Dr. Lee [continued]. They can go to our va.gov Web site and
do a search for VAR, Veteran Appointment Request.
Mr. Poliquin. Okay. And they can actually book their own
appointment?
Dr. Lee. Correct. That is correct.
Mr. Poliquin. Wonderful. In the Faster Care for Veterans
Act, Dr. Lee, I believe the way it was supposed to work is that
if an appointment slot is cancelled, then that automatically
goes back into the system as an available slot for an
appointment for a veteran; is that correct?
Dr. Lee. There were specific requirements laid out in the
legislation, and we are working on an RFP that we will be
putting out actually next week for this--to comply with this
and seek other commercial solutions for self-scheduling.
Mr. Poliquin. Okay. Dr. Thomas, looks like you want to say
something about this initiative.
Mr. Thomas. So we had 60 days to put out the RFP, we are on
schedule. We have 120 days then to make a selection, we are on
schedule for that. And then we have the remainder of that time
in order to make the selection and the pick. But we are on
track from the statute from December.
Mr. Poliquin. As a culture at the VA, Mr. Thomas, how are
your folks going to accept this new technology? You said you
have 8,000 folks that work for you in the IT area, but there
are 340,000 system-wide. Do you have a flavor or an idea of how
they are going to accept this?
Mr. Thomas. I think we have made transformation. Our
culture is changing, it changes one employee at a time. I am
very confident that the employees we have, we can deliver on
what the VA employees need and what we really need to provide
for the veterans.
Mr. Poliquin. Because, with all due respect, it is not
about the employees, it is about our veterans.
Mr. Thomas. That is exactly right.
Mr. Poliquin. Although I know many of your employees, our
employees, are also veterans, and we are very grateful for
their service. But it is about our veterans. Good.
I believe my time is just about expired.
The Chairman. Yes. Thank gentleman for yielding.
And I want to thank our witnesses. This has been a great
panel. I think it is impressive that the first thing we
started--the first hearing we have had in this Congress, 115th,
was amazingly well attended. This is an incredibly difficult
subject. And now I would like to yield to Mr. Walz for any
closing comments.
Mr. Walz. Well, thank you, Chairman. And, again, I
appreciate the collaboration and the vision that this is key to
transformation, and it is obvious all of you know that. I want
to thank you for that. I would also like to say, Mr. Powner,
thank you for giving us the eye, a candid assessment.
And, Mr. Thomas, I agree, I too am very optimistic, and I
have been here before. I often say I am the eternal optimist
because I supervised a high school lunch room for 20 years. I
think you give me reasons to be optimistic.
The one thing I would say for the gentleman from Texas,
that there is a role for us to play in this in terms of more
than just oversight, and they are right on the question gets
asked. He is right about a multi-year strategy, but what he
needs to, and I would ask him to work with us on this, we can--
there is no private business that would budget by 90 day CRs.
There is no budget that would arbitrary freezes on
positions that should be plus, and others should be gotten rid
of. Having the black and white of that without an honest
discussion makes it very difficult for you to do that. When we
made the argument, and Dr. Roe was there as a champion, for
advanced appropriations to make sure that our political
squabbles did not get in the way of delivering for the health
care side of the VA, we exempted the IT from that. Yes, our
health care folks are there but our MRI cannot be used or
serviced because the budget froze, or whatever it might be.
I want to say, we understand our responsibility in terms of
oversight, we also need to understand our responsibility giving
you consistency in the budgeting. The gentleman is right on
this is, we should know if all 8,000 of them are delivering, if
they are need. You said it right, 60 percent of them are
veterans.
We have got good folks working there, but my concern of
this is, if someone retires or leaves, do you have the capacity
to rehire them? Are all the things that go into, accountability
is more than just getting rid of people, it is filling the
right people in the right jobs to deliver to veterans. So we
take that seriously. I thank the Chairman for, what I consider,
a very important--and I have to tell you, we are at a different
spot than we have been in a while in terms of where this is
headed, and that is good.
The Chairman. Thank the gentleman for yielding.
And, again, thank the panel for you all for being here
today.
And I think just the closing comments I have, that
essentially all of these hearings are going to be based on
providing the highest quality of health care we can for our
veterans. Having them receive the benefits in a timely fashion
that they have earned.
And to do that, I think the absolute key, Mr. Thomas, is
the seat you are in. If you can't process claims, or if you
can't process, we can't build a network to see our patients,
our veterans, outside the VA unless we are paying the providers
outside the VA. When you do not make payments, they get out of
the system, they can't afford to stay in it, even though they
may want to.
And I have said this once, I have said it 50 times here, I
did not like the number they wrote on the check, Medicare wrote
on it, but they wrote the check, and at the end of the month
you got paid. So I think that is one of the things we have to
do. I think providing that network out there without the
information you get and share with us, cannot be done.
And I think the other things that were brought up today are
incredibly important about centralizing to the cloud where you
have accessibility to the information. What Dr. Lee is saying,
look there is a doctor that is going to be in the emergency
room at 3:00 a.m. this morning seeing somebody they do not have
any information on. That is hard.
You do not make the best decisions. If you can get that
information timely, you can reduce the number of tests, provide
better care. So what you do is critically important for the
whole function of the VA system. And I think it can be done
more efficiently and cheaper.
I know that our next hearing is going to be with the
Secretary, and it will have to do with the Choice Program, and
how we reintroduce that. But I really believe what you are
doing with the technology piece is centerpiece. And it sounds
to me like--and we will get better numbers going forward--there
maybe not enough, but a significant amount of money in the
budget that can be saved with an off-the-shelf program that
does all that to actually fund it. Or fund a significant part
of it. And we will get into that in more detail.
But I do want to wish you, Mr. Thomas, thank you for the
great work you are doing, and with the next assistant
secretary, great success, and a long tenure also, so we can
keep somebody in the spot a while.
I ask unanimous consent that all Members have five
legislative days which to revise and extend their remarks, and
include extraneous materials.
Without objection, so ordered.
And thank the witnesses. No further witnesses.
Meeting is adjourned.
[Whereupon, at 11:41 a.m., the Committee and Subcommittees
were adjourned.]
A P P E N D I X
----------
Prepared Statement of Mr. Rob C. Thomas, II
Good Morning, Chairman Roe, Ranking Member Walz, and distinguished
members of the Committee. Thank you for the opportunity to discuss the
progress that VA is making towards modernizing our information
technology (IT) infrastructure to provide the best possible service to
our Nation's veterans.
I am joined by Dr. Jennifer Lee, Deputy Under Secretary for Health
for Policy and Services, in the Veterans Health Administration (VHA),
and Mr. Brad Houston, Director of the Office of Business Process
Integration in the Veterans Benefits Administration (VBA).
Office of Information and Technology (OI&T) Transformation
In July 2015, a self-assessment of our current state - derived from
employee interviews, external reviews, and meetings with oversight
bodies - revealed significant internal challenges at OI&T. The
assessment presented a clear-eyed analysis of the challenges we faced,
which confirmed other indications for a change in direction. It was
also an opportunity to evaluate our role at VA, to envision an IT
organization that fundamentally changed the way our veterans interface
with VA - and empower our business partners to provide industry-leading
access, care, services, and benefits for our veterans. It required
nothing short of a major turnaround.
Our transformation delivers better services and a better user
experience to veterans, and, today, I am pleased to report progress to
you not only on our transformation, but also on several major IT
initiatives.
We Improved Our Organization
In 2016, we established five critical functions that underpin our
vision:
Enterprise Program Management Office (EPMO) - OI&T's new
control tower for IT development, provides an enterprise-wide view of
all ongoing projects, actively manages cyber risks, and ties project
performance to outcomes that directly improve the veteran experience.
EPMO manages 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).
IT Account Management - After listening to our customers
and partners, we formed the IT Account Management (ITAM) organization.
This function establishes an integrated, dedicated customer service
team at headquarters and in the field with National Cemetery
Administration (NCA), VBA, and VHA. ITAMs are the linchpin between OI&T
and our business partners; they identify opportunities for improvement
and work directly with the Chief Information Officer and EPMO to
implement solutions. ITAMs are supported by five Customer Relationship
Managers that work at the regional level to gather feedback and monitor
outcomes. The ITAM organization can now collect OI&T performance data
nationwide, enabling a collaborative approach to issue resolution,
change management, and innovation, as well as identifying and refining
solutions to meet customer and stakeholder needs.
Strategic Sourcing - To make the most of IT spending,
OI&T now focuses on buying existing cutting-edge solutions before
building customized solutions.
Quality, Compliance and Risk - OI&T measures what
matters, partners with oversight bodies such as the Office of
Management and Budget and the Office of the Inspector General, and
links input to outcomes.
Data Management -OI&T focuses on the collection,
protection, and analysis of VA's wealth of data to predict patient
needs, deliver specific outcomes, and share information across VA to
improve the veteran experience.
Outcomes from Process Changes
We focused on programs and projects that deliver direct value to
veterans by eliminating numerous processes, steps, and artifacts to
streamline our services and provide faster more efficient care.
In September 2016, EPMO reached full operational
capability, successfully transitioning over 200 projects from Project
Management Accountability Software to the Veteran-focused Intake
Process (VIP). This transition has delivered an 86 percent on-time
delivery rate and an estimated 85 percent project overhead cost
avoidance since 2015.
The Enterprise Cybersecurity Strategy Team (ECST)
transformed VA cybersecurity. Accomplishments include reducing users
with elevated privileges by 95 percent, remediating 23 million critical
and high vulnerabilities, and removing 95 percent of prohibited
software from the VA network and systems.
Outcomes from Investing in Our People
Throughout 2016, we focused on our people:
Results from the September 2016 Employee Engagement Task
Force (EETF) survey show positive upticks in every measure of employee
satisfaction since our June survey.
In October 2016, EETF became the Office of Organization
Development & Engagement, to make permanent and build upon OI&T's focus
on a work culture that is collaborative, diverse, inclusive, and
recognition-oriented.
Enterprise Cybersecurity Strategy
Cybersecurity is another principle which underpins everything we
develop, test and roll out. 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 2015, OI&T stood up an ECST to assess and address material
weaknesses, and execute a holistic VA cybersecurity strategy in record
time. Our strategy goes beyond satisfying statutory and regulatory
requirements, creating a proactive security posture. Through the ECST,
we have built a transparent, accountable, innovative, and team-oriented
organization responsible for delivering an actionable, long-range
cybersecurity plan.
ECST Strategy identified eight domains that have shifted VA
cybersecurity from a reactive to a proactive posture and set the
baseline for how OI&T manages and evaluates the enterprise environment.
Those domains are: (1) the medical cyber domain; (2) the governance
domain; (3) the application and software development domain; (4) the
cybersecurity training and human capital domain; (5) the access
control, identification and authentication domain; (6) the operations,
telecommunications and network security domain;(7) the security
architecture domain; and (8) the privacy domain.
OI&T has many accomplishments to show for this tremendous effort.
Since we began in 2015, we:
Achieved 100 percent enforcement of two-factor
authorization (2FA) for privileged users;
Implemented 100 percent 2FA for remote access;
Increased PIV enforcement from 11 percent to over 80
percent. This includes two breakthrough months when we added more than
200,000 PIV-enforced users in August, and another 111,562 in September
2016;
Reduced the average days to remediation by 52 percent for
critical vulnerabilities and by 52 percent for high vulnerabilities;
Remediated 92 percent of critical and high medical device
vulnerabilities for the first time in VA's history; and
Achieved 100 percent completion of an automated inventory
of medical devices.
In the area of veteran facing systems, VA has recently added new
protections for online safety, data protection, and identity
management. VA has added a logon feature to vets.gov that is one of the
few Federal consumer facing-logon accounts that meets high levels of
security guidance and requirements (NIST 800-63 level of assurance 3)
for credentialing and identity proofing, which has been mandated for VA
and other government agencies.
