[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


    VA ELECTRONIC HEALTH RECORD MODERNIZATION: THE BEGINNING OF THE 
                               BEGINNING

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

                                HEARING

                               BEFORE THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         TUESDAY, JUNE 26, 2018

                               __________

                           Serial No. 115-68

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-806                     WASHINGTON : 2019                     
          
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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
BILL FLORES, Texas                   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                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       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 
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                            C O N T E N T S

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                         Tuesday, June 26, 2018

                                                                   Page

VA Electronic Health Record Modernization: The Beginning Of The 
  Beginning......................................................     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Tim Walz, Ranking Member...............................     3

                               WITNESSES

Peter O'Rourke, Acting Secretary, U.S. Department of Veterans 
  Affairs........................................................     6
    Prepared Statement...........................................    59

        Accompanied by:

    John Windom, Program Executive Officer, Electronic Health 
        Record Modernization Program, U.S. Department of Veterans 
        Affairs

    John Short, Chief Technology Officer, Electronic Health 
        Record Modernization Program, U.S. Department of Veterans 
        Affairs

    Ashwini Zenooz, M.D., Chief Medical Officer, Electronic 
        Health Record Modernization Program, U.S. Department of 
        Veterans Affairs

Vice Admiral Raquel Bono, Director, Defense Health Agency, U.S. 
  Department of Defense..........................................     7
    Prepared Statement...........................................    61

David Powner, Director of IT Management Issues, U.S. Government 
  Accountability Office..........................................    39
    Prepared Statement...........................................    64

                        STATEMENT FOR THE RECORD

Project Management Institute (PMI)...............................    73

 
    VA ELECTRONIC HEALTH RECORD MODERNIZATION: THE BEGINNING OF THE 
                               BEGINNING

                              ----------                              


                         Tuesday, June 26, 2018

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committees met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. David R. Roe 
presiding.
    Present: Representatives Roe, Bilirakis, Coffman, Bost, 
Poliquin, Dunn, Arrington, Higgins, Bergman, Banks, Walz, 
Takano, Brownley, Kuster, O'Rourke, Rice, Correa, Lamb, Esty, 
and Peters.

          OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN

    The Chairman. The Committee will come to order. And before 
we get started today, I want to thank the Committee Members for 
all the hard work they did on the Blue Water Navy. This has 
been a passion of this Committee and mine and Mr. Walz for 
literally the whole time I have been in the Congress. And this 
Committee delivered, by voice vote and then yesterday, I think 
we can say we made our case for a 382-to-zero, finally this 
wrong is being righted. And I want to personally thank every 
Member of this Committee for the work you did, the dedication 
on both sides of the aisle.
    So, from me to you, thank you.
    [Applause.]
    The Chairman. Thank you all for being here today to discuss 
VA's Electronic Health Record Modernization Program. Much has 
been said and written about the program since June 1st of last 
year when former Secretary Shulkin announced his decision to 
commence negotiations with Cerner; opinions have been formed 
and conclusions have been drawn. The reality is, even with the 
contract awarded and work underway, we are at the beginning of 
the beginning. We all know the broad strokes that led to the 
EHR modernization. The VA IT budget is consumed by operations 
and maintenance costs. VA's Health Information System, VistA, 
is functional, but increasingly complicated, while the EHR 
industry continues to evolve. Also, it is well past time for VA 
and DoD to achieve seamless interoperability, because 
servicemembers and veterans deserve a lifetime medical record. 
I have heard Mr. Walz say that for 10 years.
    VA leaders were guarded in how much they would discuss 
during the negotiations. To some extent, that is 
understandable, but it is time to delve into the details. 
Fifteen point eight billion dollars over 10 years, including 
$10 billion to Cerner, is a staggering number for an enormous 
government agency. That is $15,800 million when you put it in 
terms like that. I don't know about where you are from, but 
where I am from, that is a lot of money. However, EHR software 
is only a relatively small part of the overall price tag. What 
exactly does all that money buy?
    Everyone here today knows the adage: if you have seen one 
VA hospital, you have seen one VA hospital. Part of the reason 
for that is for 35 years VHA has had a culture of creating 
software to fit any process and a technology platform, VistA, 
that facilitated it. There is much to be said for local 
authority in health care, I agree with that, but it seems to 
have gotten out of control and made the IT landscape 
ungovernable.
    EHR modernization is not just a technology project, it will 
have a major impact on the way VHA operates, that means 
clinical and administrative workflows. It also reshapes the 
culture, as VistA has. However, if imposed on clinicians from 
the top down, the culture will reject it and no amount of 
technological savvy will be able to save it.
    If we were creating a Veterans Health Care System from 
scratch, implementing an EHR would be relatively easy, but that 
is not the reality. Transitioning away from VistA is the most 
difficult aspect of the EHR modernization. VHA and VistA have 
built up around each other for decades. Amazingly, even after 
all these years, the Department does not seem to have a 
complete technical understanding of where VistA begins and 
ends. It is not an oversimplification to say the EHR 
modernization team may still be figuring out what VistA is up 
and when until the day they turn it off, if ever.
    The scale is daunting, and the ambition is impressive, that 
is evident. I am interested in the benefit at the end of the 10 
years to a veteran and to the clinician. The lifetime health 
record has to be worth the potential disruption. The ease of 
use, the new analytics in the EHR have to be worth the learning 
curve. Those things are difficult to quantify, but if the 
equation does not balance it will be abundantly clear as soon 
as the system is turned on in the first medical center.
    I believe VA has been realistic about the level of 
resources needed to manage the EHR modernization and by every 
indication the EHRM Program Executive Office is building a good 
structure to do that, but they will need a great deal of help. 
The program cannot be seen as just the responsibility of an 
office in Washington. VA senior leaders, VHAs throughout the 
country and Office of Information and Technology, and every 
other corner of the Department must be invested in its success.
    I especially appreciate all our witnesses agreeing to 
testify today. It is a large and impressive group on two 
panels, including some new faces for the Committee. You have 
all demonstrated an interest in the EHR Modernization success.
    My colleagues on the Committee and I are committed to doing 
our part, that is why Ranking Member Walz and I have decided to 
create a new Subcommittee on Technology Modernization, to focus 
on oversight of the EHR Modernization Program, as well as VA's 
other enterprise modernization projects and programs. The 
Subcommittee will allow a small group, three to five people, of 
Committee Members to focus intensively on these issues and 
strengthen the work the staff has already been doing. The EHR 
Modernization is a big bet on the future of VA and we simply 
must make sure it succeeds. More details will be available as 
we constitute the Subcommittee in the coming weeks.
    I have been through this process from paper to electronic, 
it is not easy; going from electronic to electronic I feel is 
going to be even harder. I think the technology is going to be 
difficult and we have to be patient, and we certainly have to 
start at the supply person who is working in the ER supplying 
things, from the nurses who are spending way too much time 
looking at a computer screen and not at patients, and to 
doctors who are doing exactly the same thing. If it doesn't 
free up our clinicians and our supply people and our other 
people for more time with our patients, then we have failed.
    So, with that, I yield to Ranking Member Walz for his 
statement.

         OPENING STATEMENT OF TIM WALZ, RANKING MEMBER

    Mr. Walz. Well, thank you, Chairman. And again, I want to 
thank each and every one of you and your leadership on Blue 
Water Navy. You set out to do and, as everything you have done, 
you accomplished it, and I am grateful for that and so are many 
of our warriors.
    The Chairman is right, 12 years ago in the first Committee 
here I remember saying that I hope I would be here long enough 
to see the implementation and a movement towards electronic 
health record, a joint electronic health record with DoD. And 
having an understanding that that is far more than a database, 
that is a diagnostic tool and everything else that goes with 
it. No one knows better than the Chairman on the complexities 
of this.
    To get this done right is going to take transparency and 
oversight; the creation of this Subcommittee is a great first 
step. If I have learned nothing in those 12 years of being here 
that especially when it comes to everything but the VA in 
particular, and whether it is Denver, Phoenix, or projects that 
have worked wonderfully in moving forward like Omaha, 
leadership will make or break this project. So will the 
oversight, which is why I enthusiastically support the creation 
of this new Subcommittee overseeing a $16 billion, decades-long 
process.
    There are going to need to be eyes on this all the way and 
every one of us up here, we own this now, we own this. We can 
complain about Denver, we can try and get fixes, we get to 
start fresh. And I would own that, and I said I think we should 
take the responsibility that everything that goes wrong with 
this now or goes right should be the responsibility of this 
Committee to take a look at it and that is what the Chairman is 
putting in place. But to do that, we need to have the capacity, 
and that means the GAO and the IG must be given the access they 
need to independently oversee progress on implementation.
    GAO should be in attendance at every single governing board 
meeting; GAO must have direct and frequent access to VA, 
Cerner, and program management support contractors. I want the 
GAO to review quarterly progress reports. IG must have access 
to these documents and information it needs to regularly 
monitor implementation and be ready to follow up, audit, and 
investigate when significant issues arise.
    We are going to have to partner in this. So today at 9:01, 
I received the documentation that talks about the establishment 
of the Office of Electronic Health Records Modernization. No 
communication with us before this, nothing there. You sent this 
to us electronically and on the second page, Mr. O'Rourke, it 
has your signature with attachment, no attachment was there. It 
is Electronic Health Records Management, you can't make this 
stuff up. We get an improper electronic transfer of information 
setting up the office. This is why there needs to be oversight.
    And I am going to have questions as we go through. Where is 
Mr. Sandoval today? Where is the Chief Information Officer? 
Where is the person that is going to ultimately or should be 
ultimately responsible for this?
    It is important our watchdogs are empowered to effectively 
hold VA accountable to veterans and taxpayers. This Committee 
has done that. We have held people accountable, we have 
protected whistleblowers, and we have uncovered abuses that 
hurt veterans. That only happened because the IG and the GAO 
were there.
    It is not up to the VA Secretary or Acting Secretary to 
decide when an IG investigation occurs. You do know, Mr. 
O'Rourke, you have no authority to remove an IG, none; statute 
does, you do not have that authority. When something occurs, IG 
needs to access documents and records. It is not up to you to 
determine GAO's level of access. I raise this issue because VA 
OIG has yet to be granted access to the Office of Whistleblower 
Accountability and Protection database. Mr. O'Rourke said that 
organization is accountable to him and loosely tethered to him, 
that is not the case. They are true through your budget, but 
not for the authority. What is true is, you are not loosely 
tethered to this Committee, you are constitutionally tied to 
this Committee and the oversight that will be provided from 
this Committee. I don't want to hear reports a year from now, 
IG are being denied access to documents relating to electronic 
health record modernization. VA stonewalling must not be 
tolerated, it cannot be tolerated by any administration. It 
happened where we had it last time and we needed to subpoena 
documents to get that from the administration to find out what 
was happening in Phoenix. Now we have the IG clearly asking for 
these things and being denied those things.
    So today I am going to want assurances that the IG will be 
granted access to the Whistleblower Protection Program, the IG 
and the GAO will be granted ready access to oversee electronic 
health record modernization. Capable and good leaders' welcome 
transparency and independent oversight, capable and good 
leaders do not threaten the independence of the IG. Capable and 
good leaders welcome GAO's involvement in every aspect of this 
project because the outcome is a product that delivers and 
improves care for our veterans, that is what all of us want. We 
cannot have a bureaucracy clogging that up, we cannot have a 
bureaucracy that will not let independent eyes see that, we 
cannot let a bureaucracy not be accountable to the elected 
officials that sit here who are responsible for those veterans.
    So I find it deeply concerning Executive in Charge of the 
Office of Information Technology Mr. Sandoval is not testifying 
today, since the Office of Information Technology is 
responsible for EHR's successful implementation. We are kicking 
off a glorious day, we are at the beginning of the beginning, 
and the person responsible is not here, the first transmission 
we get is incomplete, the ability to get documentation with the 
IG who is going to have to be there every step of the way is 
asking us to step in and get them information that is not being 
willingly given to them. That is not an auspicious start.
    Governance and leadership, including active engagement of 
senior officials with stakeholders and supportive senior 
department executives are critical. We don't have leaders in 
place to participate in the project's government or set the 
strategy for this project. Who is meeting with the 
stakeholders? Where is the support from senior executive 
departments? We don't have governance because critical 
leadership positions are unfilled.
    I have seen too many VA projects fail because of lack of 
leadership. Every one of you Members of Congress own this now. 
If they don't do this, it is on each of us.
    Last month, media outlets reported Cerner failed to 
effectively implement their EHR at multiple DoD facilities, 
citing a botched rollout that put patients' lives at risk and 
lacked operational effectiveness. I find the details of these 
reports disturbing and unacceptable. The root cause must be 
identified and remedied. VA cannot fail veterans again. VA and 
the White House must act now to remedy the deficiencies so that 
we have qualified leaders in place before the project 
implementation begins this fall. There is too much at stake, 
veterans have been waiting too long for this seamless 
coordinated care between DoD, VA, and private providers.
    I want to thank the Chairman. He understands this, that is 
what this Subcommittee is going to do, and you can rest assured 
they will carry out their responsibility.
    I yield back.
    The Chairman. I thank the gentleman for yielding. And just 
for the record, we did not invite the Chief Information 
Officer, Mr. Sandoval, and VA did not offer him to be here. And 
I would like to associate with your remarks, I agree with that.
    On the panel we have Acting Secretary of Veterans Affairs, 
Mr. Peter O'Rourke. He is accompanied by leaders of the EHRM 
Program Executive Office: Mr. John Windom, welcome, the Program 
Executive Officer; Mr. John Short, the Chief Technology 
Officer; Dr. Ash Zenooz, the Chief Medical Officer.
    On the panel we also welcome Vice Admiral Bono, the 
Director of the Defense Health Agency. Welcome, Admiral.
    I ask the witnesses from both panels we hear from today to 
please stand and raise your right hand.
    [Witnesses Sworn.]
    The Chairman. Thank you, and you may be seated.
    Let the record reflect that all the witnesses have answered 
in the affirmative.
    Acting Secretary O'Rourke, you are now recognized for 5 
minutes.

                  STATEMENT OF PETER O'ROURKE

    Secretary O'Rourke. Thank you, Chairman.
    Good morning, Chairman Roe, Ranking Member Walz, and 
Members of the Committee. With me from VA are Mr. John Windom, 
Dr. Ashwini Zenooz, and Mr. John Short, respectively the 
Program Executive Officer, Chief Medical Officer, and Chief 
Technology Officer for VA's Electronic Health Record 
Modernization. Thank you for inviting us to testify.
    Let me acknowledge as well Vice Admiral Raquel Bono, 
Director of the Defense Health Agency, with us this morning.
    In just the past 18 months, five major Acts of Congress 
have benefitted veterans and VA: The Veterans Accountability 
and Whistleblower Protection Act, the Veterans Choice and 
Quality Employment Act, the Forever GI Bill, the VA Appeals 
Improvement and Modernization Act, and, most recently, the VA 
MISSION Act. To find another period of such significant change, 
we would have to go back to Omar Bradley's days.
    Yet another significant step forward is Electronic Health 
Record Modernization. For transitioning servicemembers and 
veterans, it will improve care coordination and delivery. It 
will provide clinicians the data and tools they need to support 
patient safety, and veteran data will reside in a single 
hosting site, using a common system that enables health 
information sharing. So we deeply appreciate your leadership 
and bipartisan support.
    Achieving full operating capability across VA with the new 
EHR is a sizable task; it will take several years to complete. 
And we recognize and fully appreciate the challenges the 
Defense Department has faced in its own EHR implementation 
experience, so we have designed a proactive and preemptive 
contract management strategy. We are working closely with DoD, 
we are listening to advice from respected leaders in health 
care, and we are fully engaged with the Cerner Corporation 
regarding all critical activities: establishing governance 
boards, conducting current state reviews, and optimizing the 
deployment strategy. We intend to anticipate challenges and 
take full advantage of lessons learned to mitigate risk in VA's 
implementation, and our strategy will adapt as we learn, and 
technology evolves.
    VA's EHR modernization will be a flexible, incremental 
process, welcoming course corrections as we progress. Effective 
program management and oversight will be critical, critical to 
cost adherence, to time lines, to performance quality 
objectives, and to effectively implement risk-mitigation 
strategies. So we are committed to a PMO properly staffed with 
exactly the right functional, technical, and advisory subject 
matter expertise.
    To facilitate decision making and risk adjudication, we 
have designed an interim governance structure of five 
functional, technical, and programmatic teams. They are the EHR 
Steering Committee, the EHR Governance Integration Board, the 
Functional Governance Board, the Technical Governance Board, 
and the Legacy EHRM Pivot Work Group.
    We will continue to refine this structure and our processes 
over the next few months to further enhance performance and 
outcomes. In July, August, and September, VA will assess, 
validate initial operating capabilities in Medical Centers in 
Spokane, Seattle, and American Lake, Washington, as previously 
negotiated. In October, we will begin EHR deployment to these 
three sites with a full capability goal of March of 2020.
    VistA and related clinical systems will continue serving 
veterans until the EHR is fully capable.
    EHR modernization is a deep change; it is a technical and a 
cultural challenge, and the human component is central success. 
So we will fully engage end users early to train facilities 
staff and promote successful adoption. Clinical councils of 
doctors, nurses, and other front-line users will support 
workflow configuration, and they will help identify staff 
concerns and propose responsive solutions. VISNs will have the 
opportunity to configure workflows without customization based 
on their unique circumstances. And we will continue to work 
with our DoD counterparts to help navigate joint costs, 
schedules, performance, and interoperability objectives. It is 
a user-centric approach to a veteran-centric change.
    VA's Electronic Health Record Modernization represents a 
monumental improvement for veterans, possible only with the 
strong support of the President, this Committee, and the 
Congress, Veterans Service Organizations, and other 
stakeholders. Thank you for honoring our Nation's commitment to 
veterans and I look forward to your questions.

    [The prepared statement of Peter O'Rourke appears in the 
Appendix]

    The Chairman. Thank you, Mr. Secretary.
    Admiral Bono, you are recognized.

             STATEMENT OF VICE ADMIRAL RAQUEL BONO

    Admiral Bono. Thank you, sir.
    Chairman Roe, Ranking Member Walz, and distinguished 
Members of the Committee, thank you for the opportunity to 
testify before you today. I am honored to represent the 
Department of Defense and discuss the Department's experience 
in implementing a modernized electronic health record, EHR, and 
I am excited about the tremendous opportunity we have to 
advance interoperability with the VA and private sector 
providers as a result of the VA's recent decision to acquire 
the same commercial EHR that the DoD is now deploying.
    The decision by DoD to acquire a commercial EHR was 
informed by numerous advantages: introducing a proven product 
that can be used globally in deployed environments, as well as 
in military hospitals and clinics in the United States; 
leveraging ongoing commercial innovation throughout the EHR 
life cycle; improving interoperability with private sector 
providers; and offering an opportunity to transform the 
delivery of health care for servicemembers, veterans, and their 
families.
    In 2017, the Department deployed MHS GENESIS to all four 
initial operational capability, IOC, sites in the Pacific 
Northwest, culminating with deployment to Madigan Army Medical 
Center, MAMC, the largest of the IOC sites in Tacoma, 
Washington. The other sites include the 92nd Medical Group at 
Fairchild Air Force Base, Naval Health Clinic Oak Harbor, and 
Naval Hospital Bremerton, all in Washington State.
    Over the next 4 years, MHS GENESIS will replace DoD Legacy 
Health Care Systems and will support the availability of 
electronic health records for more than 9.4 million DoD 
beneficiaries and approximately 205,000 MHS personnel globally.
    By deploying to four hospitals and clinics that span a 
cross-section of size and complexity of MTFs, we have been able 
to perform operational testing activities to ensure MHS GENESIS 
meets all requirements for effectiveness, suitability, and data 
interoperability.
    Right now we are in the midst of making important 
improvements to software, training, and workflows, addressing 
the lessons we learned in the initial deployment as we prepare 
to continue our deployments into 2019.
    End user feedback to our changes have been relatively 
positive. Our success is dependent on strong clinical 
leadership, both here and our headquarters, and by clinical 
champions at the point of care. The Department is focused on 
maintaining this clinical leadership as we move to the next 
deployment wave.
    To best support MHS GENESIS, the Defense Health Agency is 
also fielding a cost-effective communications infrastructure 
and network throughout the military health system.
    When completed, DoD medical providers, whether they are 
affiliated with the Army, Navy, or Air Force, will be able to 
use their Common Access Card, CAC, into any computer on the DoD 
Health Care Network and access their identical desktop as they 
travel from one location to another, inside or outside the 
continental United States.
    We have also optimized our network to help ensure 
continuity of care for our beneficiaries. Over the past 5 
years, DoD steadily increased its data-sharing partnerships 
with private sector health care organizations. Today, DoD has 
nearly 50 health information exchange partners in the private 
sector.
    Since award of the VA contract, leaders of both departments 
have been meeting to more formally integrate our management and 
oversight activities. We are sharing all of our lessons and 
future plan deployments with our colleagues at the VA, and plan 
to synchronize deployments where possible. The VA and DoD 
understand that the mutual success of this venture is dependent 
on our continued close coordination and communication.
    Thank you again for the opportunity to come here today and 
share the progress we have made to transform the delivery of 
health care, as well as discuss the opportunity to strengthen 
the DoD/VA partnerships as we move forward together with a 
common EHR that will benefit millions of servicemembers and 
veterans. As a partner in our progress, we appreciate Congress' 
interest in this effort and ask for your continued support to 
help us deliver on our promise to provide world-class care and 
services to those who faithfully serve our Nation.
    Thank you for this opportunity and I look forward to your 
questions.