Our efforts to reduce risk, improve security, and ensure online
safety will not end when we address the current material weakness. We
will continue to identify opportunities to improve our security
posture. Let me turn now to VistA and Interoperability.
Health Care
VistA
VistA was one of the first broadly used Electronic Health Records
(EHR) in the United States, and an open source version of VistA is
currently available. It has been recognized for effectiveness and is
still a high quality EHR used as the primary tool across the country.
VA is proud of VistA, but we recognize the need for improvements.
VistA Evolution is the joint VHA and OI&T program for improving the
efficiency and quality of veterans' health care by modernizing VA's
health information systems, increasing data interoperability with the
Department of Defense (DoD) and network care partners, and reducing the
time it takes to deploy new health information management capabilities.
We will complete the next iteration of the VistA Evolution Program-
VistA 4-in fiscal year (FY) 2018, in accordance with the VistA Roadmap
and VistA Lifecycle Cost Estimate. VistA 4 will bring improvements in
efficiency and interoperability, and will continue VistA's award-
winning legacy of providing a safe, efficient health care platform for
providers and veterans.
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, shift to a commercial EHR platform as DoD is doing, or some
combination of both.
Interoperability
Access to accurate veteran information is one of our core
responsibilities. We recognize 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.
Today, our partners in VHA, VBA and DoD share more medical
information than any health care organizations in the country, public
or private. Hand in hand with our partners in DoD, we have developed
and deployed the Joint Legacy Viewer (JLV) across the country. JLV is
available to all clinicians in every VA facility in the country. It is
a web-based user interface that provides the clinician an intuitive
interface to display DoD and VA health care data on a single screen. VA
and DoD clinicians can use JLV to access, the health records of
veterans, Active Duty, and Reserve Service members from all VA, DoD and
enrolled VA external partner facilities where a patient has received
care. VA certified VA-DoD interoperability on April 8, 2016, in
accordance with section 713(b)(1) of the National Defense Authorization
Act for FY2014 (Public Law 113-66).
JLV is not a ``screenshot'' sharing technology; it organizes
medical record data in a customizable, easy-to-use web-based browser
presentation. It provides a patient-centric, rather than facility-
centric, view of health records in near realtime. Clinicians are able
to make better-informed care decisions with the click of a button.
Providers from a variety of specialties have shared positive feedback
and user stories proving information can flow seamlessly between DoD
and VA. JLV is also available in all VBA Regional Offices, to expedite
claims processing. I am pleased to share the following statistics on
JLV, as of December 11, 2016:
There were 203,785 authorized VA health care users;
14,274 authorized VA benefits professional users; and
2,000,000+ records accessed.
JLV is a critical step in connecting VA and DoD health systems.
However, 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. eHMP is a cornerstone of the VistA
Evolution Program, building on the capability for clinically
actionable, patient-centric data pioneered by JLV. eHMP will provide a
modern, secure, configurable web-based platform that will expand JLV's
capabilities. Upon completion, eHMP will offer robust support for
veteran-centric health care, team based health care, quality driven
health care, and improved access based on clinical need.
Modernization is a process - not an end - and the plan to release
VistA 4 in FY2018 will not be the ``end'' of VA's EHR modernization. VA
intends to continue modernizing VA's EHR, beyond VistA 4, with more
modern and flexible components.
Integrating new systems with old platforms is a pervasive challenge
at VA, and scheduling is an example of this kind of transition. Veteran
appointment wait time issues were partly attributed to antiquated
scheduling systems.
VSE
VistA Scheduling Enhancements (VSE) will provide critical near-term
enhancements. It will improve the appointment scheduling process by
providing a modern graphical user interface. It will also result in
reduced appointment wait times, improved adherence to industry
standards, and elimination of manual processes.
VA's current scheduling application successfully schedules millions
of appointments, but it is cumbersome to use; does not have a modern
look-and-feel; and does not include functions that can drive improved
operational efficiencies. VSE is intuitive to use with a calendar
display. The more modern view alone will enhance scheduler's
efficiency. Other functions that allow for selection by location,
clinic, clinician or specialty, improved ability to find available
appointments, a single queue for appointment requests, resource
management reporting ,and a more complete view of availability will
improve our use of clinical resources to reduce wait times. If approved
for national implementation, VSE 1.1 will be deployed March through May
2017, starting in Primary Care.
MASS
In addition to VSE, VA awarded a contract for MASS. MASS is one
option in VA's overall strategy to provide state-of-the-art electronic
health record, scheduling, workflow management and analytics
capabilities to frontline caregivers. MASS could replace the VistA
Scheduling application with a resource-based medical appointment
scheduling solution that allows VA to monitor demand for patient care,
and track VA's capacity to provide such care. VA will evaluate the
capabilities provided through the contract alongside enhancements to
the current VistA through VSE to determine the most efficient and
effective means of improving access to care for Veterans.
Veteran Appointment Request (VAR) Application
In addition to reducing wait times, we are focused on improving the
Veteran's experience. We must open our doors wider to allow more direct
contact with Veterans through the tools of their choice. To do that, we
have developed, through a public-private partnership, a mobile
application known as VAR. The software allows established primary care
patients to directly and immediately schedule and cancel primary care
appointments with their assigned Patient Aligned Care Team provider.
The application also allows Veterans to obtain online assistance from a
trained VA scheduler in booking both primary care and mental health
appointments.
Public Law No: 114-286, Faster Care for Veterans Act of 2016
The Faster Care for Veterans Act of 2016, (Public Law 114-286)
requires VA to establish an 18 month pilot program operational in at
least three Veterans Integrated Service Networks under which Veterans
can use an internet website or mobile application to schedule and
confirm medical appointments at VA medical facilities. VA is required
to seek to enter into a contract using competitive procedures to
provide the scheduling capability identified in the law. VA agrees with
the need to provide Veterans with tools to empower them while reducing
wait times and improving the Veteran experience. We will work with
Congress and the stakeholder community to ensure we meet our shared
goals.
Benefits
Veterans Benefits Management System (VBMS)
The ability to quickly and accurately provide to veterans the
benefits they have earned has always been a VA goal. Over the last
several years, VA has made progress to adjudicate disability
compensation claims more quickly and accurately. VBMS serves as the
cornerstone of VA's benefits claims processing capability. Since the
initial phases of its development, VBMS has become the foundation and
platform for automating claims processing across VBA's business lines.
Today, VBMS assists VBA with processing billions of dollars in benefits
delivery each month for millions of beneficiaries. In partnership with
VBA, and with VBMS as the foundation, we have completely reinvented
claims intake and evidence management, ensuring everything a veteran
provides is immediately digitized and available for claims processing,
leading to massive improvement in mail processing time and gathering of
evidence. As a result of these efforts, average mail handling time for
VBA personnel to process inbound mail is now only four days, down from
55 days in 2015.
The next phase of progress for VBMS will focus on the veteran
experience enabled by an integrated electronic operating environment
that will:
Empower veterans by providing common access points,
better access to information for veterans and a more seamless
experience when veterans interact with VA.
Engaging partners through improved data exchange
capabilities, automation and information access.
Enhanced operations through expansion of eFolders
capabilities, refined and/or automated business processes, and a more
integrated approach to overall benefits delivery.
Examples of specific functionality to be delivered in VBMS in
fiscal years 2017 and 2018 include:
1.Completion of automation for medical exam requests.
2.Providing full access to the claims folder to veterans online.
3.Reducing multiple touches by VBA staff and providing better
veteran experience, through `day of discharge' payments for separating
Servicemembers.
4.Centralizing and automating outbound mail to Veterans, which
eliminates manual printing and stuffing of envelopes by VBA employees,
allowing those same employees to focus on other claims development
activities
5.Automating the decision segment for `routine future' examinations
(100,000 claims per year).
6.Automating pension medical expense adjustments (75,000 per year).
VBMS will deliver key functionality that enables quicker, more
accurate and integrated claims processing while laying the foundation
for future, veteran-centric enterprise business capabilities. By
prioritizing this work above other needed functionality, VA will
deliver as planned. The system is currently operational with numerous
enhancements planned and underway to achieve the full scope of VBMS's
planned functionality. Some of these include automated decision support
tools and rules-based claims processing. Delivering the full scope of
planned VBMS functionality (both VBMS itself and integration with
legacy environment) is essential to meeting goals of VBA's
modernization of benefits delivery.
Appeals Modernization
As we have made progress in developing and deploying the tools
necessary to adjudicate claims, we have also invested in improving
technologies used to process and decide appeals of benefit claims. We
are currently working to move away from the current process that uses
disjointed uncoordinated systems. Appeals modernization is truly an
Enterprise-Wide initiative that will have a direct impact on veterans
by enabling VA to provide timely and quality appeals decisions, as well
as visibility on appeals across the Department.
The goal for appeals modernization is to improve the veteran
Experience through a streamlined the end-to-end appeals process. VA
will replace outdated technology with modern technology that is easy to
use and less expensive to maintain. The new solution, called Caseflow,
will replace veterans Appeals Control and Locator System and automate
manual processes for reviewing records and drafting appeals decisions
while improving workflows that need to cross organizations.
Under the leadership of the VA Digital Services team, iterative and
continuous delivery of usable functionality is being deployed weekly to
a limited number of users. The limited release approach allows for
improvement before deploying the solution to all users. The core
functionality will be fully delivered by end of FY2017. However, in
order to more fully address the improvements necessary to reform the
current appeals process, legislative action will be necessary.
Legacy Modernization
VA is in a continuous cycle of modernization and upgrading to new
technology, new systems and new tools for use by veterans, to improve
how we care for them, and how their data is safely managed and operated
online. VA is in the process of formalizing a new strategy to modernize
legacy systems. The purpose of this approach is to identify and
decommission outmoded technology, recapture resources, and re-program
freed resources towards priority business needs. The sequencing plan
will be integrated into the lifecycle management of VA's IT systems.
The benefits of this strategy are several and agency-wide: VA will
maintain a more affordable technology footprint; overall business
capabilities will be improved as obsolete equipment is retired;
operational performance will also improve in business and technical
systems as resources are re-programmed toward current needs.
The EPMO will lead the effort to put this strategy in place. The
strategy will:
Establish a dedicated team to operationalize these
capabilities;
Identify a list of known modernization efforts;
Develop criteria for what constitutes a legacy system and
its associated components;
Inventory legacy systems, identifying those most critical
to business continuity; and
Identify early candidates suitable for accelerated
decommissioning efforts
VA plans to integrate the legacy modernization strategy with IT
Infrastructure Library and existing VIP and OI&T governance processes.
There will be a needed training component, as well as change management
planning and execution. Looking ahead, VA will integrate full lifecycle
cost estimation and analysis into our demand management and intake
process.
Other Major Programs
Community Care IT Support is a program of 39 distinct IT projects.
These projects collectively address the six pillars needed for an
effective VA Care in the Community Program: (1) Eligibility; (2)
Referrals and Authorization; (3) Care Coordination; (4) Community Care
Network; (5) Provider Payment; and (6) Customer Experience. The program
is currently on track with a strong program management team. It is
carefully scrutinized bi-weekly by a joint VHA/OI&T executive oversight
board and is on the VHA/OI&T FY2017 Joint Business Plan as a high
impact program requiring close executive oversight and involvement/
intervention should issues arise.
Financial Systems is embarking on a multi-phase project to migrate
VA to a shared service provider. The current first phase of the project
is focused on accounting and acquisitions. The goals of this effort are
to maintain a clean opinion, eliminate material weaknesses, eliminate
improper payments, and move to an environment where clean data can
provide realtime business intelligence.
Conclusion
OI&T is transforming. Evolving veterans' needs have driven us to
change and adapt. Through the MyVA initiative, VA is modernizing its
culture, processes, and capabilities to put veterans first, prioritize
resources, and give 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 customers, partners, our employees, and veterans.
OI&T will continue to make bold reforms that will shape how we
deliver IT services and health care in the future, as well as improve
the experiences of veterans, community providers, and VA staff.