    [The prepared statement of Raquel Bono appears in the 
Appendix]

    The Chairman. Thank you, Admiral, and thank all of you all 
for being here.
    And this is--first of all, I want to thank the Members for 
being here--this is not the kind of a hearing that you are 
going to go home to the Kiwanis Club and say I am going to talk 
about the electronic health record. People are going to start 
looking at their watch and heading to the doors. But it is--I 
know this personally--it is incredibly important that we get 
this right.
    And I have only made one visit to begin to see the rollout, 
but I intend to make others as quickly as I can. And one of the 
things that first to make this all work, we have spent a year 
and a half doing the VA MISSION Act where people that can't 
access care timely or whatever the reason is, maybe live in a 
rural area, that they access care outside the VA, it is 
incredibly important that these health information exchanges 
work, that we can share information. It is a problem in the 
private sector, trust me. I mean, you can't go to your hospital 
and get the information, you can't get a lab test.
    One of the things that bothered me when I was out at 
Fairchild was on MHS GENESIS, when you came in, what was 
entered into the EHR was basically allergies, medications, 
procedures, immunizations. I can get that in one minute of 
asking somebody. Other data, which included what I really want 
to see, are your lab results, X-ray reports, notes from 
previous visits, discharge summaries, you have to use the Joint 
Legacy Viewer to look back. And my question is, our providers--
that slows you down.
    I have told people all along, if you are in a busy practice 
like I was and saw 25 people a day, you took 2 minutes is all, 
it added 2 minutes to each patient, I am an hour late at the 
end of the day. And you have frustrated people, the doctors and 
nurses are staying after hours to fill in the reports.
    So are we going to be--Mr. O'Rourke, you can answer it, any 
of your team can or, Admiral Bono, you can--are we going to be 
able to put all this information where the practitioner, the 
nurse, and the other providers are able to access it without 
using two systems? And if we do, what is the point of using 
Cerner if we have kept two systems live? You have then got the 
cost of the old system, which I think is about a billion 
dollars a year, and then what would be the cost of the new 
system, Cerner, to maintain it? If we have just added cost and 
haven't added value, we haven't added much.
    So I will start with Admiral Bono.
    Admiral Bono. Yes, sir, thank you very much. And you are 
exactly right, you have described that perfectly.
    And so one of the things that we did is we embedded the 
Joint Legacy Viewer within our MHS GENESIS, so that it is just 
within the people in the past that had to log out, log in, 
contributing to the time, now it is a click within the MHS 
program. Because having access to that information that we put 
in the Joint Legacy Viewer, that is not only a part of the care 
that people may have received in VA hospitals, but also in the 
private sector, is incredibly important to the continuity of 
their care. So what we did is we have embedded it into MHS 
GENESIS.
    The Chairman. Well, especially for you all at DoD where 60 
percent of people--
    Admiral Bono. Yes, sir.
    The Chairman [continued].--get their care outside the 
Department of Defense, if that information doesn't flow--
    Admiral Bono. Yes, sir.
    The Chairman [continued].--bad results happen.
    Will the VA be able to do that, Mr. O'Rourke, be able to 
put--because basically the people I saw at Fairchild are 
healthy airmen, I mean, they are young, healthy people for the 
most part; if not, they are not in the military. So will the VA 
be able to take these very complicated medical records, which 
have--I mean, many patients are ill and older.
    Secretary O'Rourke. Absolutely. Our goal is to make sure 
that we have seamless data transfer in all those different 
aspects.
    I am going to let Dr. Ashwini address that specifically.
    Dr. Zenooz. Congressman, we understand at the VA, as well 
as the DoD, that a complete longitudinal record is the ultimate 
goal. And as part of the lessons learned from not only the DoD 
implementation, but our use in the VA with JLV and external 
implementations, when we go live at our Cerner sites, Cerner 
implementation sites, we will have a single system that ingests 
all of the records not only from DoD, anything that is coming 
in, but also from our community providers into the appropriate 
place for a long record. That is above and beyond the PAMPI 
data that you just noted. That will include notes, clinic 
notes, laboratory exams, radiology exams, and much more.
    The Chairman. Well, that is a robust--because we are 
talking about March of 2020, and hopefully most of these 
Members will still be sitting here in 2020, if they desire, but 
that is not that long. If you are starting in October, we are 
at that point almost in 2019, so you are a looking at an 18-
month rollout in the Northwest. Would it make sense to roll out 
a Great Lakes, which is where you have a combined VA/DoD 
facility, are you going to roll that out simultaneously?
    And I know, Admiral Bono, that may not be in the works, but 
it seems like that would sense.
    Admiral Bono. Yes, sir. I think that by working with the VA 
we have identified areas where we do have some synergies that 
we want to capitalize on. We certainly looked at the Great 
Lakes area. I know that there are some infrastructure things 
that we have to address there, but I think that would be an 
opportunity we definitely want to explore.
    The Chairman. the other thing I would like to ask, are you 
all working together, sharing this information, so we don't 
recreate the wheel? And what I am asking about that is, I think 
when I read in DoD the people on the ground, the people that 
are every day I have got to click this thing on and try to make 
it work, they didn't really know who--when they had a work 
order or something, they needed an answer to a question, they 
couldn't get the answer to that question. It was basically 
there was like me calling a prescription to one of these large 
drugstore chains, 1-800-HOLD.
    So basically that is what was happening, it looks to me 
like they couldn't get an answer, so they had to do a work-
around. Have we learned things from that, so that the people 
actually implementing this thing that, you know, their stomach 
is hurting, they are taking another Zantac because of it, do 
they have a way to get an answer quickly without going through 
back to D.C. and through this big hoop?
    Admiral Bono. Yes, sir. As a matter of fact, based on the 
feedback that we were getting from the end users, as well as 
the report and observations that your group was able to share 
with us, we have put in place a more streamlined process to be 
able to address these. And we have stood up an Office of Chief 
Health Information and what that does is allow us to make some 
decisions closer to the actual site.
    The Chairman. Yeah, that would be the trouble-ticket 
resolution.
    Admiral Bono. Yes, sir.
    The Chairman. And you said DoD is making adjustments to 
software, training, and workflows; what adjustments have you 
made?
    Admiral Bono. Yes, sir. So some of the training is 
extremely important and we realize that, and that is one of the 
lessons that we have shared with the VA. Training has a large 
part to do with the changed management and, as I think you 
mentioned, it needs to be something that the providers can 
easily adapt to. And I think that is one of the pieces that we 
have learned is that the providers need to be very much a part 
of that training and that changed management.
    And so the workflows that we have introduced have to 
reflect what best supports the clinical practice.
    The Chairman. Okay. My time has expired.
    Mr. Walz?
    Mr. Walz. Thank you, Chairman Roe.
    I want to get us all on the same sheet to start with, so 
Mr. O'Rourke, let's clear this thing up from the beginning. I 
want you to guarantee me the IG will immediately have access to 
that Office of Accountability Whistleblower Protection database 
and any other information it needs to audit that program today. 
Can you give me that assurance they can have all the data they 
ask for?
    Secretary O'Rourke. Absolutely, sir. The IG has had access 
to any information of the Office of Accountability that he 
would request--
    Mr. Walz. That is incorrect.
    Secretary O'Rourke [continued].--appropriately.
    Mr. Walz. That is not the understanding of the IG.
    Secretary O'Rourke. So there is just one thing to clear up. 
The information that we protect in the Office of Accountability 
is privacy information and, just like this Committee, what the 
accountability law prescribed was the privacy of 
whistleblowers, which is sacred to us in the office. The 
privacy of whistleblower identities is specifically called out 
in the accountability law that it cannot be shared with 
anybody, including the Secretary. I can't even see at this 
point in my current role unless given written authorization by 
the whistleblower.
    Now, that is a Privacy Act now record that applies in Title 
5, which only requires that the IG request--he doesn't have to 
provide a reason, he just has to say I would like this 
information, and he will be provided that. That is all we have 
asked for.
    In fact, we took the extra step, one of the things that I 
tried to do as the Executive Director, which was to have a 
liaison from the IG in the Office of Accountability to review 
these records as we received disclosures. It wasn't something 
they were interested at the time, that's fine, it is up to 
their discretion, but that request only needs to be made so we 
can both Title 5 and the accountability law be covered, and he 
can have any information that he would like.
    Mr. Walz. We will get back with the IG today--
    Secretary O'Rourke. Absolutely.
    Mr. Walz [continued].--and make sure that they are 
satisfied, and we get in and we get that done. That's great. 
And I understand why Chairman Roe said Mr. Sandoval was not 
invited here. The thing I would mention to you, though, is at 
the heart of the single biggest electronic project maybe we 
have ever done in government, we haven't received one phone 
call, one text, or one interaction at all with Mr. Sandoval at 
the people who are involved in this.
    Secretary O'Rourke. Sure.
    Mr. Walz. So my team, so we need to know who to contact. 
And, again, we have a new office set up, the only contact was 
you. Do you want the staff to go directly through you or is 
there someone over there manning that? Is there someone we can 
contact to talk to about the issues?
    Secretary O'Rourke. Absolutely. This team that is with me 
here today is leading up the core part of that new office. As 
we stated and as we talked about in the opening statement, we 
are continuously improving both the structures and the 
approaches, that is how we are going to approach this entire 
project. We are going to share that with you as many times as 
we have the opportunity and we are highly--we are excited, 
frankly, with the special oversight Committee.
    Mr. Walz. Can they send us the attachment?
    Secretary O'Rourke. Absolutely.
    Mr. Walz. Okay. I want an assurance too that the GAO will 
have access to the officials and the contractors involved in 
the project. Can you assure me that GAO will sit in on those 
governance meetings and be allowed to review the quarterly 
reports--
    Secretary O'Rourke. Absolutely.
    Mr. Walz [continued].--at will? All right.
    Secretary O'Rourke. Absolutely.
    Mr. Walz. So setting up that governance board, now that the 
contract is out there, I am assuming that it is in place, who 
will be part of the five project governance boards and how 
often do they meet? We are just unsure of how that is going to 
function and what is there, who is on it, how it has been done. 
How far, in your assessment, on that process are you?
    Secretary O'Rourke. Well, I think it is helpful for you to 
see how the leadership is looking at this. We know and we agree 
with both you and the Chairman that leadership has to be 
involved in this, although this can't turn into some top-down 
implementation. So I know for me personally, I will be 
involved. We have set up not only the governance boards, we 
have set up overall management boards where we are looking at 
all of our priorities, this being one very specific. And so we 
are bringing the entire VA senior leadership team to view these 
projects.
    Now, specifically for the governance boards, John, do you 
want to give him some more specifics?
    Mr. Windom. Yes, sir. As we assessed potential governance 
actions, it was important to have a cross-functional team 
composing these governance boards. So you will see 
representation from the field, probably most importantly, but 
also from headquarters, from OINT, from VHA, from other 
representatives. And it is often an issue-dependent makeup of 
the board, so we will ad hoc members of the board based on an 
issue in particular that may be at hand.
    Those boards are set to meet--again, I need to emphasize 
that governance has to take place at the lowest level. We can't 
escalate things continually to the Secretary's office; 
otherwise, we are failing. And so we don't intend to fail, so 
we will be managing these governance evolutions at the lowest 
level.
    To my left, Dr. Ashwini Zenooz, she leads the Chief Medical 
Board, and to my right, John Short leads the Technology Board.
    So, again, cross-functional membership, timely resolution 
will be imperative for our boards to be successful.
    Mr. Walz. Well, I am hopeful. I know no one intends to 
fail, but I have seen it. We are going to have to find out what 
your full-time needs are and who has been staffed into that.
    The thing I will say, and it is probably not for this 
group, this is a higher level, but we still don't have a 
confirmed Secretary, Deputy Secretary, Under Secretary for 
Health, or Chief Information Officer. It is pretty important 
that those positions be filled with some stability. I pass that 
on for anybody who is listening, or if you have got a direct 
line to the person who can nominate and get those done, that 
would be great.
    Secretary O'Rourke. Yes, sir.
    Mr. Walz. So I yield back.
    The Chairman. I thank the gentleman for yielding.
    Chairman Bost, you are recognized for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    First off, let me tell you that I agree with the Chairman 
on how important this is. One of the biggest shocks that I had 
whenever coming and becoming a Member of Congress was working 
to try to get the medical records simply transferred from DoD 
into Veterans Affairs, which is just amazing to me in a Nation 
of this size and that it has taken us this morning. Of course, 
you have got to remember, I came from a time when I left the 
Marine Corps, my medical records were on microfiche. So now we 
need to step forward.
    But, Mr. O'Rourke, I need to find out, you know, the 
Commission on Care report issued June 30th, 2016, recommended 
that the VHA produce and implement a comprehensive commercial, 
off-the-shelf information technology solution to include 
clinical, operational, and financial systems that can support 
the transformation of VHA. And I believe this is a good thing 
and that the VA has finally listened to the recommendations 
after a few years, but it does not seem as though the VA has 
already--or it does seem as though the VA is already 
experiencing some delays during the contracting phase with 
Cerner.
    How does the VA plan to work with Cerner and DoD to ensure 
that the implementation time line is met?
    Secretary O'Rourke. Sir, that request to us to transform 
VHA was one of the things that has driven us to look at every 
aspect of our health care delivery system. So I can assure you 
that we are taking that charge very seriously.
    When it comes to working with DoD, I think we have talked 
this morning and I think by having the Admiral here this 
morning with us shows that we are hand-in-hand with DoD to make 
sure that veterans are served from the time that they sign up 
on Active duty to the time that they come to the Veterans 
Administration for service. We are not going to run away from 
that challenge. We see that it is one of the more important 
things that we have to face today.
    So I can assure you our full leadership team is involved in 
making sure that we address those issues.
    Mr. Bost. Okay. I think that is what is vitally important 
to this Committee, because many of us see as you move forward, 
when we hear reports and the questions that are out there, the 
big fear we have is those dates are not going to be met and we 
want to make sure--we want to make sure it is done right, but 
we also want to make sure that it is done in a way where the 
American citizens and our veterans can actually see it come to 
pass in a quick and efficient manner.
    Kind of on that is the second part of my question. 
According to an article on Military.com, it appears some of the 
hospitals implementing MHS GENESIS have been experiencing 
delays, especially at the pharmacies. Has the VA discussed with 
the DoD ways to avoid these increased delays due to the EHR and 
its systems?
    Secretary O'Rourke. So we have been reviewing those reports 
and actually the documents that we share together with the DoD 
continuously since we have started this process. So we are 
aware of what the issues are there, and we have worked together 
to provide our input on those solutions, but also taking what 
the DoD has done to solve those issues as well and integrated 
those into our plan.
    Mr. Bost. Just for me knowing, how many staff do you have 
working on this at this time, and is it a large group or is it 
pretty much turned over to Cerner?
    Secretary O'Rourke. We are not going to turn everything 
over to Cerner. We will have our internal team built, as you 
know, we are continuously developing that org structure and 
what is going to be the best to not only make sure that we have 
top-level oversight from a management standpoint, but also have 
the right governance and the right decision-making being 
happened at the deployment sites, and then also in a Program 
Executive Office.
    Mr. Bost. Thank you.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding.
    Mr. Takano, you are recognized.
    Mr. Takano. Mr. O'Rourke, I first want to echo the concerns 
raised by Ranking Member Walz. While serving on this Committee, 
I quickly learned the important role the IG plays in helping 
Congress to provide proper oversight of the VA and ensure that 
veterans are getting timely access to the benefits and care 
they deserve. The independence, the independence of the IG is 
absolutely crucial and proper oversight will be extremely 
important in the years to come as VA undertakes the massive 
endeavor of updating its EHR system, and I believe the Senate 
expressed itself unanimously in a funding bill on this issue.
    But to the matter at hand. The GAO identifies involvement 
of senior agency officials as a fundamental practice necessary 
to the successful acquisition and implementation of the EHR. We 
also heard at the hearing last week on staffing, that having 
strong leadership in place is crucial for the success of a new 
initiative.
    Mr. O'Rourke, where is the VA in the process of identifying 
a qualified Deputy Secretary, Under Secretary of Health, and a 
Chief Information Officer?
    Secretary O'Rourke. I completely agree with you that the 
top--that senior leadership involvement in these is absolutely 
critical for success. Take a look at any implementation with a 
leadership is not there--
    Mr. Takano. I get that. My time is short, but just tell me 
where you are. Where are you in the process? Have you been 
interviewing people? When can we expect these positions to be 
filled?
    Secretary O'Rourke. For the Deputy Secretary, that is 
something I will have to defer to the White House, that is a 
decision that they make on who they are going to pick for those 
senior leadership positions.
    Mr. Takano. Okay. And what about the Under Secretary of 
Health and the Chief Information Officer?
    Secretary O'Rourke. So for the Under Secretary for Health, 
there is a process for that with the Commission. So we will be 
conducting a Commission here very shortly--
    Mr. Takano. I remind you, we are undertaking a 10 to $15 
billion initiative and we don't have these critical positions 
filled.
    Secretary O'Rourke. I agree.
    Mr. Takano. How many FTE are needed to fully staff the 
Project Management Office and how many positions remain 
unfilled?
    Secretary O'Rourke. I can assure you that we are going to 
have the appropriate amount of FTE. For that specific question, 
I will turn it to John.
    Mr. Windom. I will touch on that, sir. We have 260 
identified as our organizational requirements at this phase. We 
expect that to grow as we obviously implement to more sites. 
Right now we have the requisite technical expertise on staff or 
access to that. Field support is imperative in this effort, and 
so being able to reach out to the field component, and so I 
would defer any additional comments to the Chief Medical 
Officer.
    Mr. Takano. Okay. No one has given me a number. How many 
FTE are really needed here?
    Mr. Windom. Two hundred and sixty for the next phase, sir.
    Mr. Takano. Okay. And how many positions remain unfilled of 
that 260?
    Mr. Windom. At this point right now, sir, the staffing is 
over the period of time. We have 135 clinicians that we need 
in-house to conduct the workload--
    Mr. Takano. It is a simple answer--
    Mr. Windom [continued].--all but thirty five--
    Mr. Takano [continued].--you gave me a direct answer of 
260, how many of the 260 remain unfilled?
    Mr. Windom. Thirty five, sir.
    Mr. Takano. So you have filled 260 minus 35? I can't do the 
math in my head.
    Mr. Windom. Sir, the fill rate is--again, accessibility is 
important, it is imperative that we don't disrupt the care 
being delivered to our veterans today, so we are accessing 
field support from their respective activities. So, again, the 
important thing is that we have access to the requisite 
knowledge, whether it be clinical or technical, and we have 
that at this stage.
    Mr. Takano. All right. So you said all but 35 have been 
filled?
    Mr. Windom. Thirty-five, sir. And those are likely 
permanent hires, full-time hires that the hiring process is 
presently being--
    Mr. Takano. So, just to be clear, 35 positions remain to be 
filled, is that what you are saying?
    Mr. Windom. Yes, sir.
    Mr. Takano. Okay. All right. Well, that is better than I 
thought. All right. Has the VA/DoD interagency working group 
met?
    Mr. Windom. Has the D--sir, the interagency working group 
has met to solidify its governance processes. So that is an 
ongoing process. We meet formally monthly, we meet routinely 
every Friday, and we meet--
    Mr. Takano. So you have met. Who attends these meetings, 
who attends the meetings?
    Mr. Windom. Sir, I lead the effort for the VA side and 
Stacy Cummings, who is the PEO for the DHMS effort or the MHS 
GENESIS effort leads on the DoD side.
    Mr. Takano. And you did give me an idea of how often it 
meets. It meets how often?
    Mr. Windom. It meets monthly formally, all-day session 
monthly, it meets every Friday for approximately 45 minutes, 
and it is continuously amongst the field experts and the 
clinicians and the technicians that are working specific 
issues.
    Mr. Takano. I will just conclude my time by just saying 
that I don't see how this is going to end well unless we get 
the top leadership positions in place and that these folks that 
fill, especially the Chief Information Officer as a highly 
qualified individual to oversee this project. And it is not on 
you, it is on the White House for leaving these positions 
unfilled, especially when we have this massive, massive 
contract that we have got to oversee.
    Mr. Windom. Yes, sir.
    Mr. Takano. Thank you.
    The Chairman. I thank the gentleman for yielding.
    Dr. Dunn, you are recognized for 5 minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman, and I thank 
the panel for coming today. I know it is--I can imagine how 
much fun it is to be here.
    So I want to say at the outset, I am a physician, my career 
spans the period of time that began with handwritten notes and 
faxes, a new invention back then. So now we are in fifth 
generation EHRs. I have lived through EHR purgatory on multiple 
occasions and spent a great deal of my own office's money on 
EHRs. So I am certainly sympathetic, and I understand the size 
of the project that we are taking on.
    I want everybody here to remember that fundamentally, most 
importantly, what we are doing is not building an EHR, we are 
taking care of our patients, the veterans. That our goal was 
quality, timely care for veterans, it is not to have, you know, 
the best EHR that has ever been invented.
    So with that in mind, let me start, if I may, Mr. 
Secretary, I know you have a deep experience at the VA and in 
other organizations and in health, can you address what you 
think are some of the barriers to and challenges to 
implementing this new EHR?
    Secretary O'Rourke. Thank you. What we face, as you said, 
is a historic opportunity. I think everybody at this table is 
committed to the outcomes for veterans that we all desire, 
which is a great health care delivery system, benefits delivery 
system. We see this opportunity as the next step in that 
journey of being able to provide veterans exactly what they 
deserve. We all come to this with somewhat of excitement in a 
sense of being able to be on the front end of history, of what 
we see as an opportunity that doesn't come along once or twice 
in a generation. So we are looking forward to that.
    From anything that is standing in our way, I really don't 
see that. I think we have gotten the support from the Congress 
that we absolutely need, that will come in the form of an 
oversight, working with us, taking on anything that we see as a 
problem for us. But, you know, when it comes to just 
communication between us and you all amongst ourselves with 
DoD, those are really going to be what we face.
    Mr. Dunn. So we have a historic opportunity to succeed or 
fail, and certainly I want you and your team to keep us 
informed about what we can do to push the needle towards 
success. How are we explaining this to the average, all your 
clinicians? You have got a lot of doctors and nurses, how are 
you explaining to them the benefits of this change?
    Secretary O'Rourke. We understand this was going to be a 
deep cultural change, but luckily, I have a Chief Medical 
Officer here that can provide some more detail.
    Mr. Dunn. Dr. Zenooz, go ahead.
    Dr. Zenooz. Thank you, sir. We understand that this 
requires a cultural change and that this is first and foremost 
a business transformation more than just an IT project. So with 
that in mind, changed management is number one on our list. We 
have a robust change-management plan that not only involves 
training, elbow-to-elbow, virtual sessions, et cetera, but we 
also involve the field at the very beginning of the process 
here.
    Mr. Dunn. That's good. I was going to ask you about that. 
So your doctors, your nurses, your clinical specialists, they 
are actually involved in helping design the interface, and also 
what you need to have in the way of information coming out of 
that?
    Dr. Zenooz. Correct. They will be involved not only in 
designing, but will also lead the way as we go forward.
    Mr. Dunn. So and to Admiral Bono, we say this is 
interoperable between DoD and the VHA, will it really be? I 
mean, I am a doctor in the DoD, I am doing a medical record, I 
walk over to the VA, would I be able to recognize and operate 
the system over there?
    Admiral Bono. Yes, sir. I think that is one of the benefits 
that we have got here is it is a single instance of the EHR 
record, so it is the same product.
    Mr. Dunn. Same interface?
    Admiral Bono. Yes, sir. And that is why we are very 
invested in their success, because it will mean our success as 
well.
    Mr. Dunn. So this really would be a first time. I have 
worked in I don't know how many hospitals, how many clinics, 
and every single one of them has a different interface and it 
is maddening, I can tell you. It is a reason to actually 
constrict where you work.
    I have this for Secretary O'Rourke. The VHA clinicians, are 
they actually already being prepared for this standardization? 
Maybe that should be to you, Dr. Zenooz.
    Secretary O'Rourke. I know that we are making it a regular 
component of leadership communications with the field. I know 
every visit that I take to a Medical Center director we are 
making this a topic of discussion, preparing our clinicians, 
our leadership at the local levels for what is coming, and 
providing them a positive outlook. It is going to be hard 
enough, as Dr. Ashwini had mentioned, as with the cultural 
change. So we are working very hard with what we can do at our 
level to make that--
    Mr. Dunn. Well, my time is about to expire, but I do want 
to encourage you to work with the clinicians very, very 
proactively. You mentioned a cultural change, it is a huge 
change for them, and they are focused on their patients and 
they think that, you know, sometimes we irritate them with the 
EHR changes.
    I yield back, Mr. Chairman. Thank you.
    The Chairman. I thank the gentleman for yielding.
    Ms. Brownley, you are recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    So where does the buck stop on this implementation plan?
    Secretary O'Rourke. With me.
    Ms. Brownley. And when a new Secretary is appointed there 
will be a transference of information to the new Secretary?
    Secretary O'Rourke. It is a very good thing to point out, 
because I think it goes back to an earlier question. Without a 
Deputy Secretary, and it is very clear right now that the 
Deputy has a pivotal and a critical role in this, right now 
without one that role is up to the Secretary. It will stay with 
me until we have a new nominee confirmed, and then it will be 
with him until we have a Deputy Secretary in place.
    Ms. Brownley. Thank you. So I have been on this Committee 
for five and a half years and one thing that I can say based on 
historical experiences is that lack of leadership or turnover 
in leadership has caused delays in almost, you know, any 
endeavor that has been undertaken. And so I think I share the 
concerns of many on the Committee that, you know, at the outset 
we are worried about various deadlines and meeting the interim 
goals as we move forward on this.
    The early time line the Chairman mentioned, the preliminary 
plans to include an 8-year deployment schedule beginning with 
the initial implementation sites within 18 months of October 1, 
I am concerned about that. Also, I understand that there is an 
ongoing development that the VA is working on, on life-cycle 