Throughout this transformation, our number one priority has and will
always be the veteran - ensuring a safe and secure environment for
their information and improving their experience is our goal.
Despite the progress, we cannot do it alone. We need the continued
collaboration with our stakeholder community - veterans, Veterans
Service Organizations, public and private organizations, and Congress.
We believe your support has been critical to achieving our successes
with developing claims processing tools and enabling interoperability
and will be critical towards giving our clinicians the tools they need.
Your support for the upcoming FY2018 budget will get us closer to that
future. We are committed to serving veterans and look forward to
working closely with you on their behalf.
This concludes my testimony, and I am happy to answer your
questions.
Prepared Statement of David A. Powner
VETERANS AFFAIRS INFORMATION TECHNOLOGY
Management Attention Needed to Improve Critical System Modernizations,
Consolidate Data Centers, and Retire Legacy Systems
Information Technology Management Issues
Chairman Roe, Ranking Member Walz, and Members of the Committee:
Thank you for the opportunity to participate in today's hearing on
the information technology (IT) modernization projects and programs at
the Department of Veterans Affairs (VA). As you know, the use of IT is
crucial to helping VA effectively serve the Nation's veterans and, each
year, the department spends billions of dollars on its information
systems and assets.
However, over many years, VA has experienced challenges in managing
its IT projects and programs, raising questions about the efficiency
and effectiveness of its operations and its ability to deliver intended
outcomes needed to help advance the department's mission. These
challenges have spanned a number of critical initiatives related to
sharing electronic health record data and developing major systems, in
addition to improving the efficiency of operations by closing and
optimizing data centers and decommissioning antiquated legacy systems.
We have previously reported on these and other IT management challenges
at the department.
At your request, my testimony today summarizes findings from a
number of our reports that addressed VA's efforts toward exchanging
electronic health records with the Department of Defense (DoD) and
highlighted IT challenges that have contributed to our designation of
VA health care as a high-risk area. \1\ In addition, it discusses our
prior work on the department's development and use of its benefits
claims processing system, the Veterans Benefits Management System
(VBMS), as well as our recent reports that addressed VA's data center
consolidation and legacy systems. \2\
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\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) and High
Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015).
\2\ GAO, Veterans Benefits Management System: Ongoing Development
and Implementation Can Be Improved; Goals Are Needed to Promote
Increased User Satisfaction, GAO 15 582 (Washington, D.C.: Sept. 1,
2015); Data Center Consolidation: Agencies Making Progress, but Planned
Savings Goals Need to Be Established, GAO-16-323 (Washington, D.C.:
Mar. 3, 2016); and Information Technology: Federal Agencies Need to
Address Aging Legacy Systems, GAO-16-468 (Washington, D.C.: May 25,
2016).
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In developing this testimony, we relied on our previous reports, as
well as information provided by the department on its 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's mission is to promote the health, welfare, and dignity of all
veterans in recognition of their service to the Nation by ensuring that
they receive medical care, benefits, social support, and lasting
memorials. VA is the second largest Federal department and, in addition
to its central office located in Washington, D.C., has field offices
throughout the United States, as well as the U.S. territories and the
Philippines.
The department's three major components-the Veterans Health
Administration (VHA), the Veterans Benefits Administration (VBA), and
the National Cemetery Administration (NCA)-are primarily responsible
for carrying out its mission. More specifically, VHA provides health
care services, including primary care and specialized care, and it
performs research and development to improve veterans' needs. VBA
provides a variety of benefits to veterans and their families,
including disability compensation, educational opportunities,
assistance with home ownership, and life insurance. Further, NCA
provides burial and memorial benefits to veterans and their families.
Collectively, the three components rely on approximately 340,000
employees to provide services and benefits. These employees work in
VA's Washington, D.C. headquarters, as well as 167 medical centers,
approximately 800 community-based outpatient clinics, 300 veterans
centers, 56 regional offices, and 131 national and 90 state or tribal
cemeteries situated throughout the Nation.
VA Relies Extensively on IT
The use of IT is critically important to VA's efforts to provide
benefits and services to veterans. As such, the department operates and
maintains an IT infrastructure that is intended to provide the backbone
necessary to meet the day-to-day operational needs of its medical
centers, veteran-facing systems, benefits delivery systems, memorial
services, and all other systems supporting the department's mission.
The infrastructure is to provide for data storage, transmission, and
communications requirements necessary to ensure the delivery of
reliable, available, and responsive support to all VA staff offices and
administration customers, as well as veterans.
Toward this end, the department operates approximately 240
information systems, manages approximately 314,000 desktop computers
and 30,000 laptops, and administers nearly 460,000 network user
accounts for employees and contractors to facilitate providing benefits
and health care to veterans. These systems are used for the
determination of benefits, benefits claims processing, patient
admission to hospitals and clinics, and access to health records, among
other services.
VHA's systems provide capabilities to establish and maintain
electronic health records that health care providers and other clinical
staff use to view patient information in inpatient, outpatient, and
long-term care settings. The department's health information system-
the Veterans Health Information Systems and Technology Architecture
(VistA)-serves an essential role in helping the department to fulfill
its health care delivery mission. Specifically, VistA is an integrated
medical information system that was developed in-house by the
department's clinicians and IT personnel, and has been in operation
since the early 1980s. \3\ 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.
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\3\ VistA began operation in 1983 as the Decentralized Hospital
Computer Program. In 1996, the name of the system was changed to VistA.
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VBA relies on VBMS to collect and store information such as
military service records, medical examinations, and treatment records
from VA, DoD, and private medical service providers. In 2014, VA issued
its 6-year strategic plan, which emphasizes the department's goal of
increasing veterans' access to benefits and services, eliminating the
disability claims backlog, and ending veteran homelessness. According
to the plan, the department intends to improve access to benefits and
services through the use of enhanced technology to provide veterans
with access to more effective care management. The plan also calls for
VA to eliminate the disability claims backlog by fully implementing an
electronic claims process that is intended to reduce processing time
and increase accuracy. Further, the department has an initiative under
way that provides services, such as health care, housing assistance,
and job training, to end veteran homelessness. Toward this end, VA is
working with other agencies, such as the Department of Health and Human
Services, to implement more coordinated data entry systems to
streamline and facilitate access to appropriate housing and services.
VA reported spending about $3.9 billion to improve and maintain its
IT resources in fiscal year 2015. Specifically, the department reported
spending approximately $548 million on new systems development efforts,
approximately $2.3 billion on maintaining existing systems, and
approximately $1 billion on payroll and administration. For fiscal year
2016, the department received appropriations of about $4.1 billion for
IT--about $505 million on new systems development, about $2.5 billion
on maintaining existing systems, and about $1.1 billion on payroll and
administration.
For fiscal year 2017, the department's budget request included
nearly $4.3 billion for IT. The department requested approximately $471
million for new systems development efforts, approximately $2.5 billion
for maintaining existing systems, and approximately $1.3 billion for
payroll and administration. In addition, in its 2017 budget submission,
the department requested appropriations to make improvements in a
number of areas, including:
veterans' access to health care, to include enhancing
health care-related systems, standardizing immunization data, and
expanding telehealth services ($186.7 million);
veterans' access to benefits by modernizing systems
supporting benefits delivery, such as VBMS and the Veterans Services
Network ($236.3 million);
veterans' experiences with VA by focusing on integrated
service delivery and streamlined identification processes ($171.3
million);
VA employees' experiences by enhancing internal IT
systems ($13 million); and
information security, including implementing strong
authentication, ensuring repeatable processes and procedures, adopting
modern technology, and enhancing the detection of cyber vulnerabilities
and protection from cyber threats ($370.1 million).
VA Has a Long History of Working to Share Electronic Health Records
with DoD
Electronic health records are particularly crucial for optimizing
the health care provided to veterans, many of whom may have health
records residing at multiple medical facilities within and outside the
United States. Taking 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. \4\ 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.
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\4\ 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.
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 servicemembers' 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 Exchange 2004 This capability provides clinicians at 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 Repository 2004 This interface links DoD's Clinical Data
Initiative Repository and VA's Health Data Repository to
achieve a two-way exchange of health
information.
Virtual Lifetime Ele2009nic RecTo streamline the transition of electronic
medical, benefits, and administrative
information between the departments, this
initiative enables access to electronic records
for servicemembers 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 health care 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
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. \5\ This act 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. We
have reported, for example, that the two departments' 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. \6\
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\5\ Pub. L. No. 110-181, Sec. 1635, 122 Stat. 3, 460-463 (2008).
\6\ GAO, Electronic Health Records: DoD and VA Should Remove
Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-
265 (Washington, D.C.: Feb. 2, 2011); Electronic Health Records: DoD
and VA Interoperability Effort are Ongoing; Program Office Needs to
Implement Recommended Improvement, 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).
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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, reported spending
about $564 million on iEHR between October 2011 and June 2013.
Following the termination of the iEHR initiative, VA and DoD moved
forward with plans to separately modernize their respective electronic
health record systems.
In light of VA and DoD not implementing a solution that allowed for
the seamless electronic sharing of health care data, the National
Defense Authorization Act for Fiscal Year 2014 \7\ 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 health care 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 realtime 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.
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\7\ Pub. L. No. 113-66, Div. A, Title VII, Sec. 713, 127 Stat.
672, 794-798 (Dec. 26, 2013).
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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
\8\ 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 health care data from both departments.
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\8\ This board is made up of senior clinical leaders who represent
the user community and establish priorities for interoperable health
data between VA and DoD.
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More recently, in April 2016, VA and DoD certified that all health
care data in their systems complied with national standards and were
computable in realtime. 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. \9\
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\9\ Full operational capability of DoD's modernized health
information system is not planned to occur until the end of fiscal year
2022.
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VA's IT Organization Has Undergone Recent Changes
VA's recently departed Chief Information Officer (CIO) initiated an
effort to transform the focus and functions of the Office of
Information and Technology (OI&T), which is responsible for providing
IT services across VA and managing the department's IT assets and
resources. The CIO's transformation strategy, initiated in January
2016, called for OI&T to focus on stabilizing and streamlining
processes, mitigating weaknesses highlighted in GAO assessments, and
improving outcomes by institutionalizing a new set of IT management
capabilities.
As part of this transformation, the CIO began transitioning the
oversight of and accountability for IT projects to a new project
management process called the Veteran-focused Integration Process in
January 2016, in an effort to streamline systems development and the
delivery of new IT capabilities. The CIO established five new functions
within OI&T:
The enterprise program management office is to serve as
OI&T's portfolio management and project tracking organization.
The account management function is to be responsible for
managing the IT needs of VA's major components.
The quality and compliance function is to be responsible
for establishing policy governance and standards and ensuring adherence
to them.
The data management organization is expected to improve
both service delivery and the veteran experience by engaging with data
stewards to ensure the accuracy and security of the information
collected by VA.
The strategic sourcing function is to be responsible for
establishing an approach to fulfilling the department's requirements
with vendors that provide solutions for those requirements, managing
vendor selection, tracking vendor performance and contract
deliverables, and sharing insights on new technologies and capabilities
to improve the workforce knowledge base.
According to the former CIO, the transformation strategy was
completed in the first quarter of fiscal year 2017.
FITARA Requires VA to Address Data Center Consolidation
Recognizing the importance of reforming the government-wide
management of IT, Federal Information Technology Acquisition Reform
provisions (commonly referred to as FITARA) were enacted in December
2014 as part of the Carl Levin and Howard P. ``Buck'' McKeon National
Defense Authorization Act for Fiscal Year 2015. \10\ The law was
intended to improve covered agencies' acquisitions of IT and further
enable Congress to monitor agencies' progress and hold them accountable
for reducing duplication and achieving cost savings. FITARA includes
specific requirements related to seven areas, including data center
consolidation. \11\
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\10\ Pub. L. No. 113-291, div. A, title VIII, subtitle D, 128 Stat.
3292, 3438-3450 (Dec. 19, 2014).
\11\ FITARA also includes requirements for covered agencies to
enhance the transparency and improve risk management of IT investments,
enhance CIO authority, annually review IT investment portfolios, expand
training and use of IT acquisition cadres, and compare their purchases
of services and supplies to what is offered under the Federal strategic
sourcing initiative that the General Services Administration is to
develop.
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Under FITARA, VA and other covered agencies are required to provide
OMB with a data center inventory, a strategy for consolidating and
optimizing the data centers (to include planned cost savings), and
quarterly updates on progress made. FITARA also requires OMB to develop
a goal for how much is to be saved through this initiative, and provide
annual reports on cost savings achieved.
In addition, in August 2016, OMB released guidance intended to,
among other things, define a framework for achieving the data center
consolidation and optimization requirements of FITARA. \12\ The
guidance includes requirements for covered agencies such as VA to:
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\12\ OMB, Data Center Optimization Initiative (DCOI), Memorandum M-
16-19 (Washington D.C.: Aug. 1, 2016).
maintain complete inventories of all data center
facilities owned, operated, or maintained by or on behalf of the
agency;
develop cost savings targets due to consolidation and
optimization for fiscal years 2016 through 2018 and report any actual
realized cost savings; and
measure progress toward meeting optimization metrics on a
quarterly basis.
The guidance also directs each covered agency to develop a data
center consolidation and optimization strategic plan that defines the
agency's data center strategy for fiscal years 2016, 2017, and 2018.
This strategy is to include, among other things, a statement from the
agency CIO stating whether the agency has complied with all data center
reporting requirements in FITARA. Further, the guidance indicates that
OMB is to maintain a public dashboard that will display consolidation-
related costs savings and optimization performance information for the
agencies.
VA Has Begun to Implement VistA Modernization Plans amid Concerns about
Its Long-term Approach, Metrics, and Duplication
Although VA has proceeded with its program to modernize VistA
(known as VistA Evolution), the department's long-term plan for meeting
its electronic health record system needs beyond fiscal year 2018 is
uncertain. The department's current VistA modernization approach is
reflected in an interoperability plan and a roadmap 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, \13\ such as
standardizing the VistA software across the department to simplify
sharing data.
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\13\ Technical interoperability refers to the ability of multiple
systems to be able to transmit data back and forth.
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In addition, the VistA 4 Roadmap, which further describes VA's plan
for modernizing the system, identifies 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 roadmap, 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.
Another interoperable capability that is expected to be
incrementally delivered over the course of the VistA modernization
program is the enterprise health management platform. \14\ 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.
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\14\ 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.
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However, an independent assessment of health IT at VA 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. \15\
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.
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\15\ MITRE Corporation, Independent Assessment of the Health Care
Delivery Systems and Management Processes of the Department of Veterans
Affairs, Volume 1: Integrated Report (Washington, D.C.: Sept. 1, 2015).
This assessment was conducted in response to a requirement in the
Veterans Access, Choice, and Accountability Act of 2014, Pub. L.
No.113-146, Sec. 201, 128 Stat. 1754, 1769 (Aug. 7, 2014).
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In speaking about this matter, VA's former Under Secretary for
Health asserted that the department will follow through on its plans to
complete the VistA Evolution program in fiscal year 2018. However, the
former CIO also indicated that the department would reconsider 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.
VA, Together with DoD and the Interagency Program Office, Have Not
Developed Goals and Metrics for Assessing Interoperability
Beyond modernizing VistA, VA has undertaken numerous initiatives
with DoD that were intended to advance electronic health record
interoperability between the two departments. Yet, 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,
\16\ 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 health
care or clinician satisfaction. Establishing outcome-oriented goals and
metrics is essential to determining whether a program is delivering
value.
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\16\ 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.: Mar. 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.: Jun. 1, 1996).
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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 health care 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' health care 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 departments' efforts to determine how these
metrics define and measure 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
VA has moved forward with modernizing VistA despite concerns that
doing so is potentially duplicative with DoD's acquisition of a
commercially available electronic health record system. Specifically,
VA took this course of action even though it has many health care
business needs in common with DoD. For example, in May 2010, both
departments 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.
\17\ Further, the results of a 2008 consultant's study pointed out that
over 97 percent of inpatient requirements for electronic health record
systems are common to both departments. \18\
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\17\ 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 the Department of Defense Appropriations Act, 2010 (Public
Law 111-118).
\18\ 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.
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We also issued several prior reports regarding the plans for
separate systems, in which we noted that the two 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 electronic health record system.
Moreover, we noted that the departments' plans to modernize their two
separate systems were duplicative and stressed that their decisions to
do so should be justified by comparing the costs and schedules of
alternate approaches. \19\
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\19\ 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).
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We recommended that VA and DoD develop cost and schedule estimates
that would include all elements of their approach (i.e., to modernize
both departments' health information systems and establish
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 January
2017, 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.
Scheduling System Challenges Contributed to Designation of VA Health
Care as High Risk
In February 2015, we designated VA health care as a high-risk area.
\20\ Among the five broad areas contributing to our determination was
the department's IT challenges. \21\ Of particular concern was the
failed modernization of a system to support the department's outpatient
appointment scheduling.
---------------------------------------------------------------------------
\20\ 20 GAO, High Risk Series: An Update, GAO-15-290 (Washington,
D.C.: Feb. 11, 2015).
\21\ The remaining four areas are ambiguous policies and
inconsistent processes, inadequate oversight and accountability,
inadequate training for VA staff, and unclear resource needs and
allocation priorities.
---------------------------------------------------------------------------
We have previously reported on the department's outpatient
appointment scheduling system, which is about 30 years old. Among the
problems that VA employees responsible for scheduling appointments have
cited, are that the system's commands require the use of many
keystrokes, and that it does not allow them to view multiple screens at
once. Thus, schedulers must open and close multiple screens to check a
provider's or a clinic's full availability when setting up a medical
appointment, which is time-consuming and can lead to errors.
In May 2010, we reported that, after spending an estimated $127
million over 9 years on its outpatient scheduling system modernization
project, VA had not implemented any of the planned system's
capabilities and was essentially starting over by beginning a new
initiative to build or purchase another scheduling system. \22\ We also
noted that VA had not developed a project plan or schedule for the new
initiative, stating that it intended to do so after determining whether
to build or purchase the new system.
---------------------------------------------------------------------------
\22\ GAO, Information Technology: Management Improvements Are
Essential to VA's Second Effort to Replace Its Outpatient Scheduling
System, GAO 10 579 (Washington, D.C.: May 27, 2010).
---------------------------------------------------------------------------
We recommended that the department take six actions to improve key
systems development and acquisition processes essential to the second
outpatient scheduling system effort. The department generally concurred
with our recommendations, but as of May 2016, had not addressed four of
the six recommendations. Addressing our recommendations should better
position VA to effectively modernize its outpatient scheduling system,
and ultimately, improve the quality of care that veterans receive.
Efforts to Develop and Use the Veterans Benefits Management System Can
Be Improved
In September 2015, we reported that VBA had made progress in
developing and implementing VBMS, its system that is to be used for
processing disability benefit claims. \23\ Specifically, it had
deployed the initial version of the system to all of its regional
offices as of June 2013. Further, after initial deployment, VBA
continued developing and implementing additional system functionality
and enhancements to support the electronic processing of disability
compensation claims. As a result, 95 percent of records related to
veterans' disability claims were electronic and resided in the system.
---------------------------------------------------------------------------
\23\ GAO-15-582.
---------------------------------------------------------------------------
Nevertheless, we found that VBMS was not able to fully support
disability and pension claims, as well as appeals processing. While the
Under Secretary for Benefits stated in March 2013 that the development
of the system was expected to be completed in 2015, implementation of
functionality to fully support electronic claims processing was delayed
beyond 2015. In addition, VBA had not produced a plan that identified
when the system would be completed. Accordingly, holding VBA management
accountable for meeting a timeframe and demonstrating progress was
difficult.
Our report further noted that, even as VBA continued its efforts to
complete the development and implementation of VBMS, three areas were
in need of increased management attention.
Cost estimating: The program office did not have a
reliable estimate of the cost for completing the system. Without such
an estimate, VBA management and the department's stakeholders had a
limited view of the system's future resource needs, and the program
risked not having sufficient funding to complete development and
implementation of the system.
System availability: Although VBA had improved its
performance regarding system availability to users, it had not
established system response time goals. Without such goals, users did
not have an expectation of the system response times they could
anticipate and management did not have an indication of how well the
system performed relative to performance goals.
System defects: While the program had actively managed
system defects, a recent system release had included unresolved defects
that impacted system performance and users' experiences. Continuing to
deploy releases with large numbers of defects that reduced system
functionality could have adversely affected users' ability to process
disability claims in an efficient manner.
We also noted in the report that VBA had not conducted a customer
satisfaction survey that would allow the department to compile data on
how users viewed the system's performance, and ultimately, to develop
goals for improving the system. Our survey of VBMS users in 2014 found
that a majority of them were satisfied with the system, but that
decision review officers were considerably less satisfied. \24\
---------------------------------------------------------------------------
\24\ Decision review officers examine claims decisions and perform
an array of duties to resolve issues raised by veterans and their
representatives.
---------------------------------------------------------------------------
However, while the results of our survey provided VBA with data
about users' satisfaction with the system, the absence of user
satisfaction goals limited the utility of the survey results.
Specifically, without having established goals to define user
satisfaction, VBA did not have a basis for gauging the success of its
efforts to promote satisfaction with the system, or for identifying
areas where its efforts to complete development and implementation of
the system might need attention.
We recommended, among other actions, that the department develop a
plan with a timeframe and a reliable cost estimate for completing VBMS,
establish goals for system response time, assess user satisfaction, and
establish satisfaction goals to promote improvement. While all of our
recommendations currently remain open, the department indicated that it
has begun taking steps to address them. For example, the department
informed us of its plans to distribute its own survey to measure users'
satisfaction with VBMS and to have the results of this survey analyzed
by May 2017. In addition, the department has developed draft metrics
for measuring the performance of the most commonly executed
transactions within VBMS. Continued attention to these important areas
can improve VA's efforts to effectively complete the development and
implementation of VBMS and, in turn, more effectively support the
department's processing of disability benefit claims.
VA's Progress on Data Center Consolidation Lags Behind Other Agencies
We previously reported \25\ that VA was among the agencies that had
collectively made progress on their data center closure efforts; \26\
nevertheless, it had fallen short of OMB's goal for agencies to close
40 percent of all non-core centers by the end of fiscal year 2015. \27\
---------------------------------------------------------------------------
\25\ GAO-16-323.
\26\ The 24 agencies that FITARA requires to participate in the
Federal data center consolidation initiative are the Departments of
Agriculture, Commerce, Defense, Education, Energy, Health and Human
Services, Homeland Security, Housing and Urban Development, the
Interior, Justice, Labor, State, Transportation, the Treasury, and
Veterans Affairs; the Environmental Protection Agency, General Services
Administration, National Aeronautics and Space Administration, National
Science Foundation, Nuclear Regulatory Commission, Office of Personnel
Management, Small Business Administration, Social Security
Administration, and U.S. Agency for International Development.
\27\ Until August 2016, OMB categorized data centers as ``core''
(i.e., primary consolidation points for agency enterprise IT services)
or ``non-core.''
---------------------------------------------------------------------------
VA's progress toward closing data centers, and realizing the
associated cost savings, lagged behind that of most other covered
agencies. Specifically, we reported that VA's closure of 20 out of its
total of 356 data centers gave the department a 6 percent closure rate
through fiscal year 2015-ranking its closure rate 19th lowest out of
the 24 agencies we studied. Further, when we took into account the data
centers that the department planned to close through fiscal year 2019,
VA's 8 percent closure rate ranked 21st lowest out of 24.