costs, on data migration, a change-management plan, and an 
integrated master schedule to establish key milestones over the 
life of the project.
    So I think the GAO reported that the Department intends to 
complete the development of its initial plans for the program 
within 30 to 90 days of awarding the contract between--and that 
is between mid-June, mid-August of 2018. Are you still on 
schedule to meet these deadlines?
    Secretary O'Rourke. As we discussed earlier, it is our work 
and the planning and development of those milestones over the 
next July through September of this year.
    Ms. Brownley. So do you know now when the first sort of key 
milestone will be?
    Secretary O'Rourke. Having our IOC plan to start on October 
1st.
    Ms. Brownley. Then the second milestone?
    Secretary O'Rourke. The second milestone will be getting to 
an initial operating capability at those initial sites.
    Ms. Brownley. Okay. Well, so I just--you know, I am not 
sure what the driving question is here to get some assurances, 
but certainly meeting those first couple of milestones I think 
is going to be very important in terms of reassuring this 
Committee that we are indeed on track with this implementation. 
And has been already stated, this is obviously an extremely, 
extremely important endeavor that we have invested a tremendous 
amount of tax dollars into and our desire to be successful.
    And I will just reaffirm what others have already said, is 
that the lack of leadership or the turnover in leadership right 
now is a major concern.
    The last question that I just wanted to ask you, Secretary 
O'Rourke, is that I know earlier this year there were some 
reports that the signing the Cerner contract was delayed based 
on sort of outside, non-governmental individuals were 
attempting to influence perhaps the use of commercial off-the-
shelf electronic health records rather than proceeding with 
this Cerner agreement. Can you just assure the Committee and 
assure me that you feel that your work is really free from any 
undue outside political influence?
    Secretary O'Rourke. Absolutely. As you all know, I became 
the Chief of Staff in an interesting time and one of the key 
tasks I had at that time was to bring some sense of order to 
the Department in a time when we were struggling in some ways. 
One of the key things that I focused on very quickly was the 
EHRM process, I guess if you can call it at the time, and 
seeing where it was and how do we get it finished, because I 
knew from this Committee's perspective that they wanted to see 
a result. So I became very involved in making sure that we were 
pushing toward the right result. So I would not characterize 
this as anything other than providing the best product for 
veterans which we knew was going to be, like we talked about, a 
historic opportunity, we weren't about to let that be changed 
in any way and demystify that.
    Ms. Brownley. Thank you.
    My time is up, I yield back.
    The Chairman. Thank you for yielding back.
    Mr. Higgins, you are recognized for 5 minutes.
    Mr. Higgins. Thank you, Mr. Chairman.
    Secretary O'Rourke, thank you for your service to your 
country, sir. I would like to dive deeper into what the Ranking 
Member asked you about regarding GAO and IG records requests.
    We are all pretty much universally concerned about 
transparency in government and there is no more opaque alphabet 
branch of our government than the VA, historically. So we have 
a greater responsibility to be more transparent, more 
reflective of the will of we the people in service to the 
veterans that we are dedicated to, my brother and sister 
veterans. It is more crucial that we are completely transparent 
regarding our reactions to whistleblowers and requests thereof.
    My understanding is there is a proposed rule in the VA to 
amend the Department of Veterans Affairs regulations governing 
the submission and processing of requests for information under 
the Freedom of Information Act and the Privacy Act in order to 
reorganize, streamline, and clarify existing regulations; is 
that true?
    Secretary O'Rourke. I would have to take that back for the 
record, I am not personally aware of that.
    Mr. Higgins. Okay. Specifically regarding the 
confidentiality of whistleblowers' data, it seems to me that if 
the IG or the GAO has requested data and that would include 
some whistleblower information, it seems to me that could be 
redacted, but that there can be no guarantee of confidentiality 
for whistleblowers.
    Certainly none of us in America, certainly not on this 
Committee, we don't want the VA investigating itself. We don't 
want the DoD investigating itself, we don't want the FBI 
investigating itself, and we don't want the VA investigating 
itself. The GAO and IG and the Committees like this are bound 
by oath to perform those tasks.
    And from the U.S. Director of National Security government 
website, in a question-and-answer segment regarding the 
question how realistic is it that I will maintain my 
confidentiality, it says on our website, ``At some point in an 
inquiry, it may be necessary to reveal your identity to further 
the whistle-blowing process or as otherwise required by law. 
Additionally, dependent upon the nature of the inquiry, the 
information disclosed may make your identity obvious despite 
all precautions taken to maintain your confidentiality.''
    So please explain to us and I ask you this respectfully, 
sir--I understand you have a job to do, I was a police officer 
for 14 years, I understand internal investigations, but this is 
the VA, man, we have major problems here that it is our 
responsibility to fix and our investigative services for 
government branches that respond to whistleblower data, if they 
request that data, they need to get it. So please explain to us 
what you had stated regarding whistleblowers having to get 
permission for their data to be revealed.
    Secretary O'Rourke. I will do it very concisely. It is very 
clear what the accountability law states about the identity of 
whistleblowers and what that--who and how that information is 
revealed or shared. Privacy law, since we keep that information 
in the system of records, Privacy Act law covers that 
information. For all of those entities that need that 
information, it is a simple written request. They don't have to 
provide a reason. They don't have to provide an excuse. They 
just say we want this data provided and it is provided, without 
redaction. The only redaction we--
    Mr. Higgins. Does the answer to the--in the question and 
answer section on the U.S. Directive National Security 
Government website, does that reflect the reality that you are 
explaining today regarding government employees questioning 
their confidentiality if they bring whistleblower data to a 
supervisor?
    Secretary O'Rourke. When they bring it to their supervisor, 
there is a less of a hold on their privacy because they are 
bringing up a--the disclosure that is maybe process base or 
things like that, retaliation, things of those nature when they 
are disclosing those have to have their names attached to them, 
otherwise you can't prove the retaliation.
    Mr. Higgins. Doctor, you had something to add? You 
motioned--did you raise your hand, Madam?
    Secretary O'Rourke. They are both from the H.R. program, I 
am the guy that gets to answer the questions about 
accountability.
    Mr. Higgins. All right, Mr. Chairman, my time is expired, 
but I will have a written question to submit to the panel if 
that is within the parameters of our authority, sir.
    The Chairman. It is.
    Mr. Higgins. Thank you.
    The Chairman. Ms. Kuster, you are recognized.
    Ms. Custer. Thank you very much, Mr. Chairman. I noticed at 
the outset that our Chair was quite clear that he had not 
included Acting Chief Information Officer Camilo Sandoval in 
the invitation to be here today, but I just want to note for 
the record that it does trouble me. I--this is not the subject 
of this hearing, but I can't pass it up to say that the merit 
system's protection board study has found the Veterans 
Administration as being the highest incidents of sexual 
harassment across all Federal agencies.
    I won't get into the details of Mr. Sandoval's situation, 
but do you have confidence that Mr. Sandoval can accomplish his 
mission, which is so crucial to our veterans all across this 
country? Many of us joined this Committee five and a half years 
ago. Our very first hearing was about the fact that we could 
not communicate between the Department of Defense and the VA, 
we are spending millions--hundreds of millions of dollars, and 
yet the very person that is supposedly in charge is not able to 
focus on his duties because of allegations during the campaign 
about sexual harassment.
    Secretary O'Rourke. I can't address what is in, I guess, in 
a lawsuit, but I can tell you we are setting--
    Ms. Kuster. Well, can he get the job done? Should he be 
replaced and is he being replaced? How are we going to get the 
job done?
    Secretary O'Rourke. I have a lot of confidence in Camilo 
Sandoval and what he has been able to do as the executive in 
charge.
    Ms. Kuster. Is he on the job to get the job done?
    Secretary O'Rourke. Absolutely. He has been finding--
working with us to find, and restructure, the Office of 
Information Technology because of some of the poor leadership 
that it has had in the past.
    Ms. Kuster. But if he loses his job because of these 
allegations, do you have another plan?
    Secretary O'Rourke. If the President decides to remove a 
political appointee, then we will have somebody else step into 
that role, just like he stepped into that role when the 
previous executive in charge left.
    Ms. Kuster. It just seems that with an acting secretary 
waiting for confirmation with a number of these offices that we 
have all discussed today, including the Chief Information 
Officer, I just have to note for the record we are not putting 
our best foot forward on this project and it is a 
disappointment.
    Admiral Bono and Mr. O'Rourke, can you please describe how 
you hope to use the Cerner EHR to improve the management of 
pain and opioid prescriptions with our Nation's servicemembers 
and veterans?
    Secretary O'Rourke. I know that there are some unique 
features within the Cerner product that help us provide that 
kind of oversight.
    Ms. Kuster. Is there anyone on the panel that could 
describe those features?
    Secretary O'Rourke. And I am going to pass that off to my 
Chief Medical Officer.
    Ms. Kuster. Thank you very much.
    Dr. Zenooz. Thank you. One of the main components of the 
Cerner plan for opioid risk is a risk stratification tool. It 
not only brings in all of the information from the various 
PDMS's, the prescription drug monitoring programs across all of 
the different states that participate in it, it brings it to a 
single place so that our providers have it at their fingertips. 
But it also gives them a scoring for the patient's risk for 
opioid abuse.
    So it takes it not only from the community provider's VA 
prescriptions but also any input that we get from the military 
of history of opioid prescriptions for the patient. So I think 
it is very effective.
    Ms. Kuster. Good. I would like to be kept apprised of the 
progress of that and any results, or data, or findings if there 
is research on how that has been effective.
    Dr. Zenooz. Absolutely.
    Ms. Kuster. You mentioned community care and another 
concern that I have, one of the largest concerns with 
interoperability is with the VA's community providers. What are 
Cerner's current plans to facilitate interoperable 
functionality with community care providers?
    Dr. Zenooz. Absolutely. We recognize that more than 30 
percent of the care in the VA is delivered in the community and 
that we need to have our providers across the care continuum to 
have access to all of the data. Our goal is not only to have 
data that is available to them through current practices, but 
to build on it. Whether it is our 168 HIE's that we are 
currently using, that we participate in, direct messaging, 
provider portals that we provide to the community. But also 
have the ability for the providers, inside and outside of the 
VA that participate in the care to have the analytics tools and 
the registries available to them so that they can participate 
and improve the outcomes of the patient.
    Ms. Kuster. That is another piece that we would like 
continual monitoring on.
    Dr. Zenooz. Absolutely.
    Ms. Kuster. My time is short but just briefly, if the 
community provider does not use Cerner, can you have an 
interoperable function?
    Dr. Zenooz. Yes, absolutely. We have health information 
exchanges that we participate in. We have a network of 168 that 
we partner with currently. So it doesn't have to be Cerner. It 
could be any of the other EHR systems and record sharing 
systems that they use. If the community providers--
    Ms. Kuster. My time is up. I apologize. I truly don't like 
being rude, but I know I need to yield back. Thank you, Mr. 
Chairman.
    The Chairman. Thank you for yielding. Mr. Banks, you are 
recognized for five minutes.
    Mr. Banks. Mr. Windom, I was much confused a moment ago as 
you were answering Mr. Takano's questions about the inter-
agency working group. Have you met more than once just to 
discuss governance, as you put it?
    Mr. Windom. Yes, sir. We have been meeting for the past 
year. As we negotiated the Cerner agreement, we knew governance 
would be imperative. So we have been working with the DoD--
    Mr. Banks. How many times have you met? How many times have 
you met?
    Mr. Windom. I would estimate somewhere around six or seven.
    Mr. Banks. On a monthly basis?
    Mr. Windom. Correct.
    Mr. Banks. Do you speak with your colleague more than once 
a month or do you only speak with your colleague during the 
inter-agency meeting?
    Mr. Windom. No. We have a Friday call, standing Friday call 
at 11:00 a.m. and we also have continuous interactions at the 
technical and the clinical levels. That is where the hard work 
is really being done.
    Mr. Banks. Okay. Thank you. Mr. O'Rourke, an article was 
published at the very start of this hearing, just a little bit 
ago, stating that Genevieve Morris, who is seated right behind 
you, will be leading the GENISIS office. If that is true, when 
was that decision made and why isn't she testifying today?
    Secretary O'Rourke. It is premature reporting. We were 
going through the process of actually setting up the industry 
standard structure for these kind of implementations, which 
uses more often than a chief information officer, a chief 
medical information officer.
    Ms. Morris has been instrumental with helping us through 
really the past few months. She has been loaned to us from HHS 
and has been critical to this team and has helped us with some 
broader perspectives of the industry and successful ways of 
implementing this project.
    Mr. Banks. So she won't be leading this officer?
    Secretary O'Rourke. We are evaluating that chief medical--
    Mr. Banks. Premature, perhaps inaccurate reporting?
    Secretary O'Rourke. The accuracy of it is--definitely she 
is a candidate for that job. She would be perfectly qualified 
for that.
    Mr. Banks. So to be determined.
    Secretary O'Rourke. To be determined.
    Mr. Banks. Okay. Mr. O'Rourke, in your testimony, you state 
the VA structure, the IDIQ contract to, ``Provide maximum 
flexibility.'' Can you explain what that means and what freedom 
of flexibility the VA has?
    Secretary O'Rourke. Early on, we were very concerned about 
being tied to a specific set of boundaries when it came to 
these kind of implementations. So we were very intent in the 
negotiations that John led to make sure that the VA has the 
primacy in making decisions on where we go with this and not be 
stuck with the contractor driving us to decisions we may or may 
not want to make. So we were intent on making sure that 
flexibility was there.
    Mr. Banks. So how can you use that contract flexibility to 
respond to hurdles during the implementation? For instance, if 
the planning takes longer than expected or the implementation 
in the initial sites don't go as smoothly as expected.
    Secretary O'Rourke. I would like to have John Windom 
specifically talk through that.
    Mr. Windom. Yes, sir. IDIQ stands for indefinite delivery 
indefinite quantity. The way that works is task orders are 
issues in support of the foundational contract such that you 
can issue task orders to increase timelines, increase scope, 
increase the waived appointments, or you can restrict task 
orders to more control in support of cost schedule and 
performance objectives, and obviously the management of risk.
    We never want to bite off more than we can chew. We 
understand the importance of our veterans and the care we 
deliver. And therefore, we want to make sure we optimize the 
use of that IDIQ vehicle in delivering those support services 
that we anticipate being able to deliver.
    Mr. Banks. Okay. Thank you. Mr. O'Rourke, can you assure me 
that the EHR modernization will result in one and only one EHR 
system?
    Secretary O'Rourke. That is definitely our intent.
    Mr. Banks. That would include for interoperability purposes 
and to access the Legacy data. And can you confirm to me that 
once the Cerner Millennium EHR is implemented, the VA will 
completely stop using VistA and the Joint Legacy Viewer?
    Secretary O'Rourke. It is our intent to not use Visa. The 
Joint Legacy Viewer, I think, may need some life cycle, but we 
are still in that planning part.
    Mr. Banks. But that is your intent?
    Secretary O'Rourke. Yes.
    Mr. Banks. Okay. Admiral, how is this dynamic working in 
MHS GENISIS, will Cerner completely replace CHCS and Ulta?
    Admiral Bono. Yes, sir. That--we are going to transfer all 
of our functions onto the new electronic health record, MHS 
GENISIS and sunset the Legacy lens. We will still maintain some 
connection to our Legacy databases, but in terms of the Legacy 
applications and programs that are associated with Ulta and 
CHCS, those will be sunset.
    Mr. Banks. So that is a definite, that is not just your 
intent, that is definite?
    Admiral Bono. Yes, sir.
    Mr. Banks. Okay. Thank you very much. I yield back.
    The Chairman. I thank the gentleman for yielding. Ms. Rice, 
you are recognized for five minutes.
    Ms. Rice. Thank you, Mr. Chairman. I would like to direct 
my questions to you, Mr. O'Rourke. So before you were in the 
position that you presently hold, you were actually the first 
executive director for the VA's Office of Accountability and 
whistleblower protection, right?
    Secretary O'Rourke. Yes.
    Ms. Rice. And you did that for approximately how long?
    Secretary O'Rourke. From when we stood up the office in May 
through the time, I became Chief of Staff.
    Ms. Rice. So that was what kind of time period?
    Secretary O'Rourke. Through I believe February of this 
year.
    Ms. Rice. And I--you would agree that in that position, 
which I believe is the first of its kind in any governmental 
agency, a large part of your duty there was to ensure a level 
of accountability?
    Secretary O'Rourke. Yes, it was. It was to implement the 
new accountability and whistleblower protection law and to set 
up the new office.
    Ms. Rice. So can you just go back again in your thought 
process in terms of not wanting to respond to the OIG's request 
for that information?
    Secretary O'Rourke. I think the broader story should be 
told on that. From day one, we realized that the relationships 
between the Office of Special Counsel, the Office of 
Investigative General, and others, frankly, this Committee, 
were not good. There were previous offices with MVA that had 
this responsibility to investigate senior leaders. It did not 
have a great track record.
    It was my intent early on to break through those barriers 
between those very important entities that all had their 
statute driven mandates to make sure that we were all working 
together to protect whistleblowers first and to make sure that 
we were investigating misconduct and holding people 
accountable.
    With the IG, that took the form of trying to find some 
creative and new ways to work together. There are some hard 
walls you can't cross with the IG, especially when it comes to 
criminal activity, those kinds of things. Those are not 
investigative responsibilities of our office that we were 
starting up. That is where we would partner with the IG. But as 
you can appreciate, a lot of things that happen in the VA cross 
different boundaries. And holding a senior leader accountable 
is sometimes a complex situation.
    So we wanted to work closer with the IG, especially when it 
came to disclosures because part of the accountability law 
actually puts the weight on the Office of Accountability to 
review IG received whistleblower disclosures.
    Ms. Rice. Right. But the problem is in the past, and we 
have heard this time and time again--
    Secretary O'Rourke. Yes.
    Ms. Rice [continued].--here on this Committee is that the 
VA is incapable of holding anyone accountable in their ranks. 
And so it is essential that you have a body like an OIG to be 
able to look into allegations, whatever they may be, and be 
able to do that in an independent way. Do you--you made, to me, 
what I thought were disturbing statements about how the OIG 
actually works for you and you are the supervisor of the OIG.
    Secretary O'Rourke. The IG is attached to the department.
    Ms. Rice. But they are independent.
    Secretary O'Rourke. In their investigative capability and 
their freedom to look anything in the department, absolutely.
    Ms. Rice. So then how can you deny them--giving them what 
they request?
    Secretary O'Rourke. The statute is very clear on protecting 
the identity of whistleblowers. The IG had requested--
    Ms. Rice. But don't you think that there is a way that you 
can do that and also respond to the request of an OIG, which 
has a very important function, one that the VA has not been 
able to do on their own?
    Secretary O'Rourke. Again, the IG requested unfettered 
access to a system that had Privacy Act information. If they 
want those documents, those records, they can be provided 
those. They just have to provide a written request. No reason 
for the request, which was part of the rub here. All they need 
to say is we request these things. That provides coverage for 
that--for this office, for the records that they hold to 
provide them.
    That is all they have to provide.
    Ms. Rice. So it was a technical objection that you were 
making to what they did?
    Secretary O'Rourke. Well, it came--borne more out of we 
wanted to cooperate with the IG and provide them access to this 
directly, working with us, but not unfettered access to where 
they just come in and out of that system for non-investigatory 
reasons. So we were trying to work on a way to do that. That Is 
not something that worked out initially, so now we are just 
back to what the statute says is just provide the request and 
the documents are provided.
    Ms. Rice. So much of--
    Secretary O'Rourke. And we provided documents all through 
this period of time. So it is not like they have been refused 
things. We provide disclosures to them on a daily basis as soon 
as they come in.
    Ms. Rice. So much of how much faith the public has in their 
governmental institutions is the level of transparency and very 
often the facts don't carry the day, it is the perception of 
whether there is real transparency, real accountability. So 
when you act in the way that you do, I am sure, coming from 
where you did from the accountability and the whistle blowing, 
you have to be aware that visual, that perception is not a good 
one. And it actually seems to kind of track a disturbing trend 
in this administration in different agencies and positions as 
well that they are the king and they control everything, and 
all of these agencies just are meant to serve the President.
    That is not the way the government works. So when you take 
a position like you do, that is the perception that you leave. 
And I would hope that someone with your level of experience 
would understand that and try not to make that mistake again.
    I think my time is up. Thank you. Thank you, Mr. Chairman. 
I yield back.
    The Chairman. I thank you, gentle lady, for yielding.
    Ms. Radewagen. Hello for Chairman Roe and Ranking Member 
Walz. Thank you for holding this important hearing today. I 
also want to welcome the panel. Thank you so much for your 
service to our Nation.
    Following up on a colleague's earlier question, Admiral 
Bono, as VA's EHR modernization program staffs up, do you 
believe it would be useful to have staff from it working on MHS 
GENISIS?
    Admiral Bono. Yes, ma'am. I think that is one of the 
reasons why we have continued--why we started to do our 
collaboration very early on as the VA was even in the early 
stages of getting the Cerner product. I very much want to be 
able to leverage off of any lessons learned that the VA has, as 
well as be able to share what we are learning on the DoD side 
with the VA.
    Ms. Radewagen. Can you elaborate on how this cross-
pollination can be helpful?
    Admiral Bono. Yes, ma'am. So a really good example is in 
the change management and the involvement of the clinicians. We 
have a fair amount of experience now with the change management 
and the workflow adoption and that is something that we want to 
be able to make sure and share with the VA.
    Because this is a signal instance of a medical record, that 
is it is the same medical record, we recognize that being able 
to assist in the adoption of work flows that are common across 
DoD and VA will enable a faster deployment for us both.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank you gentle lady for yielding. Mr. 
O'Rourke, you are recognized for five minutes.
    Mr. O'Rourke of Texas.* Thank you, Mr. Chairman. And I want 
to begin by thanking you and the Ranking Member for taking this 
Committee's oversight and accountability responsibilities 
seriously. I am glad that you are standing up a new 
Subcommittee to track this contract, which I think all cost in 
may total $16 billion that we know of now. And I am just 
grateful on behalf of our constituents, the veterans in El 
Paso, in making sure that we see this through and that there is 
the oversight and accountability necessary that has been 
missing in the past.
    I wanted to ask the Acting Secretary, what paused the April 
30th DoD report from the Director of Operational Test and 
Evaluation gave you in moving forward with Cerner? One of the 
bottom lines in that report was a recommendation to freeze EHR 
rollout indefinitely. There are 156 reports of critical 
deficiencies. There was the suggestion that this Cerner 
platform may not be scalable. As they added new medical centers 
onto the system, those that had already been added slowed down 
significantly. It took pharmacists two to three times as long 
to fill a prescription as it would have had they not been using 
the Cerner system.
    There were reports that clinicians literally quit because 
they were terrified that they might hurt or even kill one of 
their patients. The user score out of a possible 100 was 37. 
And there is--there are open questions about the accuracy of 
the information that is exchanged there. So what did that do to 
your, and the VA's, decision on adopting Cerner as a platform 
going forward?
    Secretary O'Rourke. I think as we discussed earlier, we 
have been working hand in hand with DoD and knew of some of the 
implementation issues that were described in the report and how 
they had been resolved. We have integrated everything that we 
have learned from them into our--both our negotiating strategy 
and into product and then into our deployment strategy.
    Mr. O'Rourke of Texas. Yes, so what pause did that give 
you? When you saw this did you say, ``Holy smokes. There are 
some significant problems here. We are going to put all of our 
eggs in this one basket: every DoD, every VA health record, 
every Active duty servicemember, every veteran, every military 
retiree.'' Did it give you any pause or did you say, ``Hey, it 
looks like they have corrected all of these problems. And even 
though that report was a little more than two months ago, 
everything is fine.''
    Secretary O'Rourke. We have never approached this project 
as just some sort of rose-colored glasses. We know this is 
going to be an extreme challenge for the VA and DoD, especially 
on the collaboration.
    Mr. O'Rourke of Texas. Let me ask it this way. What 
existing concerns do you have? So you saw the report. You 
believed that DoD/Cerner are addressing the issues. Do you have 
any outstanding concerns, anything that gives you pause, keeps 
you up at night?
    Secretary O'Rourke. So I am going to turn it to John, but 
it is cost, schedule, and performance but --
    Mr. O'Rourke of Texas. How about you just because you said 
the buck stops with you, so I would love to hear what you--
    Secretary O'Rourke. Absolutely. It is cost, schedule, and 
performance. It is our ability to track to the milestones that 
we have developed.
    Mr. O'Rourke of Texas. Anything in that report that you do 
not think has been addressed or resolved?
    Secretary O'Rourke. There are items in that report we will 
resolve and continue to work on throughout the lifetime of this 
program.
    Mr. O'Rourke of Texas. Any fundamental issue like the 
scalability of it, like the accuracy of information, like the 
fact that clinicians have quit out of fear that their patients' 
lives may be endangered? Any of that unresolved to your 
satisfaction at this point?
    Secretary O'Rourke. We continue to work with DoD to watch 
how they are resolving their--the things that have come up in 
that report and making sure that we learn those lessons.
    Mr. O'Rourke of Texas. The question that the Chairman asked 
about how information would be accessed going forward once this 
is fully online, and the response about the Joint Legacy Viewer 
being embedded and the ability to see information through that, 
what--when this, if this is ever fully working, for 
servicemembers who are going to be transitioning out over the 
next 10 years, there will be no Legacy Viewer for their 
information. It will seamlessly transfer from DoD to VA to 
third party provider. Is that correct?
    Secretary O'Rourke. That is the intent of the program.
    Mr. O'Rourke of Texas. For all three?
    Secretary O'Rourke. Absolutely.
    Mr. O'Rourke of Texas. Including the third-party provider. 
Whose information will still be in the--be viewed in the Legacy 
Viewer 10 years from now once this is fully implemented 
according to the proposed schedule and budget in here?
    Secretary O'Rourke. Our intent is that everyone departing 
DoD, coming to VA, has a seamless transition and then they are 
able to use all of the VA capability that we have.
    Mr. O'Rourke of Texas. Those veterans whose records appear 
in the Joint Legacy Viewer today, will they be in the Joint 
Legacy Viewer going forward, or will there be some fix to that?
    Secretary O'Rourke. That is the intent.
    Mr. O'Rourke of Texas. Okay. To still be in the Joint 
Legacy Viewer?
    Secretary O'Rourke. No, to be in our system--
    Mr. O'Rourke of Texas. To be fully dumped and--
    Secretary O'Rourke [continued].--fully integrated.
    Mr. O'Rourke of Texas [continued].--the data fully 
integrated.
    Secretary O'Rourke. Yes.
    Mr. O'Rourke of Texas. Okay. Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. O'Rourke. Mr. Bilirakis, you 
are recognized for five minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. Secretary O'Rourke, 
it seems to me that electronic health record modernization is 
as much a process restructuring and standardization program as 
it is an IT program. Would you agree with that?
    Secretary O'Rourke. Yes.
    Mr. Bilirakis. Okay. Admiral Bono, same question.
    Admiral Bono. Yes, sir. I fully agree with that.
    Mr. Bilirakis. Okay. How much of MHS GENISIS has so far 
been in process redesigning exercise as opposed to an IT 
exercise, meaning writing code and installing hardware?
    Secretary O'Rourke. We are fully aware of the depth of 
change this is going to bring to our health care delivery 
system, and we are on the front end of working on restructuring 
those work flows and looking at what we have to change across 
our system.
    Mr. Bilirakis. Thank you. Admiral Bono, which aspects has--
what has been the most challenging part of it?
    Admiral Bono. Yes, sir. I think that the two most 
challenging parts, and I am gratified to see that the VA is 
working on this up-front, is governance and change management. 
Certainly, the ability to make the decisions that are needed at 
the enterprise level to maintain that interoperability and the 
connection with the DoD effort is extremely important.
    And I think that what the VA is doing to help make sure 
that governance structure and framework is in place is 
extremely important.
    The second piece that is extremely important is the change 
management. And as Members and others here at the table has 
already identified, being able to involve the clinician right 
from the start is a very important part of that change 
management effort. And again, I see that what we have learned 
in our own efforts of deployment and the VA's initial steps to 
address that are very much in keeping with what we have 
learned.
    Mr. Bilirakis. Thank you. Secretary O'Rourke, how much of 
the process redesign is Cerner involved in and how much is 
purely VA responsibility?
    Secretary O'Rourke. When it comes to this project, Cerner 
will be working with us directly to make sure that the process 
as we redesign it will work in their platform.
    Mr. Bilirakis. Very good. Admiral Bono, the MHS GENISIS 
contract was awarded in 2015 and your testimony indicates its 
implementation will finish in four more years. That is a total 
of eight years, VA's schedule is ten years. Are you confident 
you will be able to finish on schedule? I know that is so 
important. If you are confident in that, how is the military 
health system, which spans the whole country, as well as 
overseas bases, able to do this relatively more quickly than 
the VA?
    Admiral Bono. Yes, sir. So we will be doing--I feel very 
confident that we will be able to stay within our timeline that 
we have projected. Part of our deployment schedule provides 
that we will be able to do many of this in parallel as we have 
been able to apply some of our lessons learned. So there is a 
lot of synchronization and amplification that we will be able 
to do as we have put in place not only the lessons learned from 
our own personal experience, but also from the lessons learned 
that we are getting from those that are reviewing our progress.
    Mr. Bilirakis. Okay, final question for Admiral Bono. You 
have already bought your version of the Cerner EHR and 
implemented it in your first sites. How did you decide to 
select some Cerner software packages and no others?
    Admiral Bono. Yes, sir. That was part of our requirements 
process in which we put together those functions and 
capabilities that we felt that we most needed to be able to 
replace our Legacy systems.
    Mr. Bilirakis. Very good. I yield back, Mr. Chairman. I 
appreciate it.
    The Chairman. I thank the gentleman for yielding. Mr. Lamb, 
you are recognized for five minutes.
    Mr. Lamb. Thank you, Mr. Chairman. I want to follow up 
first on a question by my colleague, Mr. O'Rourke, about 
integrating what you learned from the DoD failures into the 
rollout of the new system. And whoever is best to answer this, 
please answer it, but some of the specific problems that they 
saw in the DoD rollout were, for example, prescription requests 
coming out wrong and referrals not going through to 
specialists.
    So just take those two specific issues, if you can tell us 
what you learned from the DoD rollout and how this program is 
being changed to prevent something simple like that from 
happening.
    Secretary O'Rourke. Absolutely. Let me let Dr. Ashwini 
answer that.
    Dr. Zenooz. Yes, absolutely. So one of the big lessons 
learned that we had was that, again, front live providers have 
to be involved not only in designing the process but also in 
the testing process. I cannot emphasize that enough for myself 
every day, as well as the people that are involved on the team. 
Our users will be an integral component of the user testing 
process to ensure that all of this works before we go live, 
that patient safety is accounted for, that we check off all of 
the boxes to ensure safety is maintained and the process works 
if not as well as but better than the way it works today.
    Mr. Lamb. Okay. So how will you ensure that a prescription 
is always going to come out correctly? Do you do like a drill 
or a rehearsal or something with fake patients, basically, and 
your users on the other end to make sure that it works or--
explain to me how that is going to happen.
    Dr. Zenooz. Absolutely. So the process is testing is where 
this happens. We not only test the technology to ensure that 
all of the technology behind the scenes works so that the 
prescriptions are going where it needs to go, but also that the 
correct prescriptions for the right patients are going to the 
right place at the right time.
    So that not only involves the technical component, but also 
the users, like I said, on the front end to ensure that all of 
those boxes are checked. Only when you have all of those things 
checked off that says the process is working appropriately and 
that patient safety is maintained, can you go live in that 
process. And we have that accounted for in our testing process.
    Mr. Lamb. Okay. Is that a different testing process than 
what the DoD used before they rolled this out the first time?
    Dr. Zenooz. I am going to defer to--
    Admiral Bono. We tested it through many instances of the 
different MTF's that we had in the Pacific Northwest. What we 
actually found, though, was one of the challenges for us is 
that we had different staffing models up there and we had not 
accounted for that in the program. We have since addressed 
that.
    Mr. Lamb. Okay. So it will be a different testing and 
rehearsal process this time than last time is my question.
    Admiral Bono. Yes. We have incorporated that.
    Mr. Lamb. Now, Mr. O'Rourke, question for you about the VA 
budget. We just passed, and the President signed into law, the 
VA Mission Act which basically changes the funding for the 
Veterans Choice Program from mandatory to discretionary funding 
and creates an issue next year for the budget cap on the 
overall VA budget because there--this new funding that has now 
become discretionary and will count against the VA budget. Are 
you aware of the issues that could create for your overall 
budget?
    Secretary O'Rourke. We are aware.
    Mr. Lamb. Okay. Are you concerned about the VA's ability to 
implement this project with the electronic health records given 
the constraints that are now going to be on your budget?
    Secretary O'Rourke. I believe the Congress has made it very 
clear on their intent on this project. So we have less concern 
about the execution side.
    Mr. Lamb. Okay. Do you agree that although the contract is 
for $10 billion, there could be an additional $5 or $6 billion 
needed for infrastructure and project management?
    Secretary O'Rourke. We are aware of that.
    Mr. Lamb. Okay. Do you agree that is not really accounted 
for in the current budget planning, especially with this new 
money from VA Choice going into discretionary funding?
    Secretary O'Rourke. I believe they have been very 
transparent with the requirements of this contract, both from 
the contract execution side--
    Mr. Lamb. And I am not saying--I am not asking about the 
transparency. All I am asking about is do you believe that the 
money that you need, the additional $5 or $6 billion is 
threatened by this change in overall funding that is going to 
put a--
    Secretary O'Rourke. No.
    Mr. Lamb [continued].--push you up against the budget cap?
    Secretary O'Rourke. No, I don't.
    Mr. Lamb. So you feel fully confident that despite that 
change in the Mission Act that you will have the money you need 
to implement this project?
    Secretary O'Rourke. Yes.
    Mr. Lamb. Okay. Mr. Chairman, I yield back. Thank you.
    The Chairman. Thank you, Mr. Lamb. Mr. Poliquin, you are 
recognized.
    Mr. Poliquin. Thank you, Mr. Chairman, very much. Mr. 
O'Rourke, thank you very much for being here and all of you for 
being here. I understand you are a graduate from the University 
of Tennessee. Our great Chairman also represents a terrific 
part of the State of Tennessee. I am assuming that neither one 
of you have been colluded about anything and you will be 
treated as directly as everybody else is on this Committee.
    Going forward, let us take a look at this, Mr. O'Rourke, if 
you don't mind, since you are now the fellow sitting in the 
head seat over here. The reason why we are here today is 
because over a very long period of time, we have had over 100 
different medical facilities that the VA is involved with, or 
owns, or runs, or whatever you want to call it. And they have, 
over time, created their own Legacy systems, their own IT 
systems.
    Now, I am a very direct person and we love our veterans in 
the State of Maine that I represent. We have the first VA 
facility in the country, Togus, up in Augusta. However, I have 
never seen a part of our Federal government, to be very honest 
with you, Mr. O'Rourke, who is--tries to be less accountable 
than the VA. 385,000 employees. You get folks that--not you 
folks, of course, but folks that come before us and no one 
wants to take account.
    You look at the Denver medical facility that is a billion 
dollars over budget and no one takes responsibility for it. So 
I have it up to here when it comes to a lot of these issues. So 
you look like a reasonable fellow, I just want to make sure 
that I am understanding that what we have had in the past when 
it comes to folks at the VA developing their own IT systems, to 
build their own bureaucracies to protect their jobs is not 
going to be a problem going forward. Give me confidence.
    Secretary O'Rourke. Sir, that is one of the most 
straightforward concerns that I have had when I looked at our 
IT office. In fact, that is the thrust of the work that we are 
doing right now since the previous executive in charge left was 
to go in and look and find where all of those instances are, 
remove the waste of our spending, and find each and every 
opportunity we have to reinvest--
    Mr. Poliquin. Let's stop right there, Mr. O'Rourke, if you 
don't mind. My colleague, Mr. Lamb, mentioned just a moment ago 
that it is a $10 billion contract. My understanding, it is a 
$15 billion contract over five years. What is it?
    Secretary O'Rourke. It is a $10 billion contract to Cerner 
Corporation.
    Mr. Poliquin. Okay.
    Secretary O'Rourke. The mention--what Congressman Lamb was 
referring to is other infrastructure and personnel cost outside 
of what we will pay--
    Mr. Poliquin. Okay. Thank you for clarifying that. Thank 
you, Mr. Lamb. I want to make sure I am looking at the right 
person so when you come before us in the future, if it is you, 
sir, you are the person responsible for getting this done, is 
that correct?
    Secretary O'Rourke. Absolutely.
    Mr. Poliquin. Okay, good. There was another--I think it was 
Dr. Bono--Vice Admiral Bono, excuse me, a moment ago explaining 
that there needs to be deep cultural changes. What the heck 
does that mean to you because you are the head guy? What does 
that mean?
    Secretary O'Rourke. It means exactly what you described. 
When we have different hospitals creating different instances 
of IT systems, different groups that feel that they are not 
accountable to each other, to their veterans, to their 
leadership. Something that we addressed early on with the 
Office of Accountability and Whistleblower Protection of 
finding misconduct.
    Sir, I can just tell you that the process under work right 
now in VA is to become more accountable to you. We have done 
unprecedented ways of becoming more transparent, providing 
data, whether it is online or--
    Mr. Poliquin. And you know, Mr. O'Rourke, you have the 
ability to terminate people who are ill-performing, correct, or 
underperforming?
    Secretary O'Rourke. I have exercised that authority.
    Mr. Poliquin. We have--yes, okay, good. We have given you 
that authority. The President signed that. You can do that. 
Okay, good.
    I am guessing that somewhere in your office, you have a 
whiteboard, or you keep it on an IT system or a computer or 
some darn thing where you have a timeline, what you are going 
to get done, what the deliverables are, and how to measure that 
performance. Do you have that?
    Secretary O'Rourke. I have a 10 by 8 whiteboard in my 
previous office. They wouldn't let me bring that into the 
Secretary's office, but I frequently go back there to sketch 
out those timelines.
    Mr. Poliquin. Great. Wonderful. And are--is your vender, 
Cerner, is that entity paid up-front to deliver product or does 
the deliverable have to occur and you sign off on it before 
they are compensated?
    Secretary O'Rourke. With a firm, fix price IDIQ contract, 
we have that flexibility. That is what we discussed earlier to 
make sure we can hold the contractor accountable. And if they 
aren't then we can counsel task orders or delay other task 
orders if we were looking at a performance issue.
    Mr. Poliquin. Okay. And that is a fixed-base contract over 
10 years. You know, it is hard to project as a business owner 
anything two years out, but ten years out is a long period of 
time. What confidence level do you have you won't be coming 
before us asking for more money?
    Secretary O'Rourke. Our intent is to execute within the 
cost and schedule that we have today. To do that, we are making 
sure that our leadership is engaged personally, I am engaged. 
We have our senior leadership team meeting monthly and we have 
weekly updates to me on this project specifically.
    Mr. Poliquin. Good luck to you, Mr. O'Rourke, and 
everybody, we are all behind you. But we are going to hold your 
feet to the fire.
    Secretary O'Rourke. Thank you.
    Mr. Poliquin. Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Poliquin, for finishing four 
seconds early. That is a first. I would not recognize General 
Bergman for five minutes.
    Mr. Bergman. Thank you, Mr. Chairman. And you know, I feel 
listening here for the last hour or so, I feel compelled to say 
and I know you--we are all on the same sheet of music here but 
why we are here. We are here to provide quality results for our 
veterans over the long-term. It is no more complicated than 
that, but we can make life complicated if we allow the way we 
do things to get in the way.
    We talk seamless, but historically bureaucracies walk a 
rice bowl silo mentality of self-preservation. We know that. 
Only through proactive leadership that establishes a culture of 
civil collaboration across all boundaries will we even begin to 
have a chance of success in the change management that you talk 
about.
    People throughout VA, at all levels, must feel empowered to 
be part of solutions focused on results for veterans. I mean 
that is pure and simple. It is as quickly and short as a Marine 
can state it.
    So having said that, Mr. O'Rourke, the Appropriations Act 
stipulates that the EHR modernization program be controlled and 
administered by the Office of the Deputy Secretary. We have 
talked about the steering Committee, we have talked about the 
governance, we have talked about the meetings. We also know 
that position is vacant right now.
    So what is the plan here for the interim vacancy? Who has 
got the dot?
    Secretary O'Rourke. I do. And that will stay with the 
Secretary until we have a Deputy Secretary appointed.
    Mr. Bergman. Okay. So you have the dot. How much of your 
daily time is it going to take to do this because we can only 
be in one place at one time as an individual?
    Secretary O'Rourke. Weekly briefings to me from this team 
on the status, the milestones, progress, cost, schedule. Every 
visit that we make to facilities, whether it is a 
communications mission, if it is somebody that is not actively 
involved in the implementation at this point. And then with 
those places that are actively involved, taking an on the 
ground look and being able to come back and have a perspective.
    Mr. Bergman. Okay. Thank you. Admiral, you have a great 
deal of experience with operational and clinical 
standardization. The defense health agency was created in part 
to unify military treatment facilities in the military 
departments. Please walk me through standardization--
    Admiral Bono. Yes, sir.
    Mr. Bergman [continued].--in the military health system.
    Admiral Bono. Yes, sir. So we have taken an approach with 
standardization that first encompasses some of our back-office 
functions. That is those functions that are common to all 
hospitals across Army, Air Force, and Navy. Those would be 
things like logistics, facilities, education and training, and 
in this case health information technology.
    So being able to deploy the MHS GENISIS has been a 
significant enabler for us to obtain standardization. And what 
that does then in standardization, if I could just use health 
information technology as an example, is using MHS GENISIS, the 
Cerner product as an enabler to help us drive towards more 
efficient work flows that put the patient right in the center 
and are responsive to their needs versus systems that have been 
responsive to the provider's needs.
    Mr. Bergman. Okay. So what you learned--from what you have 
learned so far, can you compare and contract basically the 
military health system and the VA system? Are there specific 
crossover points or in other cases specific divides that there 
is no crossover?
    Admiral Bono. Yes, sir. I believe that there are going to 
be some significant crossovers. And that is some of the things 
that we have already identified in many of our conversations, 
as well as in some of our earlier collaboratives.
    Mr. Bergman. Thank you. And in an effort to beat 
Representative Poliquin, I yield back 50 seconds.
    The Chairman. I thank the gentleman for yielding. And I 
want to thank the panel. I am going to a lightning round. And 
Mr. Lamb, one of the things that you brought up with the 
pharmacy. These clinicians are going to want to make a medical 
visit, which is what VHA is all about, as seamless and as good 
as they can. They want to make it quality. They want to make it 
a pleasant experience. People are intimidated when they come in 
and can be until they get familiar with the system.
    So that would be our objective. And Dr. Bono knows this as 
an Admiral in the Navy, we in the military, and there are five 
of us all who are sitting up here, we will salute, and say yes, 
ma'am, and make it work, no matter how awful it is. And you are 
going to want to make that.
    So when your wife goes in to get a prescription, all she 
may know is hey, it took me five minutes. I walked up and got 
it. There are a lot of people behind the curtain to make that 
happen. And what we don't want this system to do is make that 
harder for the people to do it. It will frustrate them, and 
they will leave, I am telling you.
    I say this as a joke, but in much way, it is not, an 
electronic health record made we a Congressman. So people will 
search out something that is easier. So we have to make this as 
user friendly. And I know Cerner is here and will be on the 
next panel. My one question and one minute, I am going to yield 
everybody a minute if they want it, and I didn't get it 
answered. Maybe Cerner will do this, but--and Mr. O'Rourke, you 
may be able to answer this also.
    We are spending a billion dollars a year to maintain the 
current Legacy system. When that handoff occurs, will there be 
any savings, or will that system still cost a billion plus to 
maintain the Cerner system each year?
    Secretary O'Rourke. Theoretically, that would be the cost 
savings once we have a fully implemented Cerner solution. That 
is what we have to work towards. That has to be our intent.
    The Chairman. Is it--does it look like that can happen? I 
mean, where it--in other words, we replace a piece of 
technology, is it going to cost us just as much as what we had 
to maintain it? It is new. I mean, is there a contract 
afterwards? I know there are--you are going to have to maintain 
this system.
    Secretary O'Rourke. I am sure we would have to maintain 
that system. Whether it will cost the same as what we have 
today, I would suspect not.
    The Chairman. Because the $10 billion and the extra $5, 
almost $6 billion is for the rollout, but after 10 years or 
whenever this thing is fully operational, you are going to have 
to pay--there is going to have to be a management contract 
after that, I am sure. And my question is how much is that 
money--how much money is that going to be?
    Secretary O'Rourke. We will have to take that question 
back, sir, and come back to you, but we will keep that in mind.
    The Chairman. I yield to Mr. Walz, one minute.
    Mr. Walz. Just some yes or no, Mr. O'Rourke. Isn't it true 
the OIG has not received any information to date from the OAWP?
    Secretary O'Rourke. No, that is not correct.
    Mr. Walz. That is not true?
    Secretary O'Rourke. They have provided--we have provided 
them disclosures consistently.
    Mr. Walz. True, OIG has agreed to--by sending two staff 
members on May 2nd to review referrals but were denied access 
due to lack of reciprocity?
    Secretary O'Rourke. They were requested by us for--to have 
a meeting to collaborate with and then they requested that, 
unbeknownst to us.
    Mr. Walz. True that you conditioned access to the OAWP 
files contingent on OIG providing their files?
    Secretary O'Rourke. That is not exactly true.
    Mr. Walz. Right.
    Secretary O'Rourke. That was whistleblower disclosures to 
be shared under the statute.
    Mr. Walz. And I will state for the record that 
confidentiality was never raised by the IG to this office of 
talking to us until this testimony today, which I remind 
everyone was under oath. With that, I yield back.
    The Chairman. I thank the gentleman for yielding. Dr. Dunn?
    Mr. Dunn. Thank you, Mr. Chairman. I want to get a level of 
comfort. This is probably Dr. Zenooz. I was reading through the 
memos and the briefs there and I was seeing standardized work 
flow, and to me that meant standardizing the way the clinicians 
are using EHR, the way we enter and retrieve information. But 
as I kept reading on, it sort of morphed into a best practice's 
thing.
    And I want to be reassured that what we are not talking 
about, this is not code for clinical medical practice 
guidelines, treatment guidelines. Tell me it is not code for 
that.
    Dr. Zenooz. So work flows are the way we do business. And 
our goal is to involve our frontline clinicians to ensure that 
the way we want to do business--
    Mr. Dunn. Treatment guidelines, you know what I mean.
    Dr. Zenooz. Yes.
    Mr. Dunn. Diagnosis related treatment guidelines.
    Dr. Zenooz. So the EHR system does allow for collaborating 
with DoD to input clinical practice guidelines and have that be 
part of the clinical decision support.
    Mr. Dunn. So that would be suggestions like the NCI 
guidelines, things like that.
    Dr. Zenooz. That is correct.
    Mr. Dunn. And this is not like this is the way you will 
practice medicine.
    Dr. Zenooz. That is correct.
    Mr. Dunn. You understand as a physician, I am sure--
    Dr. Zenooz. That is correct.
    Mr. Dunn [continued].--my concern here.
    Dr. Zenooz. Absolutely. So our goal is if a clinician is 
ordering something, for example, and has the option to have 
decision support available--
    Mr. Dunn. So my time has expired, but I do want to make 
sure that you understand that when we start doing top down 
treatment guidelines, you will treat this diagnosis this way, 
we always, always get it wrong. Reliably get it wrong. The 
government has proven that repeatedly.
    Dr. Zenooz. Absolutely.
    Mr. Dunn. I yield back, Mr. Chairman.
    The Chairman. We always get it wrong. Correct. Mr. Takano, 
you are recognized.
    Mr. Takano. Mr. O'Rourke, I want to follow up on my earlier 
questions. I understand that the Deputy Under Secretary role 
and the Deputy Chief Information Officer are the province of 
the VA, not the White House. It has come to my attention that 
prior to Dr. Shulkin leaving, that a Committee--an internal 
Committee of VA, was--has reviewed potential Under Secretary 
names and has already met three times and passed the name 
along.
    Can you comment on that?
    Secretary O'Rourke. It--for the Under Secretary for Health?
    Mr. Takano. Yes.
    Secretary O'Rourke. Actually, we have had three commissions 
over the past year to evaluate names for that position.
    Mr. Takano. And that they have passed a name along, is that 
correct?
    Secretary O'Rourke. They did pass candidates along to the 
White House and I believe they weren't selected.
    Mr. Takano. Mr. Secretary, I am just really concerned that 
there seems to be no urgency to fill these positions that are 
critical to oversee a $15 billion project.
    Secretary O'Rourke. I can tell you that we are starting a 
new commission--
    Mr. Takano. And this is on you, not the White House.
    Secretary O'Rourke. Okay.
    Mr. Takano. Thank you.
    The Chairman. Ms. Brownley, you are recognized for one 
minute.
    Ms. Brownley. Thank you. I just wanted to get a 
clarification. I wanted to follow up on Congressman O'Rourke's 
question about the Legacy data being built in seamlessly to the 
Cerner. And Mr. O'Rourke, you said that was the goal, that is 
the intention to do it. Then I heard from the Admiral that 
you--within the DoD system that you have a portal, if you will, 
for the Legacy data, which sounds to me like you push that 
button and you get the Legacy data and it is not necessarily 
integrated into the system.
    So is that true, Admiral, in terms of what the DoD is 
doing? So you have a different objective than the VA?
    Admiral Bono. Thank you, ma'am, for letting me clarify. No, 
this is--we have the same objective, it is just that we are in 
transition. And while we are in transition, until we get onto 
the single instance of the electronic health record, we have to 
use some kind of bridging product that allows us to maintain 
visibility of it. So that is the Joint Legacy Viewer.
    In DoD we are also using that because in some instances for 
our patients and our MTFs, not all of us have been deployed to 
MHS GENISIS yet, so that is an interim support.
    Ms. Brownley. Thank you. I yield back.
    The Chairman. Thank you. Mr. Poliquin, you are recognized 
for one minute.
    Mr. Poliquin. Thank you, Mr. Chairman, very much. Mr. 
O'Rourke, are we on schedule and on budget with this contract?
    Secretary O'Rourke. Today, yes.
    Mr. Poliquin. Okay. And when did you start the contract? 
When did you start the project?
    Secretary O'Rourke. We started negotiating the contract May 
17th of 2017.
    Mr. Poliquin. Okay.
    Secretary O'Rourke. We signed it last month.
    Mr. Poliquin. Okay, but you have started. You are not 
waiting. There is no reason to wait. You are moving forward.
    Secretary O'Rourke. We are moving forward today as you can 
see. We are putting together organization plans and milestones 
as we speak.
    Mr. Poliquin. What keeps you awake at night that can cause 
this thing to derail and you have to come back to us and say it 
has been a failure or you need more money. We don't want that, 
either one of those to happen. So what could cause that to 
happen?
    Secretary O'Rourke. A lack of focus on cost, schedule, and 
performance. Any time you let your eye get off that ball, you 
are going to run into problems.
    Mr. Poliquin. And you are not going to let that happen?
    Secretary O'Rourke. No.
    Mr. Poliquin. Thank you, sir. I yield back my time. Ten 
seconds, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding. Mr. Lamb, 
you are recognized for one minute.
    Mr. Lamb. Question about the risk score when it comes to 
opioid abuse risk. I think that was you, Doctor, that talked 
about that. Can you just tell me who created that score and a 
little bit more about the criteria, as much as you can in this 
short time frame?
    Dr. Zenooz. Sure. I cannot remember the name of the company 
that Cerner uses, so I will have to take that for the record. 
VA internally has its own risk scoring system. We will be 
evaluating to see what efficiencies we can take out of that 
system and incorporate it into the Cerner system.
    But what we have seen so far is that all of the PDMPs that 
participate--all of the states that participate in the PDMPs 
are available to the system to aggregate and create the risk 
score. And the military health system, if they participate, or 
if they share data with--when they share data with the VA, will 
be aggregated and incorporated into that scoring system.
    Mr. Lamb. Got it. If you wouldn't mind just following up 
and letting me know who it was that created that, I would 
appreciate it.
    Dr. Zenooz. Absolutely.
    Mr. Lamb. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentleman for yielding and there 
are no further questions. So Mr. Secretary and Dr. Bono, you--
thank you for being here. It has been very helpful and very 
information and you are now excused. Thank you.
    The Chairman. On the second panel, we have again Mr. John 
Windom and Mr. John Short and Dr. Zenooz, representing the VA. 
They are accompanied by Mr. Zane Burke, president of Cerner 
Corporation. And on the panel, we also have Dr. David Powner, 
director of IT Management Issues for the Government 
Accountability Office.
    For those of you all who have not been sworn in, would you 
please rise and raise your right hand?
    [Witnesses sworn.]
    The Chairman. Let the record reflect that the witnesses 
have answered in the affirmative. Mr. Powner, you are 
recognized for five minutes.