With regard to cost savings and avoidance resulting from data
center consolidation, our analysis of the department's data identified
a total of $19.1 million in reported cost savings or avoidances from
fiscal year 2011 though fiscal year 2015. This equated to only about
0.7 percent of the total of approximately $2.8 billion that all 24
agencies reported saving or avoiding during the same time period. Also,
when we reported on this matter in March 2016, the department had not
yet estimated any planned cost savings or avoidances from further data
center consolidation during fiscal years 2017 through 2019.
VA also lagged behind other agencies in making progress toward
addressing data center optimization metrics established by OMB in 2014.
\28\ These metrics, which applied only to core data centers, addressed
several data center optimization areas, including cost per operating
system, energy, facility, labor, storage, and virtualization. Further,
OMB established a target value for nine metrics that agencies were
expected to achieve by the end of fiscal year 2015. As we previously
reported, 20 of 22 agencies with core data centers met at least one of
OMB's optimization targets. VA was the only agency that reported
meeting none of the nine targets. \29\
---------------------------------------------------------------------------
\28\ OMB, Memorandum M-14-08.
\29\ The Social Security Administration reported that it did not
meet seven of OMB's nine data center optimization targets and that the
remaining two targets were not applicable.
---------------------------------------------------------------------------
Accordingly, we recommended that VA take action to improve its
progress in the data center optimization areas that we reported as not
meeting OMB's established targets. The department agreed with our
recommendation and has since stated that approximately 70 data centers
have been tentatively identified for potential consolidation by the end
of fiscal year 2019. VA is anticipating that, upon completion, these
consolidations will improve its performance on OMB's optimization
metrics.
VA Plans to Retire Two Legacy Systems That Are Over 50 Years Old
The Federal government spent more than 75 percent of the total
amount budgeted for IT for fiscal year 2015 on operations and
maintenance, including for the use of legacy IT systems that are
becoming increasingly obsolete. VA is among a handful of departments
with one or more archaic legacy systems. Specifically, our recent
report on legacy systems used by Federal agencies identified 2 of the
department's systems as being over 50 years old, and among the 10
oldest investments and/or systems that were reported by 12 selected
agencies. \30\
---------------------------------------------------------------------------
\30\ GAO-16-468.
Personnel and Accounting Integrated Data (PAID)-This 53-
year old system automates time and attendance for employees,
timekeepers, payroll, and supervisors. It is written in Common Business
Oriented Language (COBOL), a programming language developed in the late
1950s and early 1960s, and runs on IBM mainframes. VA plans to replace
this system with the Human Resources Information System Shared Service
Center in 2017.
Benefits Delivery Network (BDN)-This 51-year old system
tracks claims filed by veterans for benefits, eligibility, and dates of
death. It is a suite of COBOL mainframe applications. VA has general
plans to roll the capabilities of BDN into another system, but has not
established a firm date doing so.
Ongoing use of antiquated systems such as PAID and BDN contributes
to agencies spending a large, and increasing, proportion of their IT
budgets on operations and maintenance of systems that have outlived
their effectiveness and are consuming resources that outweigh their
benefits. Accordingly, we recommended that VA identify and plan to
modernize or replace its legacy systems. VA concurred with our
recommendation and stated that it plans to retire PAID in 2017 and to
retire BDN in 2018.
In conclusion, effective IT management is critical to the
performance of VA's mission. However, the department faces challenges
in several key areas, including its approach to pursuing electronic
health record interoperability with DoD. Specifically, VA's
reconsideration of its approach to modernizing VistA raises uncertainty
about how it intends to accomplish this important endeavor. VA has not
yet defined 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. Further, VA has not justified 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.
The department also faces challenges in modernizing its
approximately 30-year old outpatient appointment scheduling system and
improving its development and implementation of VBMS. Further, the
department has not yet demonstrated expected progress toward
consolidating and optimizing the performance of its data centers. In
addition, VA's continued operation of two of the oldest legacy IT
systems in the Federal government raises concern about the extent to
which the department continues to spend funds on IT systems that are no
longer effective or cost beneficial. While we recognize that VA has
initiated steps to mitigate the IT management weaknesses we have
identified, sustained management attention and organizational
commitment will be essential to ensuring that the transformation is
successful and that the weaknesses are fully addressed.
Chairman Roe, Ranking Member Walz, and Members of the Committee,
this completes my prepared statement. I would be pleased to respond to
any questions that you may have.
GAO Contact and Staff Acknowledgments
If you or your staffs have any questions about this testimony,
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staff who made key contributions to this statement are Mark Bird
(Assistant Director), Eric Trout (Analyst in Charge), Rebecca Eyler,
Scott Pettis, Priscilla Smith, and Christy Tyson.
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Statements For The Record
BLINDED VETERANS ASSOCIATION
Re: Statement of the Blinded Veterans Association on VA's Failure to
Address Compliance with Sections 504/508 of the Rehabilitation Act
In Conjunction with Its IT Infrastructure Modernization Program
Dear Congressman Roe and members of the House Committee on Veterans
Affairs:
Thank you for granting the Blinded Veterans Association an
opportunity to provide a statement for the record of your hearing on
Assessing the VA IT landscape: Progress and Challenges on February 7,
2017. In March 2016, we testified before this Committee that we were
pleased by the progress that VA had made toward increasing the
accessibility of its internal communications with VA employees who have
visual disabilities, as well as external communications with visually
impaired veterans. While we continue to stand by that previous
statement, another year has passed and at the conclusion of that year,
we find that there are significant issues that remain unaddressed. VA's
responses to our inquiries about the status of their efforts to address
these issues throughout the past year have been sporadic at best and
largely uninformative. As VA undertakes its much-needed program to
update and modernize its information technology infrastructure, we
believe it is crucial that resolution of these issues must be
considered an essential component of the program, because it is far
less costly to build accessibility in at the ground level than it is to
retrofit equipment, software, and databases after they have been put in
place. As we will discuss below, we believe that failure to address
these matters now could also have adverse financial ramifications for
VA in the area of benefit claims. VA may be opening itself up to
increased liability for payment of large retroactive benefit claims due
to inadequate communications with veterans seeking eligibility for
benefits.
Two issues are of concern here:
1.What is VA doing to ensure that it has the capacity to send
correspondence and other important communications to veterans who have
known visual disabilities in formats other than standard print that
they can access independently? And
2.What is the status of VA's effort to bring its websites,
software, and hardware into compliance with the requirements of Section
508 of the Rehabilitation Act?
BVA was recently informed that A Power point from the Office of
Business process integration (OPBI) dated January 29th to 31st, 2013
states ``A recent Office of General Counsel (OGC) memo states VBA
notifications are not in compliance with Section 504 of the
Rehabilitation Act of 1973''. The rationale for the statement is that
Section 504 of that Act requires that Federal agencies use accessible
formats including but not limited to large print, braille, audio
recording, electronic mail (e-mail), or Microsoft Word document, to
communicate with beneficiaries and other users of services who have
known disabilities that prevent them from reading standard print or PDF
images. The OGC had determined that VA had not made a significant
effort to develop its capability to provide correspondence or other
important documents to veterans whom they knew had disabilities that
prevented their reading the types of documents mentioned above.
Further, since that time, VA has launched several initiatives to
upgrade its databases, including those maintained by both VHA and VBA.
We have been advised that the goal is to enhance the agencies' ability
to gather additional information about the needs and other vital
characteristics of veterans, so that services and benefits can be
delivered in a more efficient and timely manner. However, there is no
indication that these upgrades include data fields and other design
features that would enable either VHA or VBA to gather and maintain
information about a veteran's need for information in an alternate
accessible format. Neither is there any indication that VA is seeking
to build its capacity to provide materials to veterans in such formats
if requested.
In October 2009, the US District Court for the Northern District of
California found the Social Security Administration (SSA) out of
compliance with Sec. 504 of the Rehabilitation Act and Ordered that
agency to begin allowing beneficiaries whom the agency knew were blind
to request letters and other communications about benefits be sent to
them in accessible formats. The agency was further ordered to make such
upgrades to its equipment, programs, and services as were necessary to
enable them to provide information in such formats. The court also said
that once sufficient time had passed to allow the specified upgrades to
be put in place, no social security benefits may be reduced or
terminated to any individual shown in the SSA records to be blind or
visually impaired (or whose authorized payee is shown to be blind or
visually impaired) unless such person was first provided with the
notice in an alternative format (either Braille or a navigable
Microsoft Word document). The VA, like SSA, has a significant number of
beneficiaries, and users of medical services, who are unable to read
print or view images due to blindness, and, also like SSA, VA currently
knows who many, if not most, of those individuals are. In addition to
the legal basis for urging VA to act on this matter and follow SSA's
lead, there are health and safety considerations that make it wise for
VA to improve the accessibility of its communications. Veterans with
visual impairments can suffer life-threatening injury as a result of
their inability to read items like discharge instructions, or the
warnings and lists of side effects that accompany prescriptions.
Note also the language in Clarke v. Nicholson, 21 Vet.App. 130, 133
(2007), if a regional office (RO) decides a claim but fails to notify
the claimant of the decision, the claim remains open, legally, even if
the RO clears the corresponding end product (EP). Under such
circumstances, if VA denied entitlement to a benefit, failed to notify
the claimant of the denial, and then granted entitlement to the same
benefit years later, the claimant might be entitled to benefits
retroactive to the initial date of claim, because the decision on the
initial claim never became final.
By failing to comply with 504 and 508 by insuring that information
contained in correspondence and on VA websites is available in
accessible formats, the VA may find it is liable to reopen thousands of
cases, thus increasing the claims caseload and potentially requiring
payment of large retroactive payments.
Software that will enable VA personnel to convert material into
accessible alternative formats is currently and readily available to
the VA. It is also approved for use on the Department's system through
the Technical Reference Manual(TRM) which regulates VA software. We
believe it is imperative that implementation begin immediately.
With regard to the VA's progress in addressing issues related to
compliance with Sec. 508, BVA's specific outstanding concerns include
lack of a timeline for the replacement of outdated Legacy Systems that
are not compatible with adaptive software used by VA employees who are
blind or with versions of software that allow them to work as
productively as their peers using later versions of the systems, as
well as kiosks and VBMS documents which are not accessible to blind
veterans who rely on the VA for their medical care. We urge this
Committee to hold the VA accountable for insuring that its information
technologies and websites are designed to provide VA with the capacity
to disseminate information in a manner that makes it accessible to both
department employees who have visual impairments and need information
in order to serve veterans, and to those among our Nation's veterans
who have sacrificed their sight in service to our Nation.
In order to demonstrate to you one example of the means that are
currently available to accomplish the objectives discussed above, we
have included a ``Voiceye'' bar code on the upper right-hand corner of
this document. The Voiceye app is currently available for use on
Windows, iOS and Android devices and can be downloaded from the various
App Stores. It allows anyone to download the entire text of a document
such as this onto a mobile device and review it anywhere. You will find
this adaptive software for the blind, which makes documents accessible
on mobile devices, is efficient for both blind and sighted individuals
who want to scan and review a document on the go. We thought that
members and staff of this Committee might find it useful to try it out
on this document.
Thank you very much for your concern and attention to these issues.
We welcome the opportunity to work with you to address them. Please
feel free to contact us if you have questions or would like additional
information.
Respectfully,
Melanie Brunson
Director of Government Relations
DISABLED AMERICAN VETERANS
Mr. Chairman and Members of the Committee:
Thank you for inviting DAV (Disabled American Veterans) to testify
on the Department of Veterans Affairs (VA) Information Technology (IT)
modernization projects, programs and needs. As you know, DAV is a non-
profit veterans service organization comprised of 1.3 million wartime
service-disabled veterans that is dedicated to a single purpose:
empowering veterans to lead high-quality lives with respect and
dignity. Virtually all of our members rely on the VA health care system
for some or all of their health care, particularly for specialized
treatment related to injuries and illnesses they incurred in service to
the Nation.