                   STATEMENT OF DAVID POWNER

    Mr. Powner. Chairman Roe, Ranking Member Walz, and Members 
of the Committee, thank you for inviting GAO to testify on VA's 
EHR modernization and our ongoing work for this Committee 
looking at VistA.
    Our review is looking at both the cost to operate and 
maintain VistA and exactly what VistA is. Understanding the 
costs are important since VistA will be around until EHRM 
solution is fully employed. Knowing the full scope is important 
to inform the planning of the EHR modernization.
    This morning I will cover the cost of VistA, what VistA is, 
and provide suggestions as the VA proceeds forward with the EHR 
modernization.
    The VA currently spends about a billion dollars a year to 
operate, maintain, and enhance VistA. Major components of these 
costs include interoperability efforts, electronic health 
records, and infrastructure costs for hosting and storage. 
Tallying these costs is not an easy exercise since it entails 
contracts, internal labor, major programs, and components 
funded by both VHA and OINT. These detailed costs over the past 
three fiscal years are provided in my written statement.
    Now turning to what VistA is. Understanding the full scope 
of VistA is essential to effectively planning for the new 
system. There is no single source that fully defines the scope 
of VistA. However, VA has undertaken several analysis to better 
understand it. One that I would like to highlight is their 
application view of their health IT environment.
    There are over 330 applications that support health care 
delivery at a VA medical center. About 128 of these are 
identified as VistA applications and 119 have similar 
functionality to the Cerner solution. The bottom line here is 
that it is important to know how much of VistA the Cerner 
solution will replace. Some analysts say around 90 percent. The 
application view suggests a much lower percentage.
    Mr. Chairman, we want to avoid a situation down the road 
where there are surprises as to exactly what the Cerner 
solution is replacing. This understanding of VistA is further 
complicated by unknowns caused by individual facility 
customization that has occurred over the years.
    Now turning to the 10-year, $10 billion Cerner contract 
that was awarded last month. It is important to note, as 
mentioned prior, that the EHR program is expected to cost about 
$16 billion because VA estimates about $5.8 billion for project 
management support and infrastructure over the 10 years. Not 
included in the $16 billion are all internal government 
employee costs. So the 10-year price tag is even higher.
    I want to be clear here that going with DoD Solution is the 
right move, but given the complexity and cost, and the fact 
that both VA health care and IT acquisitions and operations are 
both on GAO's high-risk list, this acquisition needs to be 
effectively managed.
    My written statement highlights several detailed practices 
that we have seen applied to successful IT acquisitions that 
are important to the EHR program going forward. But there are 
some big-ticket items that are critical to pulling this off. 
These are number one congressional oversight. We commend this 
Committee for proactively establishing the technology 
modernization Subcommittee. Continuous oversight of the EHR 
program will make a different in ensuring that it is executing 
according to plans and budgets.
    Number two, executive office of the President involvement. 
The White House involvement can elevate the importance in 
accountability here. The current administration has several EOP 
offices who involvement can help. We also think that the 
Federal CIO's involvement is important.
    Number three, governance in building a robust program 
office. Both interagency governance with DoD, as planned, as is 
the governance process that reports the VA's deputy secretary. 
It is important that this governance structure has a strong CIO 
role and that it ensures better collaboration between VHA and 
the CIO shop than has historically occurred.
    Also, we have seen governance structures embed the 
contractor to create better transparency and teamwork. In 
addition, if a governing structure is robust and open to risk. 
We have also seen congressional and GAO staff welcome to attend 
these meetings. We believe this is a best practice and frankly 
save agencies time in responding to oversight questions.
    Number four, business change management. A major issue with 
Federal agencies is adopting commercial products and their 
unwillingness to change their business processes. For the EHR 
initiative, this entails clinical work flows. This is 
definitely a high-risk area for VA.
    And finally number five, building an appropriate 
cybersecurity measures and optimizing infrastructure. VA has 
cyber challenges that are important to this new EHR 
acquisition, including controls associated with network 
security and controls for monitoring systems hosted by 
contractors. Regarding infrastructure, these costs appear 
exceptionally high with the VistA program and VA needs to 
consider a more comprehensive data center optimization strategy 
that coincides with their new EHRM approach.
    Mr. Chairman, this concludes my statement. I look forward 
to your questions.

    [The prepared statement of David Powner appears in the 
Appendix]

    The Chairman. Thank you very much for your testimony. Mr. 
Burke, you are recognized for five minutes. We will go to 
questions Bill tells me. So I will go to questions.
    First of all, I would like to start, and I appreciate you 
all being here. And Mr. Burke, help me with some back of the 
envelope math here. The EHR modernization is going to cost 
almost $16 billion over 10 years, $1.58 billion per year. 
According to the GAO, the cost to run VistA is about $1 billion 
a year.
    And again I asked this a minute and the Secretary couldn't 
tell us. What does the cost to run the Cerner EHR look like 
after the 10-year implementation? And does the total cost of 
Cerner drop below the billion a year, is that just going to be 
the cost to keeping this up and running? Or does anybody know 
that answer yet?
    Mr. Burke. Mr. Chairman, thank you for conducting this 
hearing and our participation in it. As it relates to that 
question, we do believe that the costs will be less than the 
ongoing costs of the current VistA system. Several of those 
items that reflect some savings will be around the fact that 
today the VistA instances--over a hundred different instances. 
You have a number of different training. The people, the 
upgrades, the updates, those kinds of things are significantly 
more expensive in those models. So we do anticipate taxpayer 
savings over time.
    The Chairman. Well, 10 years is a long time. I was at Oak 
Ridge national labs a couple of weeks ago. They spent $200 
million on a supercomputer in 1996. They told me that now your 
iPhone has as much computing power as that 200. So in 10 years, 
who knows how much the technology is going to--it is going to 
change dramatically. I can tell you from the rollout that DoD 
is doing right now in the northwest and what VA is starting in 
October is going to look totally different in 2028.
    So I think there will be added cost and they--I don't see 
how it couldn't be more cost. Dr. Zenooz, one of the things 
that--and again, Dr. Dunn and I will continue to go back to 
this, is how important it is to make an EA--I hear this all the 
time, to make the clinicians job easier and more efficient 
instead of just--just punching boxes and entering data.
    You know, that is what we feel like we are now. And I 
understand that in some respects and VistA, believe it or not, 
people kind of liked that system. They are used to it. So we 
are asking the clinicians and people, 380,000 people to make a 
gigantic change in the way they do their business right now.
    And is it designed around how people want to do things, not 
necessarily the most efficient way. And you have to configure 
the EHR from the ground up, not the top down. Dr. Dunn just 
mentioned that. And that starts by collecting input from really 
thousands of people who you--nurses, and doctors, and supply 
technicians, and all that, scheduling people. All of those have 
ideas and many of them good ideas. Are we doing that or are we 
just turning that into a check the box and we are going to go 
on and do exactly what Cerner has already laid out?
    Which is it going to be?
    Dr. Zenooz. Thank you so much. As the--in my role as the 
functional champion, change management obviously is the number 
one priority for me. And I recognize as a clinician that 
burnout because of checking boxes, as you say, is a key reason 
why people get frustrated with this process.
    So we have ensured from the very beginning that we have 
front line folks involved in this process, in the requirements 
process. So not just the doctors, and the nurses, and the 
dentists, but also the medical support assistants, the 
schedulers, etcetera, supply chain folks sitting at the table 
with us to put in the requirements for this process.
    They will be integral in designing the work flows to ensure 
that it is both efficient and meets their needs. I mean, we 
have to look forward to make sure that we are no just doing 
things current state, because we understand in VA that there 
are efficiencies to be gained. But at the same time, we will 
make sure that we take in best practices and work with our 
front-line folks to design the system that works for VA.
    The Chairman. What we are doing is we are making data entry 
people out of our clinicians. And we have--we are doing, I 
think, a pilot program now on scribes just to help let the 
doctors and nurses be doctors and nurses. And then a few 
years--several years ago when my wife was critically ill in the 
hospital and I got to sit there and watch a system, not as a 
physician going around making rounds, but as a patient, I saw 
the clinicians and the nurses spend more time entering data 
than actually at the bedside.
    That is not good. That is where technology has not helped 
us. It has not made quality better. It has not done any of 
that. So I would strongly encourage you to make sure that you 
include all of these people that are going to be using it.
    And then the other thing, I think, was said by the Admiral 
Bono was that you have to train people on what you are going to 
use. I don't think DoD actually did that to start with. And you 
have to have them well trained because it is going to be a very 
anxiety-producing incident when we roll this out. The next 18 
months, if I am at--if I am in the northeast, if I am in 
Washington State and I am at a VA, I might want to transfer to 
Mountain Home.
    So I now yield to Mr. Walz.
    Mr. Walz. And thank you all for being here. Mr. Powner, you 
talk about the governance board. It sounds like you are pretty 
confident they are standing that up and you are--my request was 
is that you be involved as you say you are and that you be 
involved in those quarterly progress reports. Do you feel at 
this point in time that is one track and you feel comfortable 
being part of that team?
    Mr. Powner. Yes, we feel that is important. We have 
experience doing this with other modernization efforts too, 
when you look at some of the things that have gone on like at 
IRS and other agencies. We have been embedded in some of those 
governance processes. And, again, if you are confident in your 
governance process and I have talked to Mr. Windom about this, 
he is confident, and I think he welcomes us there. I think it--
it saves time for everyone.
    Mr. Walz. This is really encouraging, and I think that is 
where you saw the line of questioning. There is always another 
partner at the desk with us on this because oftentimes you ask 
us to implement the IG findings, the IG that does that. It is 
obvious that the IG is not a welcome partner at this point in 
time. There is open hostility. It is no secret to anyone here. 
And that is the point we are trying to get you.
    In your experience, how important is it from those IGIs in 
these types of projects and implementation?
    Mr. Powner. Well, I think both GAO and IGs need to have 
access to the right information and timely. I will say from 
GAO's perspective, we get access. Historically, it has been 
slow. Okay? We get data but it is slow. But I will say Mr. 
Short and Mr. Windom, they have been more responsive than 
others in the past, but we--in needs to be timely. We don't 
have time to be slow here.
    And the bottom line is you got it or not, don't create it.
    Mr. Walz. This is a--
    Mr. Powner. If you are creating it, you are not managing 
it.
    Mr. Walz. Yes, this is a new dynamic, though. It is not 
just a slowness or whatever. There is a reinterpretation of 
what we have to do and what we don't have to do. There is a 
whole new dynamic at play here with the secretary basically 
saying I am in charge with you and I will tell you when you 
investigate. That is what is different here.
    And at the start of a project like this, I cannot stress 
enough that I think that is your fatal flaw if this is not 
fixed, addressed, and cleared up immediately because so many 
things have come out of that IG. So I appreciate you being 
there.
    Mr. Burke, congratulations. You got a $10 billion contract 
and now you have got a whole bunch of partners. So we are here 
to ask how you interface on this. How do you see the role of 
this new Subcommittee that is set up with the responsibility to 
the veteran and the taxpayer, and you as a private entity that 
is providing a contract and a service to improve veterans' 
health care, to do is what is needed for our warriors, but 
rightfully so, you have a financial stake, as you should, to 
make this work? How do you view what we are setting up here and 
how that interaction would work and how you would view our 
request for information in the appropriate way to find out 
where we are at?
    Mr. Burke. We view it as part of an appropriate governance 
model. So we are very excited actually about this Subcommittee 
and think that it is a great approach. Our obligation is to 
serve the veterans at the end of the day. And we want to bring 
seamless care, help the clinicians who serve those veterans, 
and have them have the most effective means possible to do 
that. And so we view that very positively.
    Mr. Walz. I really appreciate that. And I know your team. 
This was months ago, way before this was going when I wanted to 
come up to speed on different systems and you set really good 
people out who sat down with a layman to look at how this would 
work with myself. Dr. Roe knows a lot more about this and 
understands this. I represent the area of Southern Minnesota 
where the Mayo Clinic is. So I am familiar with their 
electronic record, their switch to Epic, and looking at all of 
that.
    So I said from the very beginning, though, I really want to 
make note that your team was very open, they were there. They 
were talking about things that worked and didn't work. They 
were projecting ahead of potential problems that may arise. And 
I think that openness, the transparency, that seeing us as 
partners in different eyes on this to the same goal is really 
healthy. So I am grateful for that and I yield back.
    The Chairman. I thank the gentleman for yielding. Dr. Dunn, 
you are recognized.
    Mr. Dunn. Thank you, Mr. Chairman. Mr. Burke, welcome to 
our panel. I look forward to working with you. I am the 
Chairman of VA Health Subcommittee, so I think we will be 
seeing a lot of each other over the next few years.
    What--I want to address a question of work flow counsels 
right now that are doing the mapping and the work flow 
standardization. What is Cerner's interaction with them at this 
point?
    Mr. Burke. We are just beginning that process. So the teams 
are coming together. The plan is basically we will work with 
the VA. And we will also bring other third-party industry 
partners that are industry experts in that space and the VA 
will supply the leading folks on their side to be part of those 
counsels as we move forward.
    Mr. Dunn. Okay. So you have an immense amount of experience 
with EHR's. I do too. I am one of your clients. I want to know 
how you are making--to Dr. Roe's point, how are we going to 
make this a not frustrating--a productive interface for the--
for all of the clinicians: doctors, nurses, everybody. How do 
you do that? Because I can tell you, there is a lot of 
frustration.
    Just as a point, last--two weeks ago there was an article 
that came out and said that the average physician in America 
spends 53 hours a year just logging onto his EHR, 53 hours a 
year longing on. Help--make me feel better.
    Mr. Burke. Well, first off here, and it is an appropriate 
question to ask is the process by which we will go forward and 
come up with best practice. We will bring the best practice. 
The buy in from the clinicians is incredibly important. We will 
do--together, we are doing current state analysis. So what do 
the clinicians have today and then do a crosswalk, what will it 
look like in the future.
    So the set of expectations, we understand if they already 
have certain capabilities. Will they get enhanced capabilities? 
Are there elements where we will be challenged? We try to 
understand those kinds of things up-front so that we can do 
that work, along with those best practice elements.
    The other side that I would look at is as a company, our 
number one priority is the clinician experience. And 
unfortunately, EHRs have become really box ticking exercises 
for the clinicians. And it is the little--it has reduced the 
time with the patients overall. And our obligation as an 
industry is to come forward with other technologies, which make 
it where people--where the clinicians can actually spend more 
time with the patients. It can be much more natural in the work 
flow and those kind of things.
    And over time, what the VA has done has really contracted 
for those upgrades to be part of the solution set. So as you 
think about the go forward spaces, absolutely the EHR of today 
will be different--the EHR in the future, the VA is contracted 
for those upgrades. That is part of the process--
    Mr. Dunn. Do you currently have biometric log-on's?
    Mr. Burke. That is part of the capabilities.
    Mr. Dunn. So that can if it works, you can make that a lot 
faster?
    Mr. Burke. Correct.
    Mr. Dunn. Of the $10 billion contract, how much is hardware 
and how much is software?
    Mr. Burke. I am sorry, sir. I would have to get back to you 
on exactly--that is--
    Mr. Dunn. Does it include hardware?
    Mr. Windom. Sir, we have acquired software and related 
services from Cerner Corporation. Things like maintenance, 
software updates, installation--
    Mr. Dunn. I am asking, you know, do the laptops and things, 
are they included in that?
    Mr. Windom. That is part of our infrastructure buy. Cerner 
is not buying those.
    Mr. Dunn. So outside of the $10 billion, there is a whole 
lot of computers to be bought?
    Mr. Windom. That is why the $16 billion number, $10 billion 
is allocated to Cerner--
    Mr. Dunn. Okay, so it is in the other $5.8 billion.
    Mr. Windom [continued].--for the Cerner contract. $4.59 
billion for infrastructure upgrades that would include that 
type of hardware and then 1.2 billion for program management 
oversight.
    Mr. Dunn. I was just trying to get a sense of where that 
was located. That is very good. So I am getting short on time, 
but I do want to leave--Mr. Burke, we are happy to work with 
your people. We are going to be working with them. We want to 
work with them up-front. We want to make sure that you have got 
a system that is palatable to the people who are actually using 
it.
    And I know you know in your business that is really not a 
very common thing. We all have a love/hate relationship with 
REHRs. I have spent literally millions of dollars on EHRs. And 
I was kind of hoping I wouldn't have to do that when I got to 
Congress, but now I went from millions to billions.
    Mr. Chairman, I yield back.
    The Chairman. I was going to say you are spending billions 
now, not millions. Mr. Takano, you are recognized for five 
minutes.
    Mr. Takano. Thank you, Mr. Chairman. Mr. Powner, you in the 
opening testimony said something about the percentage of VistA 
that needed to be replaced or addressed varied, can you expound 
on that a little more because I want to understand what you are 
saying?
    Mr. Powner. Yes. So there are a couple different views when 
you look at what VistA is. And you can define it in what is 
called modules. And the module view says that the Cerner 
Solution will replace about 90 percent of what VistA is. But if 
you take an application view, it is much less. So that is why 
it is a little confusing. I don't have an exact number for you, 
and I do think the VA has attempted to look at this.
    But again, I think what is very clear here is similar to 
how Mr. Windom just answered this question. What is in the 
Cerner contract and what isn't? And then what is in the $5.8 
billion? You don't want surprises that you have got $10 billion 
here and $5.8 billion here to cover infrastructure and program 
management and you find out there is another $2 billion outside 
of that to implement the solution.
    That is still a little fuzzy in our mind. We have a report 
that we are currently working on for this Committee that we 
will be hoping to provide some more clarity on that.
    Mr. Takano. Do you believe you--within GAO have the 
requisite expertise, the numbers of experts to be able to 
perform this analysis?
    Mr. Powner. That analysis, no. We are not performing--well, 
we are relying on VA's analysis on the specific applications 
and modules. But I have got experts that could say whether that 
analysis that VA is conducting is appropriate or not, yes.
    Mr. Takano. And do we--do they believe that VA has the 
resources, the personnel?
    Mr. Powner. Yes, they have got the resources and the 
personnel. The problem is the--they have got a lot of unknowns 
because of the customization. I mean, I think it is very 
unclear. The best way to characterize it, there are all of 
these unknowns and how much of those--you don't know what you 
don't know. And when these specific site reviews that are 
currently ongoing are going to shed a lot more light on that.
    Mr. Takano. So there is kind of a scan of all of the 
different sites and what individual customizations occur in 
those sites and--
    Mr. Powner. Yes, exactly.
    Mr. Takano. You said it could be up to 90 percent, what is 
the other view? How much--
    Mr. Powner. Well, the other view is like in the 50 percent 
range. But again, we think that application view and tells a 
little more than VistA, so it is hard to compare the two. But I 
will get back to this question about long-term post 10 years 
about the O&M cost. I sure hope that it is a hell of a lot less 
than the $1 billion that we currently spend.
    We have got standardization, we won't have an old language. 
And we can save a lot of money in the hosting arena. I can tell 
you the data center optimization initiative that the Federal 
government undertook, VA is one of the worst agencies on 
consolidating and optimizing their data centers. This is an 
opportunity to do that right with the Cerner implementation.
    Mr. Takano. And so on balance, you believe--you stand by 
the decision to go with the, as you said, DoD's solution, 
right? I mean, there were people who were advocating--
    Mr. Powner. No, we advocate go with a common solution and 
go with a commercial product. We have advocated that all along 
because you have got to get there eventually or you are--VistA, 
it is just long-term it is going to be more and more to 
maintain.
    Mr. Takano. Mr. Burke, I know that the emphasis, and my 
colleagues were all excited about the potential of integrating 
to interoperable degree these systems--the VA system with the 
DoD system. I am also concerned about the interoperability with 
the non-VA providers because that is a significant part of what 
we do.
    And I am concerned about the idea of portability of data, 
patient data. And I think viably that data belongs to the 
patient. But I don't believe that is how even the private 
sector operates, that we have proprietary behavior among the 
other EHRs out there. Is this an opportunity for the VA to be a 
leader in this case? And I will just stop and let you comment 
on what I have raised here.
    Mr. Burke. I appreciate the question. It is absolutely a 
space where the VA can be a--is--we believe will lead the 
country on this side and both the DoD will help in that 
perspective.
    I have a personal belief that is the same as your, is that 
the personal health record ought to be mine, ought to be yours. 
As part of that, we will actually be offering personal health 
record for free to the--in terms of any one of our clients in 
that space. And we announced that probably nine months ago, in 
that realm. We participate in all of the HIEs and all the 
connections. We also believe that other technologies will be 
written, that will need to go on top of our platform. And so 
making our platform more open in that perspective is also 
important.
    So interoperability/openness is part of the foundational 
elements of the contract and really what we anticipate doing 
both with the DoD and the VA.
    Mr. Takano. Mr. Chairman, I look forward to this new 
Subcommittee you are setting forward because I think we can 
help the American people understand what is at stake here in 
terms of the potential--greater portability and the VA's 
ability to leverage its position with regard to the other EHR 
systems that are out there. I yield back.
    The Chairman. Thank you for yielding. Mr. Powner, I hope 
you are right, but my experience in the private world was that 
I always spent more and more on technology, not less.
    Mr. Banks, you are recognized.
    Mr. Banks. Thank you, Mr. Chairman. Mr. Windom, how did you 
select the Spokane, Seattle, and American Lakes as your initial 
implementation sites? And was this because the defense health 
agency had already selected nearby sites or did VA reach this 
conclusion independently?
    Mr. Windom. We had an ongoing negotiation with Cerner 
Corporation as part of our contract award actions that took 
place this past May. And so as we sit down and we negotiate 
parameters that are going to be cost drivers and variables 
within the framework of that negotiation, the economies of 
scale associated with labor were one. DoD was in that region.
    Negotiating on behalf of the taxpayers and our veterans, I 
am always conscious of what we are going to pay, especially and 
still with an eye on not compromising the care of--to our 
veterans. So economies of scales of labor were introduced by 
Cerner Corporation and going to the Pacific Northwest.
    In addition, that foundational issue of interoperability. 
If we were in the region with DoD, that is a quick way to test 
whether our interoperability strategies work. And so being in 
that same region, to me, demonstrated one of the major premises 
of the D&F, the determination and findings, that were at the 
forefront of our efforts, which was interoperability.
    So we look forward to demonstrating that in the Pacific 
Northwest once we deploy there. But that is part of the terms 
and conditions that we agreed to and with a focus on economies 
of scale with labor and also interoperability objectives, sir.
    Mr. Banks. Have you been to each of the initial 
implementation sites?
    Mr. Windom. Sir, I had the fortunate opportunity to lead 
the DoD effort. I was the program manager overseeing that while 
I was still on Active duty in the Navy, so I am now on the VA 
side. So the answer to your question is I have been to those 
sites, I have--
    Mr. Banks. But not since they were selected as the initial 
implementation sites?
    Mr. Windom. Not since they have been selected, not since I 
have been working with the VA, I have not been to those sites.
    Mr. Banks. What about our other VA guests, have you been to 
all three?
    Mr. Windom. Mr. Short has been there.
    Mr. Banks. Mr. Short?
    Mr. Short. I was at the Fairchild go-live when--
    Mr. Banks. And Doctor?
    Dr. Zenooz. I have been to other sites in that area, but 
the particular site. I have worked in several VAs--
    Mr. Banks. So you have not been to the initial 
implementation sites?
    Dr. Zenooz. Not to the initial sites. I have visited 
Seattle, the city, the Seattle VAMC, but not in this capacity.
    Mr. Banks. Okay. So, I just want to clarify, Mr. Short, you 
have been to the initial implementation sites since they have 
been the initial implementation sites?
    Mr. Short. The DoD sites when they went live.
    Mr. Banks. The DoD sites.
    Mr. Short. We went through them as they brought in new 
patients and processed them, and we went through their training 
facilities, their war room, went through all that.
    Mr. Banks. Okay.
    Mr. Windom. Sir, I just want to make sure I am clear. We 
just characterized our initial visits to the DoD sites.
    Mr. Banks. I understand.
    Mr. Windom. Our initial operating capability sites we have 
visited as part of our pre-screening efforts associated with 
establishing them as the sites to be deployed to.
    Mr. Banks. I apologize. I am easily confused, I suppose. So 
do you believe that the IT and clinical departments at these 
Medical Centers are sufficiently strong, or will the VA be 
making additional investments in them to prepare the 
implementation?
    Mr. Windom. Sir, they deliver high-quality care today. I 
can't emphasize the change-management strategy that we are 
about to subject them to and how difficult that is, so I am 
going to defer to the clinician, because she has got the pulse 
of the people on the ground and she can give you more of a 
characterization.
    Mr. Banks. Doctor?
    Dr. Zenooz. Thank you. So we have been working with the 
VISN director in that area since the sites were selected and we 
have been working with them to ensure that they will have the 
staff that is required. We have identified change-management 
leaders on the ground, executives as well as informaticists 
that will be participating in this project. Several of the 
folks are involved on my team directly and have received the 
appropriate change-management training.
    If we go to the--not if, when we go to the site review and 
identify any gaps, we intend to address that immediately, so 
that by the time of go-live, which is 18 months from October 1, 
they will be ready for what is coming.
    Mr. Banks. Doctor, are there any discussions at all 
occurring about changing the implementation sites, to your 
knowledge?
    Dr. Zenooz. I think we are always evaluating what is best. 
We have had several discussions to see if we should be looking 
at other sites, but we have always been talking about it from 
day one to ensure that we are going to the right place. As we 
evaluate leadership, informatics leadership, IT leadership, 
executive leadership--
    Mr. Banks. So, yes or no, are there conversations about 
changing the implementation sites?
    Dr. Zenooz. We have had these conversations since day one. 
So, yes, we are continually evaluating, absolutely.
    Mr. Banks. Okay, my time has expired.
    The Chairman. Thank you.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    Mr. Burke, I wanted to ask you, this might be an elementary 
question, but it relates to the interoperability issue and the 
concern about being compatible in the community. It seems to me 
that Cerner, Epic, nobody has been able to achieve 
interoperability so far. So it seems to me that--I get that we 
will be able to communicate with DoD, being the same system, 
but to be able to go out and communicate with the other systems 
out in the universe, it seems to me like we are going to have 
to create new software, a new system that has not been 
identified yet to be able to do that, so we are going to have 
to invent somehow to make that possible.
    Mr. Burke. It is a great question. Historically speaking, 
there were a lack of standards as it related to data flowing 
between systems, and so there were some technical elements 
between different systems. And there is, interestingly, almost 
200 different EHRs out there between the ambulatory side and 
the acute side. And beyond just the ambulatory and acute, there 
is the full continuum of care that ultimately, we need to 
connect.
    There has been quite an evolution of those standards, which 
has been very helpful, and part of that has been part of our 
conversations as we paused in the contracting process was to go 
through that evolution and codify that in the contract to say 
what is possible today and then what is the art of the future 
tomorrow. And so there are parts of those elements which are 
let's go implement the things that we can go do today and then 
there are other elements in there that we are contractually 
obligated on a go-forward basis for enhanced interoperability 
as we move forward.
    So I would look at it and say that technically speaking 
there isn't as big a challenge on interoperability today as 
there once was from a technical perspective. There are still 
business processes within the communities that create a 
different experience on the availability of that information, 
one of those is who actually does own the personal health 
record itself. And so that is one of the reasons why we are 
offering a personal health record for free for any of our 
clients, anybody that wants to do that, because we think that 
is ultimately one of the ways we move past some of those 
business model challenges in that space.
    So it is a very complex arena. I can assure you that we 
have spent a significant amount of time on that. We are 
committed to this process and we actually do think it is an 
opportunity for the VA and the DoD to lead in the space, and I 
am convinced that we have the capabilities to go forward and do 
that. And VA also has the funding mechanisms by which to really 
enhance the community to want to participate in the process as 
well.
    Ms. Brownley. So to sort of break those barriers, if you 
will, is it going to require the cooperation of the other 
electronic health records out there to be able to get to the 
ultimate, as you said, the art of the future? Is it going to--
is that the requirement or is it, you know, some really IT 
person back in a room creating a system that is going to, you 
know, encompass all these other systems out there to make it 
compatible?
    Mr. Burke. Today there is an organization called 
CommonWell, which is a not-for-profit interoperability group 
that actually is committed to standards, which is it has over 
50-plus different members from the EHR community that have 
agreed to code their solutions to a certain spec. And so that 
has been an industry-led element, we were one of the founding 
members of that organization.
    In addition to that, that group, CommonWell, is what is 
called a Care Quality Implementer. So it is a second group that 
really has a set of standards which connects my major 
competitor and as they are not part of the CommonWell standard, 
but they are Care Quality standard.
    So CommonWell will do the implementation, so it should 
connect all those pieces there. It will--
    Ms. Brownley. But if they don't succeed, we don't succeed?
    Mr. Burke. That is part of the dynamic of the 
interoperability side. The pressure side coming from the 
providers and their clients will be quite significant in that--
and I am in a spot where I think I should defer to Ash and let 
her communicate as some of the sticks that the VA has for 
compelling some of that in the community care.
    The Chairman. Just to--
    Ms. Brownley. My time is up.
    The Chairman [continued].--let you know, one of the big 
mistakes we made in electronic health record was that we didn't 
make them where there is the same platform look. Everybody, 
whether it is Cerner or Epic or Allscripts or whomever, they 
all silo their information, because information is money. And I 
do understand--
    Ms. Brownley. They have to know how we are actually going 
to do this--
    The Chairman. Yeah, and it is incredibly important to be 
able to share this data. And I agree with you all, the person's 
health record is whomever the person's health record is. It is 
yours, Mark, or mine or whomever's record, I totally agree that 
is who owns it.
    Mr. Poliquin, you are recognized.
    Mr. Poliquin. Thank you, Mr. Chairman.
    Doctor, use some of my time right now to go ahead and 
answer your question or answer the question that Mr. Burke 
threw over to you.
    Dr. Zenooz. Absolutely. Interoperability is not an end 
state, it requires constant care and maintenance, and it is not 
just you get to a certain data element or you share something, 
and it is done. Users are going to continually ask for more and 
more things to be shared for the providers to provide adequate 
care and patients are going to want that data available to 
them.
    For that to be possible, I think there are a couple of 
different elements that you need to address, one is the 
technology. As technology advances, we need to ensure that VA 
keeps up, and it is our intent and part of our contract to keep 
up with that through innovation, through adoption, et cetera. 
Number two is policy and legislation, which is very important. 
I know that Congress had pushed forward on information blocking 
to ensure that that ends, that we share more information across 
the system, but obviously that can be expanded, as you have 
said. And, number three, I think the VA will participate and 
engage directly with the Office of Community Care and the 
Community Care networks that we contract with to ensure that we 
get as much information as possible. And not just limited to 
certain data elements, whether it is allergies or medications, 
et cetera, that we get as much information as we can and need 
to provide the adequate care that is necessary.
    So I think it is a three-pronged approach.
    Mr. Poliquin. Thank you, Doctor, very much.
    Mr. Burke, congratulations for your company winning a $10 
billion contract over a 10-year period of time. Your job, and 
you know this better than I do, is to deliver a project that 
works, on budget and early, and I am going to be one of the 
people on the Committee that is going to hold you accountable 
and everybody else that is involved.
    That being said, I would love to have you comment on this, 
sir, if you don't mind. I think you have two problems, one of 
which is convincing people that it is better for them to use 
this instead of a flip phone, that is one. That is the 
technology piece that I am sure you folks can get to. And the 
second one is one I think is more significant and I would love 
to hear your comment on this, is how do you convince the people 
at one of the--arguably the largest bureaucracy in the world, 
or one of them, to do something differently that might, at 
least they might have the perception it is going to threaten 
their job. Because they have built these Legacy systems 
throughout our country that are incredibly expensive, they 
don't talk to each other, so our veterans are being hurt, but 
now you are asking them to do something entirely different, not 
only using different technology as time goes on and maybe now, 
but also threatening the bureaucracies they have built up in 
the protection of their jobs. How do you tackle that problem?
    Mr. Burke. Well, as you described, the technology works, it 
is just really these projects are very complex and this will be 
a significant undertaking, and all of these kinds of projects 
have some what I call white-knuckle moments in them and I would 
anticipate that this will have a handful of those.
    What I do feel good about is that we have a governance 
model to address those and one of the key, you know, reasons 
for success or failure.
    Mr. Poliquin. Give us an example.
    Mr. Burke. Of when they work well?
    Mr. Poliquin. Give us an example of how you are going to be 
asking one of the 385,000 employees at the VA to do something 
different that they will embrace, even though they might 
perceive that it threatens their job?
    Mr. Burke. Right. It is a continual sales process, as I 
describe it, which is we legitimately go out and meet with 
those individual groups and you are actually continuing to sell 
them, here are the advantages. It is why it is really critical 
we do this cross-walk properly.
    We did have an opportunity as part of this contracting 
process to do something different than there was in the DoD 
process, because the DoD process was a response to a request. 
In this case, this was a direct to contract. It allowed us to 
work together for the past year to really learn and understand 
what each one of the--what really are the hot buttons here--
    Mr. Poliquin. Now, the DoD is ahead of the VA in this whole 
scheme and how are they doing?
    Mr. Burke. I believe that they are doing well. Like all 
complex projects--
    Mr. Poliquin. Are they on time and on budget?
    Mr. Burke. To date, they were on that side. We think we 
will be able to stay on time and on budget--
    Mr. Poliquin. Good.
    Mr. Burke [continued].--as it relates to that and in that 
perspective. But I do feel like that the teams that we have put 
together and how we will go about the sales process and the 
collaboration will be effective here. It is critical we get the 
right people to the table. When these projects do well, you 
have the key clinicians that people look to; when they don't do 
well, it is done by a Committee, that it is not part of those 
that are seen as maybe the informal versus the formal leaders.
    Mr. Poliquin. We wish you tremendous success, Mr. Burke, 
and everybody else involved. Thank you.
    I yield back my one second of time.
    The Chairman. I thank the gentleman for yielding back.
    And just to show you how rapidly technology is changing, 
the new, the fastest new super-computer in the world at ORNL 
that calculates 200,000 trillion calculations per second, that 
is 10 to the 18th power. So that is how fast this technology is 
changing.
    General Bergman, you are recognized.
    Mr. Bergman. Well, given that bit of data, Mr. Chairman, I 
am going to reflect to you a bit of change that occurred about, 
oh, 18 to 20 years ago when we were designing the Joint Strike 
Fighter. And I had a chance to sit in a meeting where one of 
the initial design criteria was to design an entirely new 
aircraft around a 2,000-pound bomb. Think about how backwards 
that was. Someone very wise at the meeting said, how about 
changing the bomb? We are designing an airplane here, not a 
bomb carrier.
    And that is exactly what we are doing here in different 
ways. We are designing a system of systems that is going to be 
flexible enough to take advantage of changing technology. We 
have used the word change management here several times. Well, 
part of the change management is to manage the changes in 
technology so you stay ahead of the power curve as best you 
can.
    And as it relates to my district, one of the serious 
considerations we have in technology is rural broadband. Okay? 
We think about this system that we are going to design has to 
work for all of our veterans and all of our providers in those 
remote areas that as we transition the entire country to rural 
broadband, we have to realize that we don't want to leave 
anyone or any area behind.
    Now, Mr. Powner, how do you assess VA's readiness to 
standardize their clinical and administrative workflow, how 
ready are they to do that?
    Mr. Powner. I think it is in its early stages right now and 
I do think that is something that this tech Subcommittee, I 
know it is a tech Subcommittee, but it is almost like the 
technology, it probably isn't as hard as the standardizing the 
clinical workflows, and I think that tech Subcommittee needs to 
have a hand-in-hand focus on that. Right now, it is in the 
early stages.
    Mr. Bergman. So compare that to the task of mapping VistA?
    Mr. Powner. I think mapping VistA is further on down the 
pike. Again, that is close to being finished with the work that 
we looked up on mapping VistA.
    Mr. Bergman. Okay. Well, your written testimony mentions 
VA's present efforts to standardize VistA. Medical Centers have 
to request approval to alter their version of VistA and 
apparently there have been roughly 10,000 of these waiver 
requests in recent years. What can you tell me about these 
requests? What does a typical request entail?
    Mr. Powner. So we don't have specific details on those 
requests, Congressman, but I will tell you this: there are 
thousands of those requests and that is too many when you start 
looking at the customization that needs to occur. And that is 
the whole reason why we are going the route that we are going 
here--
    Mr. Bergman. So would you consider--
    Mr. Powner [continued].--we need to control that. If there 
is any customization, it needs to be a waiver, and you really 
need to control it or deny it.
    Mr. Bergman. So in some ways is this an attempt for the 
tail to wag the dog, we would like to do it our way here 
locally and we want to get a waiver because we don't like 
change?
    Mr. Powner. Absolutely.
    Mr. Bergman. Okay. So we need to, again, going back to 
build that culture that embraces the change necessary.
    Doctor, VA's testimony states that its planning will be in 
full swing over the next 3 months, implementation begins 
October the 1st and is scheduled to finish in Spokane in March 
of 2020. Do you believe that is enough time to conduct those 
thorough site assessments, finish VistA mapping and map all the 
workflows, have we got enough time to do that?
    Dr. Zenooz. Based on our discussions with several industry 
experts and bringing in those experts who in these 
conversations we feel that that is adequate time for our 
workflow decisions and site reviews. We also have a partner 
that has done this at least 15,000 times. So, you know, I am 
hoping that Cerner, with all of their experience and expertise 
that they bring to the table, can add to this.
    I think what really helps here is that we are not trying to 
customize things and we are trying to adopt--or we are adopting 
industry best practices and we are adopting what Cerner has 
already built in to ensure that it fits our model. So I think 
there is adequate time for us, but of course, you know, we will 
be working with the Committee very closely and keeping you 
appraised of our progress. If we feel that we need adequate 
time to evaluate or work on something or delay the process, I 
think that is absolutely okay on my end from a clinical 
perspective and I will be the first to speak up.
    Mr. Bergman. Okay.
    Dr. Zenooz. On the VistA mapping, I would defer to Mr. 
Short.
    Mr. Bergman. Okay. In 17 seconds or less.
    Mr. Short. On the VistA mapping, we have done a couple 
different things. Right now we have identified all the 
functional clinical modules we are confident that Cerner will 
replace. The non-clinical modules that do other functionality, 
we have five of them left, we are still analyzing them.
    Mr. Bergman. Okay, thank you.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding.
    Mr. Short, I was about to--you were about to remind me of 
what one of my good friends who was the mayor of the county I 
lived in, retired now, George Jane said--he said, son, when you 
go to Congress, remember, you can't vote silence. I was about 
to ask you if you wanted to speak after almost 3 hours at this 
hearing.
    Mr. Short. Thank you, sir.
    The Chairman. So one question that--and we will just do a 
2-minute lightning round here--that came up with the DoD 
application--and I know, Mr. Windom, you know the answer to 
this, but became so enamored with the security, as obviously we 
can, obviously cyber security we are very concerned with about 
protecting patients, it slowed the process down so much that it 
became almost too cumbersome to use. I think that has been 
worked out and I think that is one of the scalable things that 
VA can learn from what DoD did, and I am glad you are where you 
are to sort of pass that information along. Am I correct or 
not?
    Mr. Windom. Sir, I am going to defer one more time to the 
Chief Technology Officer, because he is my expert that we pay 
in that arena. And I think I have the answer, but I will let 
him give you the answer, if you don't mind, sir.
    Mr. Short. DoD has been very successful in getting the 
latency--along with Cerner, getting the latency out of the 
system. VA is going to be incorporating the same security model 
the DoD put together that has a higher security posture than we 
normally have historically in VA to make sure everything is 
encrypted, secure perimeter-wise, and have been following that 
same model.
    The Chairman. And, as I understand, that was one of the 
things that slowed the DoD implementation down initially. That 
should not slow VA down?
    Mr. Short. That is correct. From the lessons learned, we 
are taking the best of that. I am in talks with the DoD on 
security every week.
    The Chairman. Thank you.
    I yield now to Mr. Takano.
    Mr. Takano. Mr. Burke, does the contract you have with VA 
also include responsibility for the Community Care 
interoperability?
    Mr. Burke. It does, there are the standards for that 
Community Care interoperability, yes, sir.
    Mr. Takano. And do you know on the DoD side whether the 
Cerner contract with DoD, it covers the internal medical 
operations, as well as TRICARE and that sort of thing? Because 
TRICARE is going to, you know--
    Mr. Windom. Sir, we can take that for the record. We don't 
really want to speak on behalf of DoD, if we--
    Mr. Takano. Okay, fine. Mr. Burke, we started to get into a 
conversation with Ms. Brownley about the sticks that the VA 
might have in order to compel the other EHRs out there to kind 
of meet VA standards, and you were about to defer to the Doctor 
to talk about that. Could you comment on the possible sticks?
    Mr. Burke. Are--Doctor--
    Mr. Takano. Either you or the Doctor.
    Dr. Zenooz. I will just to make a comment quickly that, you 
know, I think the big thing on our end is user adoption, it is 
measuring to ensure that our users are actually using it and 
embracing the new technology to improve their work. And we have 
several ways to monitor that through things that we are 
purchasing in Cerner, several tools and dashboards. And we will 
continue to do that if we feel that it is inadequate training, 
or we need better training--
    Mr. Takano. What I am getting at is that the Community Care 
providers, that obviously we have provider agreements that we 
have with them and that we could through those provider 
agreements leverage the interoperability and the standards that 
they must adopt in order to meet VA's. I don't think it is fair 
we compare VA care to Community Care without comparing apples 
to apples and having equivalent transparency, is what I am 
getting at.
    Dr. Burke, do you want to--or Mr. Burke?
    Mr. Burke. The reimbursement piece from the VA and the 
Community Care is the important, what I refer to as stick. It 
is basically the VA can compel those organizations to at least 
meet some of the data standards and the transaction elements, 
and that is what we are looking for on some of the business 
side from a provider perspective.
    So, technically speaking, I feel confident that actually 
the industry is moving towards the right pieces around 
interoperability. It will be about how we get the rest of the 
ecosystem of health care to participate. And so what I am 
referring to specifically is some of the reimbursement elements 
of the VA as they engage with those Community Care providers.
    Mr. Takano. Well, thank you.
    I yield back, Mr. Chairman. Sorry for going over.
    The Chairman. Okay, I appreciate the gentleman for 
yielding. And I will now yield to you if you have any closing 
comments.
    Mr. Takano. Mr. Chairman, let me just say that I agree with 
you, I feel a sense of trepidation about the amount of money 
that we are about to expend on this project. I also certainly 
hope, along with the GAO, that the ongoing costs after full 
implementation is going to be far less than the billion 
dollars, we are spending to maintain VistA. And there are 
plenty of people out there watching from the IT world who 
regularly see the Government being hoodwinked by--well, people 
seeking an advantage, taking advantage of the Government's 
lesser ability to kind of judge these systems. This is one of 
the reasons why I have asked the Congress to actually re-fund, 
to fund again the Office of Technology Assessment, so that we 
are in a better position to be able to interact with technology 
issues.
    But I also see with the VA being the largest health care 
provider in the country and our potential ability to interact 
with many, many private sector entities in health care, that we 
have a real chance to push issues like who owns medical data 
and to truly put that data in a portable position for the 
patient, and to really shine a light on the proprietary 
practices of health care systems.
    The VA is publicly owned and is therefore in many ways far 
more publicly accountable, and I think we have an opportunity 
to extend that accountability into the private sector. And, you 
know, that is my hope in this opportunity and that is why I 
want to make sure we get this right, because we have not only 
the ability to affect the health care of veterans, but 
potentially all Americans through what we are trying to do 
here.
    So I yield back.
    The Chairman. I thank the gentleman for yielding.
    Sorry, General Bergman, I missed you over there. You are 
recognized.
    Mr. Bergman. Well, as a Marine, I spent a lot of time 
camouflage, so there is nothing wrong with that, nothing wrong 
with that.
    Doctor, I would like to just follow up with you just one 
more time to dig a little deeper into the planning activities 
and the implementation. Do you have any triggers in place that 
is going to give you a sensing if the schedules are all of a 
sudden not matching or things are out of whack?
    Mr. Windom. Sir, within the next 60 days from Cerner we 
have a multitude of deliverables, including an integrated 
master scheduling, an implementation plan, a change-management 
plan. We are reviewing those documents in earnest, so we are 
going to make sure we apply the appropriate rigor.
    Mr. Bergman. Let me ask you the question--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--a different way. You have got all 
the documents, you have got everything, is there anything in 
place to--when a red--call it a dashboard, all of a sudden it 
goes from green to red--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--you know, is there anything in 
place, that is all your documents, the interplay between all 
the things you are doing--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--to all of a sudden raise a flag?
    Mr. Windom. Yes, sir. The risk management plan that we 
manage captures a multitude of risks that we think exist 
throughout the program. Red flags, yellow flags, green flags 
are all being monitored to assess whether we have a problem. We 
want to be preemptive and proactive. We have got a team of 
experts, both technical and clinical, to support that. And so 
we will be ready to respond, sir.
    Our success revolves around program management oversight 
and picking the right partner; we think we have both and so we 
are ready to execute.
    Mr. Bergman. In terms of--I have got 23 seconds--in terms 
of an airline flight from takeoff to cruise to touchdown, where 
are you?
    Mr. Windom. I would say on the runway, sir.
    Mr. Bergman. Okay.
    Mr. Windom. On the runway, yes, sir.
    Mr. Bergman. Very good. I yield back.
    The Chairman. That is a very good question.
    You know, at the end of the day, I am going to simplify 
this. This is obviously a highly technical thing we are doing. 
At the end of the day, all the patient wants to know is why did 
I come in and how am I doing. I mean, that is really why you 
came--any of us that go to the doctor, that is what you want to 
know, am I all right, did you find out what I need to know. And 
does this new tool we have allow us providers to easily access 
that information, give that simple answer to the question to 
you. That is a simplified why somebody goes to the doctor, why 
are you here today. At the end of the day, can we figure out 
what is wrong with you in simple terms, tell you what is wrong, 
and how we are going to help you fix that.
    And we are going to continue. As I was sitting down 
thinking about how enormous this project was, I know the little 
rollout we did in our practice was not the easiest thing we 
ever did, and this is an enormous rollout and it is going to 
take a team effort from everybody. And we are on the team with 
you. We are not here to fuss at you, we are here to try to make 
you successful, because ultimately it is about the quality of 
care, we provide our veterans and our patients, and that is 
what it is all about.
    And so we are going to have many of these and I thought 
standing up a separate, very small Committee, probably we will 
have five Members on that Committee, that is all, and that is 
their only focus is to keep an eye on this and keep us on 
track, and find out where we get off track and how we can get 
back on.
    I am going to head back out to the Northwest at some time 
in the fairly near future and get a look and see how it is 
looking, so that I can be up to speed in October when VA kicks 
this off.
    I really appreciate all of you being here today. I know you 
saw how many of our Committee Members engaged in this long 
hearing.
    If there are no further questions, I ask unanimous consent 
that all Members have 5 legislative days in which to revise and 
extend their remarks, and include extraneous material.
    Without objection, so ordered.
    The hearing is adjourned.