INFORMATION SECURITY
In order for veterans to access and utilize VA benefits and
services, we are required to provide and sign over control of personal
information to VA. But over the last decade, challenges in VA's
information security practices have led to unintended loss of veterans
information including exposure of Personally Identifiable Information
(PII). Such losses erode our confidence in the Department, may cause
some veterans to not engage or disengage and not receive critical
services and support they need and have earned.
Under the Federal Information Security Management Act, or FISMA,
VA's Office of Inspector General (OIG) is required to assess VA's
information security programs, procedures and practices against FISMA
requirements, applicable National Institute for Standards and
Technology guidelines for information security and risk management, and
the annual reporting requirements from the Office of Management and
Budget.
In 2012, VA's Office of Information Technology (OIT) launched the
Continuous Readiness in Information Security Program (CRISP), a three-
pronged approach towards information security, addressing annual
reporting requirements and ongoing system security weaknesses, with the
goal of transforming how the Department accesses, transfers, and
protects information. It is encouraging to see OIG and OIT working
collaboratively to identify weaknesses and foster continuous
improvements in an environment with shifting priorities, changing
requirements and creating new objectives.
Meeting information security in such a complex environment among
inter and intra-agencies takes time to mature and show evidence of
their effectiveness and we appreciate Congress' supportive and vigilant
oversight of the Department efforts in operationalizing its IT
Enterprise Strategy to address persistent internal challenges.
MEANINGFUL INTEROPERABILITY
Over the last decade, more veterans are coming to VA at
significantly higher rates. To leverage technology and ensure timely
and accurate delivery of veterans' benefits and services, VA IT systems
must have efficient and meaningful interoperability.
Seamless flow of electronic information from DoD, other government
agencies and private organizations is vital to support efficient and
accurate processing of disability, pension and other claims veterans
file with Veterans Benefits Administration (VBA).
Central to the VBA claims processing is the development of new
organizational model and a new IT system, known as the Veterans
Benefits Management System (VBMS). Deployed nationally in 2013, VBMS is
a web-based electronic claims processing solution that serves as VBA's
technology platform for quicker, more accurate processing. Improvement
in interagency interoperability are needed and discussed in more detail
in the VA Reform Efforts section below.
For the Veterans Health Administration (VHA), the constant drive to
achieve more cost-effective and high-quality care, meaningful
interoperability to facilitate care coordination and effective patient
and population health management must remain a high priority for VA and
Congress.
The development of the Joint Legacy Viewer as an interim solution
is a significant and positive step in providing clinicians in the VHA
and DoD real-time access to integrated medical information from VA and
service treatment records from DoD. Such an enhancement greatly
increases the clinician's ability to use best practices in clinical
care and provide appropriate treatment.
But a majority of VA's veteran patient population receives care
from other Federal health care systems and the private sector. As this
Committee is aware, VA is prohibited from sharing health information
due to title 38, United States Code, Sec. 7332, except when required
in emergencies, without written authorized consent from the patient.
This requires legislative relief and DAV recommends Congressional
action to amend this section while applying all protections under
HIPAA.
It should be noted however that addressing the legislative
prohibition will help increase health information sharing and not
necessarily interoperability. Gaps in clinical data standards and
tailoring of the Veterans Health Information Systems and Technology
Architecture (VistA) to meet local VA facility needs is delaying Joint
Legacy Viewer (JLV) enhancements to allow other Federal and private
health care providers to share information and be available to VA and
DoD clinicians through JLV. These same challenges will need to be
address when developing a long-term solution to replace JLV.
THE AGING VistA
One of the greatest challenge for VHA is its aging Veterans Health
Information Systems and Technology Architecture (VistA), a self-
developed public domain software. VistA has software modules for
clinical care, financial and infrastructure functions. The Computerized
Patient Record System (CPRS)-the primary computer application that VA
clinicians' use when treating veteran patients-set the standard for
electronic health record (EHR) systems in the United States and has
been publicly praised by many independent observers.
VistA is now aging not having received the attention needed to
maintain its pioneering status and lags in some areas behind some
commercial systems. To modernize VistA, VA introduced VistA Evolution
in 2014 as a joint program between VA OIT and VHA to address several
challenges in information security and risk management, business
processes, clinical care, patient engagement, etc.
However, VA and VHA have changed direction numerous times since the
introduction of VistA Evolution and its reverberations are causing
confusion within the Department. Today, as major reforms are being made
in VBA and VHA, the agency has still not made a decision on whether it
should move forward with VistA or follow the lead of the DoD and
procure a commercial EHR system.
As the new Secretary of Veterans Affairs assumes the office, we
strongly urge this decision to be one of the first to be made. Whether
it is to modernize or replace VistA, VA should ensure its strategic and
operational plan should be the prominence of VistA (the database,
systems and applications) were developed in close collaboration between
clinicians, programmers, developers and engineers.
The size and scope to modernize VHA's IT infrastructure requires
the commitment from all levels of VA leadership and an improved
enterprise-level management and governance. Not anymore, In addition,
Congress must change how VA IT is currently budgeted by creating a
separate VA health care IT account and funded through advanced
appropriation.
VA REFORM EFFORTS
IT and Reforming the Claims and Appeals Process
To have efficient claims and appeals processing within VA, records
of compensation and pension examinations, those from the DoD, other
government agencies and businesses, must flow seamlessly within the
electronic environment.
Heeding our calls to address outdated and ineffective
infrastructure, leadership in the Veterans Benefits Administration
(VBA) determined in 2010 that it would be necessary to completely and
comprehensively transform and modernize its claims infrastructure and
processes. The Secretary of Veterans Affairs established an ambitious
goal of zero claims pending more than 125 days, and to complete all
claims with 98 percent accuracy. These goals are still guiding
principles for VBA today. VBA outlined a three-year strategy to achieve
these goals.
Central to the VBA claims processing is the development of new
organizational model and a new IT system, known as the Veterans
Benefits Management System (VBMS). Deployed nationally in 2013, VBMS is
a web-based electronic claims processing solution that serves as VBA's
technology platform for quicker, more accurate processing. To
facilitate more efficient claims processing, VBMS collects and stores a
veteran claimant's military service records, medical examinations and
treatment records from VA, DoD, other Federal and private sector health
care providers.
VBMS also automates much of the adjudication process, improving
workflow and the quality of disability. New technologies continue to be
developed and deployed such as the Stakeholders Enterprise Portal
(SEP), which allows stakeholders like DAV to perform our functions as
representatives of veterans submitting claims for benefits and
services. The National Work Queue (NWQ) is another piece of technology
VBA recently deployed that is designed to increase its claims
processing efficiency. The NWQ allows VBA to move its work among its 57
VA regional offices to balance its overall workload. The NWQ is still
in its infancy and Congress must perform oversight to ensure this
technology is functioning as intended to ensure tax payer dollars are
being used optimally.
While incremental improvements in VBMS give us greater access and
functionality to better serve veterans, their families and survivors,
we agree with the Government Accountability Office's recommendation
that VBA institute user and customer satisfaction goals for VBMS and
conduct satisfaction surveys. However, we recommend these goals should
apply to technology based on VBMS and other users and customers such as
DAV and other veterans service organizations.
VBMS functionality must be improved for claims and appeals
processing. At present, it requires enhancements for the Board of
Veterans' Appeals (Board) to process appeals more efficiently. Although
a substantial repository for documents, VBMS has been identified to be
cumbersome in properly evaluating evidence and adjudicating claims in
both the claims and appeals processing environments.
Presently, the Board is evaluating and implementing new
technologies to replace its workload management system, the Veterans
Appeals Control and Locator System (VACOLS). We believe any platform
the Board finds best suited to its needs must facilitate seamless cross
functionality for work requirements of VBA personnel, DAV, other VSOs
and stakeholders involved in the claims and appeals process.
IT and Reforming the VA Health Care System
Access to VA care remains a challenge as the agency is required to
provide care to an aging veteran patient population suffering from more
chronic conditions with more complex health care needs, address
disparities in care for women veterans, and delivering on the
expectations of younger veterans in need of services and supports. The
Department is expected to provide needed care regardless of where the
veteran resides and accomplish its health care mission with significant
gaps in its health care workforce, limited authority to acquire and
dispose of infrastructure to manage its footprint, and an evolving
authority to purchase high quality care from community providers.
Because veterans are unable to receive care from the VA in a timely
manner, DAV and our partners in The Independent Budget (VFW and PVA)
have proposed creating a high-performing VA health care network
comprised of VA, other federal, and community providers to create
seamless health care access for enrolled veterans.
VHA must have robust state-of-the-art information technology and
tools to integrate administrative processes (billing, claims payment,
supply chain, infrastructure and workforce) and clinical processes
(scheduling, interoperable electronic health record, and patient-
centered navigation tools) aligned with VBA and the National Cemetery
Administration to support VA's organizational mission.
Patient Scheduling
Veterans deserve high quality care and a fundamental aim for any
health care system to deliver timely care. In 2008, DAV raised our
concern about the validity of VA's data in measuring timely access to
VA care and highlighted weaknesses in VA's scheduling software,
ambiguous policies and inconsistent procedures. For example, VA's
legacy Medical Appointment Program, first deployed in 1985, is a
burdensome roll and scroll scheduling application. There have been a
number of attempts to improve on this system since and current efforts
include evaluating two concurrent pilot programs and an evaluation of a
commercial off the shelf (COTS) solution, which has not yet been
piloted. The COTS solution is intended to be a far more comprehensive
solution and is expected to, among other things, include patient facing
utility, standardize scheduling processes, data and business rules
across VHA, and manage demand, supply and utilization of resources.
The two concurrent pilot programs include VistA Scheduling
Enhancement (VSE) and the Veteran Appointment Request (VAR)
application. VSE is intended to reducing the burden on schedulers using
a modern graphical user interface layered on top of the Medical
Appointment Scheduling System. After testing at 10 locations, VA has
announced it will make a decision this week to make it broadly
available across the health care system.
VAR is a mobile and online application for veterans to self-
schedule primary care appointments and request assistance in booking
both primary care and mental health appointments at the VA facilities
where they receive care. In addition to scheduling appointments,
veterans can use VAR to track appointment details and the status of
requests, send messages about requested appointments, receive
notifications and cancel appointments.
The COTS solution is intended to be a key component in VA's long-
term strategy to address the aging VistA by improving scheduling and
provide workflow management and analytics capabilities. If VA decides
to pursue VSE and VAR and forgo a more comprehensive COTS solution, it
is imperative that VA address the gap it creates based on its long-term
strategy to have a state-of-the art health information technology
system.
Telehealth
Telehealth minimizes barriers associated with geography by using
technology to deliver timely care. It also alleviates some of the
struggles in the VA health care system from increasing cost of care to
the shortage of VA clinicians.
To facilitate greater use of telemedicine, Congress must enact
legislation to allow any VA clinician licensed to provide telemedicine
to do so to any veteran enrolled in the VA health care system. Equally
important, VA should address the current requirement to privilege and
credential telehealth providers at each location the provider is to
deliver telemedicine. Proposals include centrally administering
credentialing and privileging or establish a national service agreement
to grant providers national level privileges and credentials rather
than requiring privileges and credentials for each VA facility.
Purchasing Care in the Community
In fiscal year (FY) 2016, nearly a third of all medical appointment
(25.5 million of 83.8 million appointments) was made with community
providers-a 61 percent growth from FY2014. Yet when referring veterans
to community care, VHA continues to experience challenges in processing
claims and payments. Timely and accurate claims processing and payment
is as important to community providers as it is to veterans (who are at
risk of being billed and sent to collections when community providers
are not paid).
Despite the tremendous growth in claims processing workload,
commensurate resources have not been dedicated to make needed
improvements. VHA continues to have separate claims processing systems
using VistA, Fee Basis Claims System (FBCS), and manual processes, all
of which are antiquated compared to what is available commercially.
In addition, claims for adult day care, bowel and bladder care,
contract nursing homes, dental, dialysis, home health services, newborn
care, and pharmacy, are not processed through FBCS but rather through
VistA (dialysis is processed in a commercially acquired system).