    [Whereupon, at 12:49 p.m., the Committee was adjourned.]


                           A P P E N D I X

                              ----------                              

                  Prepared Statement of Peter O'Rourke
    Chairman Roe, Ranking Member Walz, distinguished Members of the 
Committee; thank you for the opportunity to testify today in support of 
the Department of Veterans Affairs (VA) initiative to modernize its 
electronic health record (EHR) through the acquisition of the EHR 
solution. Let me also thank the Committee, and other members of 
Congress, for your prior and on-going support of this program. Without 
that support, VA would not have been able to move forward with the 
acquisition in support of our Veterans. I am accompanied today by Mr. 
John Windom, the Program Executive Officer, Dr. Ashwini Zenooz, the 
Chief Medical Officer, and Mr. John Short, the Chief Technology Officer 
all from the Electronic Health Record Modernization (EHRM).
    On May 17, 2018, the Department of Veterans Affairs (VA) awarded an 
Indefinite Delivery/Indefinite Quantity (ID/IQ) contract for an 
electronic health record system to Cerner Corporation. Given the 
complexity of this environment VA has awarded this ID/IQ to provide 
maximum flexibility and necessary structure to control cost. The 
solution allows patient data from VA and the Department of Defense 
(DoD) to reside in a single hosting site utilizing a single common 
system to enable the sharing of health information, improve care 
delivery and coordination, and provide clinicians with data and tools 
that support patient safety. VA believes that implementing a single EHR 
platform will allow for seamless care for our Nation's Servicemembers 
and Veterans.
    VA is making progress towards these positive outcomes for Veterans 
by issuing the first three Task Orders (TO) on this contract. The 
awarding of these firm fixed price TOs allow VA to manage workflows and 
modify deployment strategies more efficiently. VA would like to provide 
additional details regarding the first three task orders:

      Task Order 1- EHRM Project Management, Planning Strategy, 
and Pre-Initial Operational Capabilities (IOC)
    Under this task order, the contractor will provide project 
management, planning, strategy, and pre-IOC build support. More 
specifically, the scope of services included in this task order are 
project management; enterprise management; functional management; 
technical management; enterprise design and build activities; and pre-
IOC infrastructure build and testing.

      Task Order 2- EHRM Site Assessments - Veterans Integrated 
Service Network (VISN) 20
    Under this task order, the contractor will conduct facility 
assessments to prepare for the commercial EHR implementation for the 
following VISN 20 IOC sites: Mann-Grandstaff VA Medical Center (VAMC), 
Seattle VAMC, and American Lake VAMC. The contractor will also provide 
VA with a comprehensive current-state assessment to inform site-
specific implementation activities and task order-specific pricing 
adjustments.

      Task Order 3- EHRM Hosting
    Under this task order, VA will fund the contractor to deliver a 
comprehensive EHRM hosting solution and start associated services to 
include hosting for EHRM applications, application services, and 
supporting EHRM data.

Implementation Strategy

    The EHRM effort is anticipated to take several years to complete 
and continue to be an evolving process as technology advances are made. 
The new EHR will be designed to accommodate aspects of healthcare 
delivery that are unique to VA, while bringing industry best practices 
to improve VA care for Veterans and their families. Most medical 
centers should not expect immediate, major changes to their EHR 
systems.
    Over the course of the next three months, VA will be full steam 
ahead with activities to support the EHR implementation. VA and the 
contractor are conducting ongoing discussions regarding several 
critical activities including optimizing the deployment strategy, 
establishing governance boards, and conducting current state reviews. 
Knowing the potential challenges with large-scale Information 
Technology (IT) projects, VA's approach involves deploying the EHR 
solution at targeted IOC sites to identify challenges and correct them 
before deploying to additional sites. The contractor will begin 
conducting site assessments for the IOC sites beginning in July 2018 
and concluding in September 2018. These site assessments include a 
current state technical and clinical operations review and the 
validation of the facility capabilities list. VA anticipates the system 
implementation for the IOC sites to begin October 1, 2018, with an 
estimated completion date set in March 2020. With this IOC site 
approach, we will be able to hone governance, identify efficient 
strategies, and reduce risk to the portfolio by solidifying workflows 
and detecting course correction opportunities prior to deployment.

Change Management Strategy

    An impactful change management strategy involves working with users 
earlier in the implementation process to determine their needs and 
quickly alleviate their concerns. VA understands that a significant 
factor involved in this transformation is the human component. In the 
end, implementation is not primarily a technical challenge, but a 
cultural challenge. VA leaders are essential to success. We have also 
solicited advice from leaders of large, renowned private sector 
healthcare systems, regarding challenges and solutions. VA is working 
to engage end-users early in the process to train facility staff, 
ensuring successful user adoption. Furthermore, EHRM is establishing 
clinical councils that include nurses, doctors, and other EHR users 
from the field to support configuration of workflows. Through these 
councils, staff can elevate their workflow concerns and propose 
solutions. In addition, VISNs will also be given the opportunity to 
configure their workflows without customizing, based on any unique 
circumstances for that VISN. Councils will be working to document 
existing workflows and ensure that the work already being done will be 
supported by the EHRM solution. Certain changes in clinical workflows 
will require council decisions and may need to be adjudicated through 
interagency governance with DoD. This provides VA a structured approach 
to work through joint cost, schedule, performance, and interoperability 
objectives with DoD counterparts.
    During the multi-year transition effort, VA will continue to use 
Veterans Information System and Technology Architecture (VistA) and 
related clinical systems until all legacy VA EHR modules are replaced 
by the EHR solution. For the purposes of ensuring uninterrupted 
healthcare delivery, existing systems will run concurrently with the 
deployment of the new EHR platform while we transition each facility. 
The entire roll-out will occur over a period of years. During the 
transition, VA will work tirelessly to ensure a seamless transition of 
care. A continued investment focused patient safety, security, and 
interoperability in legacy VA EHR systems will ensure a working 
functional system for all VA health care professionals.

Governance Structure

    The EHRM PEO interim governance structure consists of five Boards 
that will meet myriad of challenges the program will undoubtedly 
encounter. VA has a foundational challenge to replace 130 instances of 
VistA across the enterprise and to establish a single common solution 
with DoD to promote interoperability and seamless care. To mitigate 
these risks to the EHRM program, VA will govern through the involvement 
of these five Boards: (1) EHRM Steering Committee; (2) EHRM Governance 
Integration Board; (3) Functional Governance Board; (4) Technical 
Governance Board (5) Legacy EHRM Pivot Work Group. Moving forward, 
these Functional, Technical and Programmatic governance boards will 
implement a structure and process, which facilitates efficient and 
effective decision making and the adjudication of risks for rapid 
implementation of recommended changes.
    To ensure interagency coordination, there is an emphasis on 
transparency through integrated governance both within and across VA 
and from a decision-making perspective. VA and DoD have instituted an 
interagency working group to review use cases and collaborate on best 
practices for business, functional, and IT workflows, with an emphasis 
on ensuring interoperability objectives between the two agencies. VA 
and DoD's leaders will meet regularly to verify the working group's 
strategy, and course corrections as necessary.

Efficiencies and Lessons-Learned

    Understanding the significant challenges related to DoD's EHR 
implementation, VA is proactively working to address these areas to 
further reduce potential risks at VA's IOC sites. Both Departments are 
working closely together to ensure lessons learned at DoD sites will 
enhance future deployments at DoD as well as VA.

Program Management Office (PMO) Oversight

    A major key to successful EHR implementation will be PMO oversight. 
The PMO will be properly staffed with the requisite functional, 
technical, advisory, and other subject matter experts. Its primary 
responsibilities will be enforcing adherence to cost, schedule, and 
performance-quality objectives. In addition, the PMO will ensure that 
the appropriate risk mitigation strategies are implemented, promoting 
proactive and preemptive contract management approach.

Closing

    This initiative will honor our Nation's commitment to Veterans by 
better enabling VA to provide the high-quality care and benefits our 
Veterans have earned. It will support Department efforts to modernize 
the VA health care system and ensure that VA is a source of pride for 
Veterans, beneficiaries, employees, and taxpayers. Mr. Chairman and 
Members of the Committee, this concludes my statement. Thank you for 
the opportunity to testify before the Committee today to discuss the 
EHRM efforts. I would be happy to respond to any questions you may 
have.

                                --------
          Prepared Statement of Vice Admiral Raquel Bono, M.D.
REGARDING

ELECTRONIC HEALTH RECORD MANAGEMENT

    Chairman Roe, Ranking Member Walz and distinguished Members of the 
Committee, thank you for the opportunity to testify before you today. I 
am honored to represent the Department of Defense (DoD) and discuss the 
Department's experience in implementing a modernized electronic health 
record (EHR). I also want to highlight the tremendous opportunity to 
comprehensively advance interoperability with the VA and private sector 
providers as a result of the VA's recent decision to acquire the same 
commercial EHR that the DoD is now deploying.
    The decision by DoD to acquire a commercial EHR was informed by 
numerous advantages offered by this pathway: introducing a proven 
product that can be used globally in deployed environments and in 
military hospitals and clinics in the US; leveraging ongoing commercial 
innovation throughout the EHR life cycle; improving interoperability 
with private sector providers; and offering an opportunity to transform 
the delivery of healthcare for servicemembers, veterans, and their 
families.
    Our mission aligns with Secretary Mattis' National Defense Strategy 
(NDS) to modernize the Department of Defense and provide combat-ready 
military forces. The threats facing our Nation continuously evolve and 
a medically ready military force is critical to our national defense. 
MHS GENESIS, our new EHR, supports that mission.
    Similar to the VA, the DoD was an early pioneer in the development 
of a provider-centric electronic health record. Over time, demands by 
the private sector health institutions, as well as Federal investments, 
led to major advances in civilian health care technology. As result, in 
2013 the DoD made the decision to transition from multiple home-grown 
government-developed EHRs to a single, integrated commercial-off-the-
shelf (COTS) capability.
    The Department recognized that MHS requirements could be better met 
by state-of-the-market commercial applications. Furthermore, the DoD 
could leverage private sector investments in technology and established 
data sharing networks with civilian partners to enhance healthcare, 
reduce costs and improve the customer experience. Staying current with 
the latest advancements in technology without being the only investment 
stream enables the DoD to benefit from some of the best products in 
health IT without carrying the financial burden alone.
    In July 2015, the DoD awarded a $4.3 billion contract to Leidos 
Inc. to deliver a modern, secure, and connected EHR. The Leidos 
Partnership for Defense Health (LPDH) team consists of four core 
partners, Leidos Inc., as the prime integrator, and three primary 
partners in Cerner Corporation, Accenture, and Henry Schein Inc. MHS 
GENESIS provides a state of the market COTS solution consisting of 
Cerner Millennium, an industry-leading EHR, and Henry Schein's Dentrix 
Enterprise, a best of breed dental EHR module.
    In 2017, the Department reached an important milestone by deploying 
to all four Initial Operational Capability (IOC) sites in the Pacific 
Northwest, culminating with deployment to Madigan Army Medical Center 
(MAMC), the largest of the IOC sites, in Tacoma, Washington. The other 
sites include the 92nd Medical Group at Fairchild Air Force Base; Naval 
Health Clinic Oak Harbor; and Naval Hospital Bremerton - all in 
Washington State.

DEPLOYMENT, STABILIZATION AND OPTIMIZATION

    To streamline and improve healthcare delivery, MHS GENESIS will 
integrate inpatient and outpatient best-of-suite solutions that connect 
medical and dental information across the continuum of care, from point 
of injury to the military treatment facility, providing a single 
patient health record. This includes garrison, operational, and en 
route care, increasing the quality of care for our patients and 
simplifying medical record management for beneficiaries and healthcare 
professionals. Over time, MHS GENESIS will replace DoD legacy 
healthcare systems and will support the availability of electronic 
health records for more than 9.4 million DoD beneficiaries and 
approximately 205,000 MHS personnel globally.
    The deployment and implementation of MHS GENESIS across the MHS is 
a team effort. Complex business transformation requires constant 
coordination and communication with stakeholders and partners, 
including the medical and technical communities, to ensure 
functionality, usability, and data security. DoD engaged stakeholders 
across the MHS to identify requirements and standard workflows. The 
result was a collaborative effort across the Services and the DHA to 
ensure the clinical workflows enabled by MHS GENESIS are standardized 
and consistent across the enterprise to minimize variation in the 
delivery of healthcare.
    Representatives from functional communities also collaborated to 
identify critical data to transfer from legacy systems into MHS 
GENESIS: Problems, Allergies, Medications, Procedures, and 
Immunizations (PAMPI). Other data, including lab results, radiology 
results, discrete notes, discharge summaries, etc., are still available 
through the Joint Legacy Viewer (JLV) as we sunset legacy systems.
    Through a tailored acquisition approach, DoD leveraged commercial 
best practices and its own independent test community to field a 
modern, secure, and connected system that provides the best possible 
solution from day one. One example of leveraging commercial best 
practices was opting to utilize commercial data hosting, which allowed 
DoD to combine private sector speed and technology with the 
Department's superior data security knowledge and provide advanced 
analytics for our end users and beneficiaries. While there is still 
much work to be done, the integration of the commercial data hosting 
into DoD networks and systems represents a new direction in Pentagon 
information technology (IT) culture and practice. This innovative 
approach set the bar for COTS systems and commercial partnerships by 
the DoD and other Federal agencies in the future.
    Additionally, we are employing industry standards to optimize the 
delivery of MHS GENESIS. Rollout across the MHS follows a ``wave'' 
model. Initial fielding sites in the Pacific Northwest were the first 
wave of military treatment facilities (MTFs) to receive MHS GENESIS. By 
deploying to four IOC sites that span a cross-section of size and 
complexity of MTFs, we are able to perform operational testing 
activities to ensure MHS GENESIS meets all requirements for 
effectiveness, suitability, and data interoperability to support a 
decision to continue MHS GENESIS deployments in the coming year. 
Deployment will occur by region-three in the continental U.S. and two 
overseas-in a series of concurrent wave deployments over the next four 
years. Each wave will include an average of three hospitals and 15 
physical locations and will last approximately one year. Regionally 
grouped waves, such as the Pacific Northwest, will run concurrently. 
This approach allows DoD to take full advantage of lessons learned and 
experience gained from prior waves to maximize efficiencies in 
subsequent waves, increasing the potential to reduce the deployment 
schedule in areas where necessary. We are sharing our planned 
deployments with our colleagues at the VA, and plan to synchronize 
deployments where possible.
    As with any large-scale IT transformation, there are training, user 
adoption, and change management opportunities. The configuration of MHS 
GENESIS deployed for IOC provided a minimally suitable starting point 
to assess the system as well as the infrastructure prior to full 
deployment. Now that DoD has the results from operating MHS GENESIS in 
a representative cross-section of military hospitals and clinics, DoD 
is making adjustments to software, training, and workflows.
    We are working with our industry partner, LPDH, to engage 
representatives from the sites, the functional communities, the 
technical community, and the test community with the goal to validate 
the MHS GENESIS baseline software configuration based on IOC lessons 
learned. For an eight-week period starting in mid-January, we sent 
representatives from DoD and contract partner offices to collaborate 
with initial fielding site users with a focus on MHS GENESIS 
configuration as well as training, adoption of workflows, and change 
management activities. Specific areas of refinement included: roles, 
clinical content, trouble ticket resolution, and workflow adoption. 
Following this period, we collected feedback, evaluated, and provided 
enhancements to the system. These activities were always part of our 
IOC process, and we are experiencing measurable improvements. End user 
feedback is positive. Our approach has and always will be functionally 
led and frontline informed.