Several weaknesses exist in the end-to-end process to purchase care
in the community. For example, clinical and administrative
determinations to authorize veterans to receive care in the community
are approved in VistA and manually entered in FBCS-where each VA
Medical Center (VAMC) or Veterans Integrated Service Network (VISN) had
its own version of FBCS. FBCS is then used to authorize, process and
pay for community care. This lack of integration between VistA and FBCS
creates increased risk for error and inefficiencies.
Without a comprehensive IT solution, VHA still relies heavily on
paper claims requiring manual handling. Electronic claims received from
community providers remain low despite the Federal government mandate
in Affordable Care Act (ACA) addressing the administrative burden faced
by community providers in the claims and reimbursement process. In
general, transaction standards that were adopted under HIPAA enable
Electronic Data Interchange (EDI) through a uniform common transaction
standard.
The benefits of electronic claims interchange include reduced
administrative overhead expenses, improved data accuracy, cleaner
claims submission and reduced claims processing time. Because VHA is
unable to deliver on the benefits of EDI, community providers remain
hesitant to comply with the government mandate reinforcing the status
quo within VHA.
Another weakness is that costs for some purchased care
authorizations are manually estimated and entered into FBCS, leading to
inconsistencies estimating costs and thus affects the ability to
accurately report available resources for the purposes of budgeting.
In the ``choice'' program, gathering of information on
registration, appointment and authorization provided to VHA by the
third-party administrators (TPAs) is manually intensive, inefficient,
and increased the risk of error. Moreover, VHA does not have the proper
IT system in place to properly oversee the ``choice'' program currently
relying on both manual and systems possibly due to the significant
reorganization of CBO as required by the same law requiring the
establishment of the ``choice'' program and the short timeline to
implement the ``choice'' program.
For well over a decade, we have spoken to numerous community
providers who are dedicated to providing ill and injured veterans the
best care they can provide. They consistently describe their dilemma
with VHA in terms of the reimbursements they receive. They are able to
continue caring for veterans if their reimbursement rate is low but
received quickly. They are also able to continue to work if their
reimbursement rate is adequate but slow. However, they are unable to
continue to partner with VHA is their reimbursements are both slow and
low-as is the general case today.
If in the future, VA is to have a high performing integrated health
care network with other Federal and community providers, it must show
it values committed partners in which VHA IT plays a crucial role.
Closing
Because of the breadth and depth of the three major IT challenges
of information security, interoperability, and the aging VistA, as well
as the other agency IT issues, it is clear that Congress and the VA
must work together and engage all stakeholders transparently and
collaboratively.
Mr. Chairman, DAV appreciates the opportunity to provide this
statement to the Committee on this important topic and urges Congress
to legislatively address the IT needs of VA. I would be pleased to
further discuss any of the issues raised by this statement, to provide
the Committee additional views, or to respond to specific questions
from you or other Members.
THE AMERICAN LEGION
Chairman Roe, Ranking Member Walz, and distinguished members of the
House Committee on Veterans' Affairs on behalf of National Commander
Charles E. Schmidt and The American Legion; the country's largest
patriotic wartime service organization for veterans, comprising over 2
million members and serving every man and woman who has worn the
uniform for this country; we thank you for the opportunity to testify
regarding The American Legion's position on Assessing the VA IT
Landscape: Progress and Challenges.
``Overhauling the health care system for Americans who answered the
call of duty by serving in the military is a national priority. The
country's largest integrated health care delivery system is responding
to these challenges and aims to reestablish trust by expanding methods
of providing care and emphasizing the concept of ``whole health'' and
adopting a veteran-centric approach in everything we do. It will be
necessary to reimagine the future of VHA health care delivery.
Partnerships with Federal and community health care providers may
result in better access and broader capabilities and will require a new
infrastructure. The future requires the use of best practices in
science and engineering to improve the quality, safety and consistency
of veteran's experience, regardless of the site or type of care.''
David Shulkin, M.D. \1\
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\2\ New England Journal of Medicine http://www.nejm.org/doi/full/
10.1056/NEJMp1600307
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Department of Veterans Affairs (VA) Information Technology (IT)
infrastructure has been an evolving technological necessity over the
past 37 years, sometimes leading the industry, and sometimes trailing.
The American Legion has been intrinsically involved with VA's IT
transformation from the inception of Veterans Health Information and
Technology Architecture (VistA) to the recent introduction of VistA-
e[volution] for medical records, as well as being a pioneer partner in
the concept and integration of the fully electronic disability claims
process.
Leading the field in 1978, VA doctors developed an electronic
solution to coordinate and catalogue patients healthcare long before
their private sector colleagues, who were slow to follow, while some
private physicians still refuse to automate today.
As has been well documented, the Veterans Benefits Administration
(VBA) suffered from horrific backlogs peaking in March 2013 at over
611,000 claims. Today, that backlog has been reduced to approximately
100,000 claims. VBA was mired in a mid-20th century work model lacking
IT integration. Shuttling physical cases from one station to the other
and from regional offices to medical centers adding to delays to
adjudication decisions. Though not perfect, the implementation of
Veterans Benefits Management System (VBMS) and stakeholder enterprise
portal (SEP) has significantly reduced VA's reliance on hard copy
cases. Today, cases can be viewed throughout the Nation collectively,
greatly assisting advocates, VA, and ultimately, millions of our
Nation's veterans.
IT automation is expensive to implement and expensive to maintain,
especially when maintaining legacy equipment. As in all digital space,
IT infrastructure advances so quickly that most IT infrastructure is
outdated by the time it is fully implemented, and VA's IT
infrastructure is no different. Unfortunately, in this case it is
simply the cost of doing business in a technologically advancing
society. With this in mind, companies are turning to rented cloud based
resources and Software as a Service (SAS) to mitigate costs. These
services have a lower up-front investment and negate the need for
hardware maintenance and software upgrades in many cases.
Information Technology is inextricably intertwined into many of the
services we take for granted, such as; telephone systems, appointment
scheduling, procurement, building access and safety controls, and much
more. Maintaining an up-to-date system is not a luxury, it is
necessary, and The American Legion has found that VA's IT
infrastructure is aged and failing our veterans.
One of the primary complaints The American Legion receives
regarding VA healthcare is scheduling issues. VA's inability to
schedule the full complement of veterans' healthcare needs from one
central location causes a multitude of delays and billing problems and
puts veteran patients at risk when all of the members of the veteran's
health team are unable to effectively collaborate online.
In order for VA to safely and effectively serve veterans going
forward they need a 21st century data system that incorporates;
A single lifetime Electronic Health Record system (EHR),
One Operation Management Platform consisting of one
resource allocation, financial, supply chain, and human resources
system that are integrated seamlessly with the EHR,
A single Customer Relationship Management (CRM) system
If proprietary, the system needs to be built using open source
code, which will allow the program to remain sustainable and enable
future competitive Application Programming Interface (API) Framework
that will provide seamless interoperability with internal and external
systems.
Once this system is developed, metrics and analytics will be
available to all levels of leadership from decentralized locations.
Legacy viewer and 130 different versions of VistA simultaneously
running across the national and international VA landscape that has
been patched together is outdated and ineffective. A veteran should be
able to walk into any VA medical Center (VAMC) anywhere in the country
or abroad, and the first intake specialist to assist that veteran
should be able to pull the patient's record up instantly. This is not
possible today.
Initiatives like MyHealtheVet, eBenefits, and the recently launched
Vets.gov are all steps in the right direction, and all need to be tied
into a single user interface system. The American Legion also supports
extended use of public/private partnerships similar to the team
detailed to VA from the private sector who have spent the past 18
months building the Vets.gov portal. IT industry leaders such as
Amazon, Google, Microsoft, and Cisco have already partnered with VA in
a number of areas and appear willing to help ad cost, below market
cost, or even donated services, and VA needs to have the flexibility to
maximize these relationships.
Finally, as we struggle to keep up with the multitude of programs
and expenditures related to VA's IT program, The American Legion is
outraged that one of VA's first experiences with integrating cloud
services into the VA program was mismanaged and squandered more than $2
million in taxpayer funds. VA does not have the freedom to learn as
they go and needs to partner with or hire experts in cloud computing
before they engage in cloud brokerage services. A few days ago the VA
Office of Inspector General found \2\;
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\2\ VAOIG https://www.va.gov/oig/pubs/VAOIG-15-02189-336.pdf
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``OI&T spent over $2 million on a cloud brokerage service contract
that provided limited brokerage functionality and that VA's actions did
not ensure adequate system performance or return on investment. We
determined total project costs exceeded $5 million and the system's
limited brokerage service functionality prevented it from being used in
a production environment. This capability is essential for delivery of
cloud services. The project manager did not ensure that formal testing
and acceptance were conducted on project deliverables.''
These deficiencies occurred because of a lack of executive
oversight and ineffective project management. Without enforcement of
oversight controls, project leadership cannot ensure it will receive
the value of contract deliverables or demonstrate an adequate return on
investment for the project.''
In closing, The American Legion calls on Congress to ensure that VA
is tying all of their IT programs together into a seamless program
capable of processing claims, managing veterans' healthcare needs,
integrating procurement needs so that VA leaders and congress can
analyze annual expenditures versus healthcare consumption, integrating
patient communications into their profiles, and ensuring seamless
transition between the Department of Defense and VA.
These are the needs of our 21st century fighting force, these are
the needs of our returning veterans, these are the needs of our aging
veterans, and these are the responsibilities of our Federal government
who called on these heroes to defend the Constitution of the United
States, against all enemies, foreign and domestic.
Conclusion
The American Legion thanks this Committee for their diligence and
commitment to our Nation's veterans as they struggle to receive the
benefits they have earned for their service to the country. Questions
concerning this testimony can be directed to Warren J. Goldstein,
Assistant Director in The American Legion Legislative Division (202)
861-2700.
VETERANS OF FOREIGN WARS
MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE:
On behalf of the men and women of the Veterans of Foreign Wars of
the United States (VFW) and our Auxiliary, thank you for the
opportunity to offer our thoughts on the progress and challenges we see
in the Department of Veterans Affairs' Information Technology (VA IT)
landscape.
Historically, VA has faced significant challenges in developing and
deploying state-of-the-art IT systems. Throughout the agency's history
we have seen stops and starts that have brought about significant
innovation, only to see these systems neglected and deteriorating over
time.
VA was the first health care system in the country to deploy a
fully electronic and interoperable health care recordkeeping system;
but as we have observed over the years, sustainment of this system has
slowly led to its obsolescence. Now the agency is playing catch up.
VA should be applauded for its efforts to make information more
accessible to veterans by developing and deploying interactive portals
through which veterans can manage their health care and benefits--
eBenefits, MyHealtheVet and vets.gov. However, these systems are
imperfect and at times unstable, leading to frustration for those who
seek to access them and utilize their features. Regardless, VA must be
commended for moving out deliberately on a number of these innovations
with the goal of improving the veteran experience.
Progress:
Over the past few years, VA has moved out aggressively to reform an
antiquated, paper-based disability claims process through the
development of the Veterans Benefits Management System (VBMS), and new
stakeholder tools for accredited veterans service organizations (VSOs)
like the VFW, specifically the Stakeholder Enterprise Portal (SEP)--a
direct upload portal for VA Central Scanning, and the Digits-2-Digits
(D2D) electronic claims submission pilot.
The VFW is generally impressed with the VBMS system. Since its
deployment, our network of accredited representatives who assist
veterans across the country have found the system to be generally user-
friendly and efficient in tracking veteran claimants. This is a
significant step in the right direction as VA seeks to develop 21st
century IT capabilities. However, VBMS continues to have critical flaws
that must be addressed.
VA's development of a direct upload portal through which accredited
VSOs can submit claims documents and evidence directly to VA Central
Scanning has the potential to be a game-changer for VA, if deployed
properly. Since the rollout of SEP this fall, the VFW is generally
happy with this system. It is intuitive. It is easy to monitor work
flow. It is meticulous in keeping records of transactions. The VFW
believes this capability was a longtime coming for VSOs and has the
potential to significantly improve the efficiency of our service to
veterans.
Though eBenefits and MyHealtheVet have proven to be helpful
resources for veterans, each system requires a different unique user
name, an onerous password combination, and in-person verification for
full access. The systems have also proven to be unstable with regular
outages or disabled features. Veterans have consistently communicated
these challenges to the VFW, and the VFW has in turn asked VA for a
more intuitive, single-portal solution. Thankfully, VA listened and is
incrementally deploying a quality single-portal solution via the
vets.gov migration.
The VFW has been privy to demonstrations of vets.gov and we have
been repeatedly asked to stress test new features of the portal. To
date, we are very satisfied with the product. VA should be commended
for seeking out a competent third party, veteran-owned contractor--
ID.me --who developed a state-of-the-art identity verification system
that makes full access to the portal an easy transaction. When our
staff was asked to sign up for the portal on our own time, it took many
of us a matter of only minutes to verify our identity and start working
inside the portal, rather than the burdensome verification process that
was required to reach the same level of authentication for VA's
eBenefits and MyHealtheVet. We sincerely appreciate VA's collaboration
on this initiative and we look forward to continuing to work together
to deliver a high quality, full service benefits management portal to
our veterans.
VA has also made significant progress in leveraging health
information exchanges to integrate private sector health care data with
the VA electronic health care records of veterans who receive their
care from VA and community care partners. Originally developed as a way
to bridge the gap between VA and Department of Defense, the Virtual
Lifetime Electronic Record (VLER) has also helped VA integrate the
private sector and VA health care records of nearly 700,000 veterans.
VLER eliminated the need for veterans to carry their records from one
appointment to another, private providers faxing records to VA, and VA
needing to scan paper records into its system. Doing so improves health
care outcomes by reducing duplicate tests, improving coordination of
care, and expediting the delivery of care for veterans.
The VFW supports continuing the VLER program and calls on Congress
to eliminate barriers to its success, such as an outdated law that
limits VA's ability to share health care records with its community
care partners. The outdated law requires VA to withhold the medical
information of veterans who have been diagnosed with substance use
disorder, human immunodeficiency virus, and sickle cell anemia,
hindering VA's ability to transfer medical records with its community
care partners. Congress must remove this statutory limitation.
Finally, we must commend the Board of Veterans Appeals for
pragmatically seeking out new ways to manage workflow. Though we have
not seen finite deliverables to date, we support their efforts of
leaning on IT professionals to stress test potential solutions before
prematurely deploying an unworkable solution.
Challenges:
Though the VFW applauds the initiative VA has taken in developing
and deploying IT solutions, we face challenges in collaboration to
develop the best possible resources to serve veterans. We have also
heard a dangerous word around VA of late that has the VFW deeply
concerned about the future viability and functionality of these
products: sustainment.
The VFW and our VSO partners consistently meet with VA to discuss
our shared objectives in helping veterans navigate the complex VA
benefits landscape. We have provided consistent feedback on the
development and deployment of VA IT systems at all levels of the
agency, to include meetings directly with the Office of Information
Technology (OIT). However, some recent developments have left the VFW
feeling neglected in helping to execute our part of VA's mission:
meeting face-to-face with veterans to help them understand and navigate
their benefits.
As VA develops new IT systems, the agency has a bad habit of
prioritizing internal business processes over the needs of veterans.
Past VA Secretary Bob McDonald consistently articulated this as one of
his chief concerns in transforming VA from a rules-based organization
into a principle-based organization. The VFW agrees that this is a
draconian task that has sadly not improved much over the past couple of
years. Two examples of this are the recent decision by VA to enforce
Personal Identity Verification (PIV) access rules for VA computer
systems; and the deployment of the National Work Queue (NWQ) for
veterans' claims within VBMS.
First, the VFW continues to have significant problems in accessing
VA computer systems because of the PIV card access rules set forth by
VA. Last spring, VA recognized its significant challenges in issuing
timely PIV identification cards and loading proper IT permissions all
across the agency. VA also recognized the need to increase IT security,
which is something the VFW understands. However, instead of fixing the
PIV card issuance problems, VA OIT eliminated exemptions and now
requires PIV card access to log onto VA IT systems.
Make no mistake; the VFW understands that VA needs to ensure
information security across its systems, but PIV enforcement and the
simultaneous neglect to the PIV issuance processes has locked many VFW
advocates out of the IT systems to which we need access to serve as
responsible advocates for veterans. For example, one of our accredited
representatives in Kansas City, Missouri still needs his IT permissions
added to his PIV card to once again access VBMS. He has raised the
issue locally and the VFW has raised the issue here in Washington.
Instead of finding a solution, VA business lines point fingers at one
another. Our representative has lacked the proper access to the systems
he needs for more than eight months.
What the VFW finds so disappointing about the PIV issue is that
this is not new technology and this is not a new challenge for VA. As a
matter of fact, the Federal government is already contemplating
migrating away from this technology, as it is already more than a
decade old. By a point of reference, this technology was first
introduced to the Federal government through the military. Back in
2006, while still serving in the U.S. Army Reserve, my military ID card
was set to expire. At the time, I was a Department of the Navy civilian
who required a PIV badge to access the Navy networks. During my lunch
break, I was able to visit the ID office on Naval Station Newport where
they took my photo, issued me a new U.S. Army ID card, and loaded it
with the proper IT permissions to access the Navy network. I walked
back to the office with my new, functional ID and continued my work
unabated. Fast forward ten years, and VA still cannot figure this out.
The VFW believes this is inexcusable.
Next, as VA deployed VBMS, they also worked to develop NWQ to
distribute work around the country. The VFW generally supports the
concept of NWQ and we agree with VA that if implemented properly, it
has the potential to ensure consistent, accurate and timely benefits to
veterans. Since its inception, VA has asked for VSO input on NWQ.
Sadly, very few of our needs have been addressed in its deployment. The
VFW will present on this topic before the Disability Assistance &
Memorial Affairs Subcommittee next week, but we will summarize our
concerns here.
For decades, accredited VSO representatives have been afforded 48
hours to perform a final review of a proposed rating decision before it
is promulgated and sent to the veteran. The VFW and our partner VSOs
view this as a final quality assurance check to ensure VA and our
accredited representatives have produced an accurate rating decision
for our veterans. Unfortunately, the deployment of NWQ has prevented us
from performing this final quality check.
VA moves work around its regional offices very quickly via NWQ. The
VFW understands this. It makes sense for VA to shuffle its business
processes to offices that have the capacity to complete the work in a
timely manner. However, when VA proposes a rating decision and posts it
for review, they do not return the claim to the regional office where
the claim originated --depriving the accredited VFW service officer
familiar with the claim the opportunity to review it for accuracy
before the claim is finalized. This makes no sense to the VFW,
especially considering that our resources are customer-facing and
aligned to serve the veterans in a particular community.
This becomes a problem when VFW representatives are overwhelmed
with excessive rating reviews in offices postured to handle only a
small population of veterans. This is also a problem in states that
invest finite state tax dollars in veteran claims assistance programs
designed to serve veterans within their borders.
Our argument to VA is that the processes they have sought to
automate through NWQ are rules-based. This means any properly trained
VA employee should be able to execute the business process to a high
standard. This makes sense for VA. However, when VA assigns the rating
review to a VSO in a random office, they do not take into account the
customer-facing aspect of the VSO's job. VSOs and state governments
align their resources to meet the needs of the community. Our job is
customer service. Our clients share sensitive personal information with
our advocates in confidence. It is our duty as veterans' advocates to
ensure they receive the best possible service at the time and place of
their choosing, not VA's choosing. Currently, the distribution of work
via NWQ makes it nearly impossible for VSOs to do our job to a high
standard.
VA has offered workarounds to this problem, but workarounds are not
solutions. The VFW believes that once VA is ready to propose a rating
decision, they must return the claim to the Station of Origination
(SOO) for the 48-hour review. The VFW not only believes this will allow
VSOs to conduct a proper review, but this will also make it easier on
VA. When VSOs catch errors in the rating review, the process is
improved. Our accredited representatives learn how VA rates, VA learns
about its deficiencies, and veterans fully understand their rating
decisions. This is a mutually supportive process that avoids conflict
and cuts down on appeals. For the VFW, we consistently find errors in
10 percent of our rating reviews. If these are corrected, we help VA
get it right the first time.
When we have raised this issue with VA, they have responded with
indignation. They feel that their workarounds should be sufficient and
they claim that resources will not allow them to reroute the work. The
VFW believes that VA already has the capability to reroute the work,
but they are unwilling to do so. Since NWQ moves work from office to
office so frequently, and then eventually returns the work to the SOO,
the VFW believes that the infrastructure is in place to move the work
to reflect the veteran's needs in the final review process.
Again, as VA's partners, we believe NWQ can be a very good system
to help veterans receive consistent, accurate, and timely benefits. We
understand and support VA's initiative in resourcing work based on
capacity in a digital environment. All we ask is that VA lets us help
them deliver the best possible outcome to our veterans.
With regard to sustainment of projects, conversations about the
future viability of IT initiatives have become more pessimistic as the
agency prepares for the sustainment phase. Simply put, VA has told the
VSOs that there is no more money to continue developing many of its IT
systems, particularly its claims management systems, and that
sustainment means they will only have the ability to fix emergency
glitches.
The VFW believes VA has made significant progress in the
development and deployment of many of its IT systems. However, we must
warn against stagnation. In the past, we have seen Congress make
significant investment in the development of IT resources, and we have
seen VA move out aggressively to deploy these solutions. Unfortunately,
once deployed, we usually see these solutions stagnate, meaning
veterans, VSOs and VA employees are left to work with half solutions
that quickly become obsolete.
Proper IT development requires consistent investment in the
development and evolution of a product. For example, I was an early
adopter of Facebook back in 2004 when it was relegated to connecting
with other students on college campuses in the Northeast. At the time,
there were no photo albums, no news feeds, no external applications,
and no public access. Since then, Facebook has continued to make
investments internally and externally to build what has become one of
the largest interconnected information networks in the world. The
developers at Facebook never settled on what they believed to be a
``good enough'' solution. The same can be said for Google, which
evolved from a state-of-the-art search engine into a full-service
digital platform for communication, information management, and
commerce.
By contrast, VA develops groundbreaking systems, like the
aforementioned electronic health care record --Veterans Health
Information Systems and Technology Architecture (VistA) ----
but stagnation and VA's inability to keep pace with the private
sector quickly renders such innovations obsolete. When it was first
developed more than 30 years ago, VistA won awards for changing the
medical records landscape and was praised for ushering in 21st century
health care. VistA continues to serve as a critical tool for America's
largest integrated health care system, but it is no longer the state-
of-the-art system it once was. Private sector electronic health care
record systems have not only caught up to VistA, they have surpassed
its ability to assist health care providers in caring for their
patients.
The VFW agrees with the Commission on Care that it is time for VA
to adopt a commercial-off-the-shelf (COTS) solution to its aging
electronic health care system. VA must be commended for its innovation
and for continuing to modify VistA to meet today's needs, like
developing a new user interface called the Enterprise Health Management
Platform (eHMP) to reduce the time providers spend on the computer and
maximize face-to-face time with their patients. To that end, VA has
devoted time and resources to developing workarounds or patches to
update VistA's aging infrastructure. We are glad VA has continued to
turn to the VFW and our VSO partners when developing such workarounds
and patches to make certain they meet the needs of veterans. However,
the VFW believes VA would be better served by adopting a commercial
electronic health care record infrastructure that can incorporate many
of its new projects or completely eliminate the need for patches to
VistA.
VA can never build an IT system then declare victory and walk away.
Our veterans need and deserve better, which is why we ask this
Committee to continue supporting the investment and evolution of VA IT
resources. We all know there are significant challenges in this
mission, but we look forward to working with VA and this Committee in
addressing them.