    MEASURING USER ADOPTION OF MHS GENESIS

    Recognizing the sizeable investment in an EHR for its 9.4 million 
beneficiaries and more than 200,000 providers, the DoD required a 
standardized way to independently measure the progress and 
effectiveness of MHS GENESIS adoption. To that end, the DoD engaged the 
Healthcare Information and Management Systems Society (HIMSS) Analytics 
to assess adoption and conduct IOC usability assessments for MHS 
GENESIS. HIMSS Analytics provided adoption scoring and benchmarking gap 
analysis assessments on IOC sites to rate the top usability principles 
including the Electronic Medical Record Adoption Model (EMRAM) and the 
Outpatient-Electronic Medical Record Adoption Model (O-EMRAM).
    The HIMSS Analytics EMRAM is widely recognized as the industry 
standard for measuring EHR adoption and rated from Stage 0 to Stage 7. 
Prior to MHS GENESIS deployment, the average score for the IOC sites 
was below a Stage 2 EMRAM and slightly above Stage 2 O-EMRAM. Post 
deployment, the sites scored at or above a Stage 5 on the EMRAM and O-
EMRAM, with Fairchild Air Force Base achieving an O-EMRAM Stage 6. 
These scores are well above the national averages of Stage 2 and Stage 
3 respectively. It is important to note, Stage 6 obtained by Fairchild 
is an indicator that an organization is effectively leveraging the 
functionality of its EHR. Stage 6 is an accomplishment only 20 percent 
of ambulatory healthcare organizations have attained. To achieve this 
level, the facility was required to demonstrate a number of technology 
functionalities that contribute to patient safety and care efficiency, 
including establishing a digital medication reconciliation process, a 
problem list for physicians, and the ability to send patient 
preventative care reminders.
    We recognize that our success is dependent on strong clinical 
leadership both here in our headquarters, and by clinical champions at 
the point of care. The Department is focused on maintaining this 
clinical leadership as we move to the next deployment wave.

DEPARTMENT OF DEFENSE AND OTHER AGENCY COLLABORATION

    In June 2017, the VA announced its decision to adopt the same EHR 
as DoD, and last month, they executed a ten-year contract with Cerner 
Corporation. This decision and subsequent action is the next step 
toward advancing EHR adoption across the Nation and is in the best 
interest of our veterans. As then Acting VA Secretary Wilkie said at 
the contract announcement, the contract will ``modernize the VA's 
health care IT system and help provide seamless care to veterans as 
they transition from military service to veteran status and when they 
choose to use community care.''
    The VA's adoption of the DoD's EHR will fundamentally solve the 
problem of transitioning patient health record data between the 
Departments by eliminating the need for moving data altogether. The VA 
and DoD are committed to partnering in this effort and understand that 
the mutual success of this venture is dependent on the close 
coordination and communication between the two Departments which 
continues to be supported by the DoD/VA Interagency Program Office.
    During Fiscal Year 2018, the DoD and VA collaborated to provide 
updates on the Departments' modernization efforts, technical 
challenges, and joint capabilities. The DoD also supported joint 
collaboration meetings between DoD and VA Chief Information Officers 
(CIO) and other senior leadership to facilitate other future activities 
relating to a single integrated EHR. As a result of these meetings, 
leadership established a DoD-VA CIO Executive Steering Committee as 
well as working groups focused on identity management, joint 
architecture, and cybersecurity. Since the award of the VA contract, 
leaders from both Departments have been meeting to more formally 
integrate our management and oversight activities.
    Our Federal partnering extends beyond the VA. In April 2018, the 
DoD announced a partnership with the United States Coast Guard for MHS 
GENESIS. The Coast Guard will adopt and deploy MHS GENESIS to its 
clinics and sick bays. Approximately 6,000 Active duty Coast Guard 
members receive care in DoD hospitals and clinics. A complete and 
accurate health record in a single common system is critical to 
providing high-quality, integrated care and benefits, and to improving 
patient safety. MHS GENESIS will supply Coast Guard providers with the 
necessary data to collaborate and deliver the best possible healthcare.

ADVANCING INTEROPERABILITY AND DATA SHARING

    As the DoD transitions to MHS GENESIS, our commitment to expand 
interoperability efforts with the VA and private sector providers 
remains unchanged. Service members and their families frequently move 
to new duty assignments, they deploy overseas, and eventually, 
transition out of the military. As a result, there are many different 
places where they may receive medical care.
    More than 60 percent of Active duty and beneficiary healthcare is 
provided outside an MTF, through TRICARE network and non-network 
providers. Healthcare providers need up-to-date and comprehensive 
healthcare information to facilitate informed decision making whenever 
and wherever it is needed-from a stateside MTF to an outpost in 
Afghanistan, from a private care clinic within the TRICARE network to a 
VA hospital, and everywhere in between.
    The DoD and VA are two of the world's largest healthcare providers 
and today, they share more health data than any other two major health 
systems. The two Departments currently share health records through the 
Defense Medical Information Exchange (DMIX) program, which includes the 
Joint Legacy Viewer (JLV), a health information portal that aggregates 
data from across multiple data sources, to include MHS GENESIS, to 
provide read access to medical information across multiple government 
and commercial data sources.
    In addition to enabling enhanced data sharing between DoD and VA, 
JLV allows DoD to expand relationships with private-sector providers to 
give clinicians a comprehensive, single view of a patient's health 
history in real-time as they receive care in both military and 
commercial systems. JLV is available to DoD providers in AHLTA and is 
now incorporated into MHS GENESIS.
    Over the past five years, DoD steadily increased its data-sharing 
partnerships with private sector healthcare organizations. In March 
2017, there were over 20 Health Information Exchanges (HIE) that 
partnered with DoD. Today, the number has more than doubled as the DoD 
has nearly 50 HIE partners. DoD leverages its partnership with the 
Sequoia Project, a network of exchange partners who securely share 
clinical information across the United States. We are also targeting 
CommonWell-an independent, not-for-profit trade association with 
connections to more than 5,000 private sector healthcare sites as a 
partner. Leveraging this connection through MHS GENESIS will expand the 
great work DoD accomplished through HIEs. As DoD and VA continue to 
improve data sharing between the Departments and with the private 
sector, deployment of MHS GENESIS will enable more advanced data 
sharing capabilities through the existing architecture.

CONCLUSION

    Thank you again for the opportunity to come here today and share 
the progress we've made to transform the delivery of healthcare for 
servicemembers, veterans, and their families, as well as discuss the 
opportunity to strengthen the DoD-VA partnership as we move forward 
together with a common EHR that will benefit millions of servicemembers 
and veterans. As a partner in our progress, we appreciate the 
Congress's interest in this effort and ask for your continued support 
to help us deliver on our promise to provide world-class care and 
services to those who faithfully serve our Nation. Again, thank you for 
this opportunity, and I look forward to your questions.

                                 --------
                 Prepared Statement of David A. Powner
VA IT MODERNIZATION

Preparations for Transitioning to a New Electronic Health Record System 
    Are Ongoing

    This is a work of the U.S. government and is not subject to 
copyright protection in the United States. The published product may be 
reproduced and distributed in its entirety without further permission 
from GAO. However, because this work may contain copyrighted images or 
other material, permission from the copyright holder may be necessary 
if you wish to reproduce this material separately.

    Chairman Roe, Ranking Member Walz, and Members of the Committee:

    Thank you for the opportunity to participate in today's hearing on 
the planned implementation of the Department of Veterans Affairs' (VA) 
Electronic Health Record Modernization (EHRM) program.
    As you know, the use of information technology (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. Over many years, however, VA has experienced challenges in 
managing its IT projects and programs. These challenges have spanned a 
number of critical initiatives related to modernizing major systems 
within the department, including its electronic health information 
system-the Veterans Health Information Systems and Technology 
Architecture (VistA).
    We have issued numerous reports on the challenges that the 
department has faced in managing VistA and working to increase the 
interoperability \1\ of health information. \2\ We also have ongoing 
work for the Committee on Veterans' Affairs to review VistA and the 
department's transitional efforts to replace the system with a new, 
commercial-off-the-shelf (COTS) system that it is acquiring from Cerner 
Government Services, Inc. (Cerner) under the EHRM program.
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    \1\ Interoperability is the ability to exchange and use electronic 
health information.
    \2\ GAO, Veterans Affairs Information Technology: Historical 
Perspective on Health System Modernization Contracts and Update on 
Efforts to Address Key FITARA-Related Areas, GAO-18-267T (Washington, 
D.C.: Dec. 7, 2017); VA Health IT Modernization: Historical Perspective 
on Prior Contracts and Update on Plans for New Initiative, GAO-18-208 
(Washington, D.C.: Jan. 18, 2018); Veterans Affairs: Improved 
Management Processes Are Necessary for IT Systems That Better Support 
Health Care, GAO-17-384 (Washington, D.C.: June 21, 2017); VA 
Information Technology: Pharmacy System Needs Additional Capabilities 
for Viewing, Exchanging, and Using Data to Better Serve Veterans, GAO-
17-179 (Washington, D.C.: June 14, 2017); 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); 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); 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); and 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).
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    At your request, my testimony today summarizes preliminary 
observations from our ongoing review. Specifically, the statement 
discusses our preliminary observations regarding (1) costs incurred for 
the system and related activities during the last 3 fiscal years; (2) 
key components that comprise VistA and are to be replaced; and (3) 
actions VA has taken to prepare for its transition to the Cerner 
system. In addition, the statement discusses critical success factors 
related to major information technology acquisitions. We have 
previously reported that these success factors could enhance the 
likelihood that the new electronic health record system acquisition 
will be successful.
    In developing this testimony, we considered our previously 
published reports that discussed the history of the department's VistA 
modernization efforts. In addition, we relied on our prior report that 
discussed critical success factors of major IT acquisitions. \3\ The 
reports cited throughout this statement include detailed information on 
the scope and methodology for our prior reviews.
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    \3\ GAO, Information Technology: Critical Factors Underlying 
Successful Major Acquisitions, GAO-12-7 (Washington, D.C.: Oct. 21, 
2011).
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    Further, we considered preliminary observations from our ongoing 
review of VistA's costs, components, and the actions VA has taken to 
prepare for transitioning from VistA to the Cerner system. With regard 
to the total costs of VistA, we obtained records of obligations for 
VistA-related programs for fiscal years 2015, 2016, and 2017, as 
tracked by the Veterans Health Administration (VHA) \4\ and VA's Office 
of Information and Technology (OI&T) \5\. We then combined the amount 
of those obligations with the amount of other obligations, such as 
those for supporting interoperability and infrastructure, identified by 
VA as being closely related to the development and operation of VistA. 
We interviewed VA officials to understand the source and relevance of 
the obligations identified by the department and determined that the 
data were reliable for our purposes.
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    \4\ VHA is the major component within VA that provides health care 
services, including primary care and specialized care, and it performs 
research and development to improve veterans' health care services.
    \5\ VA's OI&T oversees the department's IT acquisitions and 
operations. OI&T has responsibility for managing the majority of VA's 
IT-related functions. The office provides strategy and technical 
direction, guidance, and policy related to how IT resources are to be 
acquired and managed for the department. According to VA, OI&T's 
mission is to collaborate with its business partners (such as VHA) and 
provide a seamless, unified veteran experience through the delivery of 
state-of-the-art technology.
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    To identify the key components of VistA and the extent to which 
they support health record capabilities for the department, we analyzed 
VA documentation that describes the scope of the system. This 
documentation included the department's Health Information System 
Diagram, the VA Monograph, \6\ the VA Systems Inventory, and the VistA 
Product Roadmap. We also reviewed program documentation identifying 
components of VistA to be replaced by the Cerner system. We analyzed 
these documents for consistency to provide a reasonable basis for our 
observations.
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    \6\ VA, VA Monograph, (Washington, D.C.: Jan.13, 2017). The VA 
Monograph documents an overview of the VistA and non-VistA applications 
used by VHA.
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    To summarize the actions VA has taken to prepare for its transition 
from VistA to the Cerner system under the EHRM program, we reviewed 
available program briefings, governance documents, and draft plans for 
the EHRM program related to, for example, interoperability, data 
migration, change management, and requirements. We supplemented our 
analysis with information obtained through interviews with relevant VA 
officials.
    The work upon which this statement is based is being or was 
conducted in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audits 
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. In carrying out this mission, the department operates one of 
the largest health care delivery systems in the United States, 
providing health care services to approximately 9 million veterans 
throughout the United States, Philippines, Virgin Islands, Puerto Rico, 
American Samoa, and Guam.
    In 2015, we designated VA health care as a high-risk area for the 
Federal government, and we continue to be concerned about the 
department's ability to ensure that its resources are being used cost-
effectively and efficiently to improve veterans' timely access to 
health care. \7\ In part, we identified limitations in the capacity of 
VA's existing IT systems, including the outdated, inefficient nature of 
certain systems and a lack of system interoperability as contributors 
to the department's challenges related to health care.
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    \7\ GAO maintains a high-risk program to focus attention on 
government operations that it identifies as high risk due to their 
greater vulnerabilities to fraud, waste, abuse, and mismanagement or 
the need for transformation to address economy, efficiency, or 
effectiveness challenges. VA's issues were highlighted in our 2015 
high-risk report, GAO, High-Risk Series: An Update, GAO-15-290 
(Washington, D.C.: Feb. 11, 2015) and 2017 update, GAO, High-Risk 
Series: Progress on Many High-Risk Areas, While Substantial Efforts 
Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017).
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    Providing health care to veterans requires a complex set of 
clinical and administrative capabilities supported by IT. VA's health 
information system-VistA-has been essential to the department's ability 
to deliver health care to veterans. VistA contains an electronic health 
record for each patient that supports clinical settings throughout the 
department. For example, clinicians can use the system to enter and 
review patient information; order lab tests, medications, diets, 
radiology tests, and procedures; record a patient's allergies or 
adverse reactions to medications; request and track consults; enter 
progress notes, diagnoses, and treatments for encounters; and enter 
discharge summaries.
    VistA was developed in house by clinicians and IT personnel in 
various VA medical facilities and has been in operation since the early 
1980s. \8\ Over the last several decades, VistA has evolved into a 
technically complex system comprised of about 170 modules that support 
health care delivery at 152 VA Medical Centers and over 1,200 
outpatient sites. In addition, customization of VistA, such as changes 
to the modules by the various medical facilities, has resulted in about 
130 versions of the system-referred to as instances.
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    \8\ 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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    According to VA, VistA modules are comprised of one or more 
software applications that support various health care functions, such 
as providing care coordination and mental health services. In addition 
to VistA, the department has other health information systems that must 
interface with VistA to send, exchange, or store related health (e.g., 
clinical and patient) data. \9\
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    \9\ Interfaces enable VistA to communicate with applications within 
other VA systems, as well as selected systems or other Federal agencies 
(e.g., DoD health information systems used to treat injured 
servicemembers), health information exchange networks, and other COTS 
products. There are various mechanisms used to facilitate these 
exchanges to allow the extraction of health information to and from 
these external products. These interfaces utilize, for example, remote 
procedure calls, Health Level 7, and in a few cases secure file 
transfer protocol for queries and other transactions with VistA.
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    Since 2001, VA has identified the need for enhancements and 
modifications to VistA and has pursued multiple efforts to modernize 
the system. Two major efforts have included the VistA Evolution program 
and, most recently, the planned acquisition of the same electronic 
health record system that the Department of Defense (DoD) is acquiring.
    In 2013, VA established VistA Evolution as a joint program between 
OI&T and VHA that was comprised of a collection of projects and efforts 
focused on improving the efficiency and quality of veterans' health 
care. This program was to modernize the department's health information 
systems, increase VA's data exchange and interoperability capabilities 
with DoD and private sector health care partners, and reduce VA's time 
to deploy new health information management capabilities. \10\
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    \10\ VA's former Executive in Charge for Information and Technology 
testified in December 2017 that the cost to upgrade and maintain VistA 
to industry standards would be approximately $19 billion over 10 years, 
and this still would not provide all the needed enhancements, upgrades, 
and interoperability with DoD.
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    In June 2017, the former VA Secretary announced a significant shift 
in the department's approach to modernizing VistA. Specifically, rather 
than continue to use VistA, the Secretary stated that the department 
planned to acquire the same Cerner electronic health record system that 
DoD has been acquiring. \11\
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    \11\ In July 2015, DoD awarded a $4.3 billion contract for a 
commercial electronic health record system developed by Cerner, to be 
known as MHS GENESIS. The transition to the new system began in 
February 2017 in the Pacific Northwest region of the United States and 
is expected to be completed in 2022. The former Secretary of Veterans 
Affairs signed a ``Determination and Findings,'' to justify use of the 
public interest exception to the requirement for full and open 
competition, and authorized VA to issue a solicitation directly to 
Cerner. A ``Determination and Findings'' means a special form of 
written approval by an authorized official that is required by statute 
or regulation as a prerequisite to taking certain contract actions. The 
``determination'' is a conclusion or decision supported by the 
``findings.'' The findings are statements of fact or rationale 
essential to support the determination and must cover each requirement 
of the statute or regulation. FAR, 48 C.F.R. Sec.  1.701.
---------------------------------------------------------------------------
    Accordingly, the department awarded a contract to Cerner in May 
2018 for a maximum of $10 billion over 10 years. Cerner is to replace 
VistA with a commercial electronic health record system. This new 
system is to support a broad range of health care functions that 
include, for example, acute care, clinical decision support, dental 
care, and emergency medicine. When implemented, the new system will be 
expected to provide access to authoritative clinical data sources and 
become the authoritative source of clinical data to support improved 
health, patient safety, and quality of care provided by VA.
    As previously mentioned, this acquisition is being managed by VA's 
EHRM program. According to program documentation, EHRM is also to 
deliver program management support and the infrastructure modernization 
required to install and operate the new system.
    According to EHRM program documentation, the department has 
estimated that an additional $5.8 billion in funding, above the 
contract amount, would be needed to fund project management support and 
infrastructure improvements over the 10-year period. This amount does 
not fully include government employee costs.
    Deployment of the new electronic health record system at the 
initial sites is planned for within 18 months of October 1, 2018, \12\ 
with a phased implementation of the remaining sites over the next 
decade. Each VA medical facility is expected to continue using VistA 
until the new system has been deployed at that location.
---------------------------------------------------------------------------
    \12\ The three initial deployment sites are the Mann-Grandstaff, 
American Lake, and Seattle VA Medical Centers.

VA Has Reported Obligating about $3.0 Billion to VistA and Related 
---------------------------------------------------------------------------
    Activities from Fiscal Years 2015 through 2017

    According to VA, the department's costs for VistA and related 
activities are approximated by funding obligations of about $1.1 
billion, $899 million, and $946 million in fiscal years 2015, 2016 and 
2017, respectively, for a total of about $3.0 billion over 3 years to 
support the system. Specifically, VHA and OI&T reported obligations to 
cover the costs for the VistA Evolution program, including costs for 
development, operation and maintenance, and payroll for government 
employees over the 3 fiscal years.
    Further, in their efforts to fully determine the costs associated 
with VistA, VA officials also reported obligations for activities that 
supported VistA, but were not included in the VistA Evolution program. 
These other obligations were for investments in interoperability 
initiatives, such as increasing data standardization and data sharing 
between VA, DoD, and other government and non-government entities, and 
the Virtual Lifetime Electronic Record Health. \13\ These obligations 
also include other VistA-related technology investments, such as 
networks and infrastructure sustainment, continuation of legacy 
systems, and overall patient safety, security, and system reliability.
---------------------------------------------------------------------------
    \13\ Virtual Lifetime Electronic Record Health is a program 
initially started in 2009 to streamline the transition of electronic 
medical, benefits, and administrative information between VA and DoD. 
It is now referred to as the Veterans Health Information Exchange.
[GRAPHIC] [TIFF OMITTED] T5806.002


VA Is Working to Define VistA's Scope and Identify Components to Be 
---------------------------------------------------------------------------
    Replaced by the Cerner System

    Understanding the scope of VA's current health information system 
is essential to effectively planning for the new system. However, 
according to VA officials, there is no single information source that 
fully defines the scope of VistA. Instead, existing definitions of the 
system, including the components that comprise it, are identified by 
multiple sources. These sources include the VA Systems Inventory, VistA 
Document Library, and VA Monograph.
    Each of these sources describes VistA from a different perspective. 
For example, the VA Monograph provides an overview of VistA and non-
VistA applications used by VHA. The monograph also describes modules 
and their associated business functions, but does not document all 
customization at local facilities. The VA Systems Inventory is a 
database that identifies current IT systems at VA, including systems 
and interfaces that are related to VistA. The VA Document Library is an 
online resource for accessing documentation on VA's nationally released 
software applications, including VistA.
    In the absence of a complete definition of VistA, EHRM program 
officials have taken a number of steps to define the system's scope and 
identify the components that the Cerner system will replace. These 
steps have included conducting two analyses, performing preliminary 
site assessments, and planning for Cerner to perform a detailed 
assessment of each site where the new system will be deployed.
    Specifically, EHRM program subject-matter experts undertook an 
analysis that identified 143 VistA modules and 35 software applications 
as representing the scope of the system. They then compared the 
functionality provided by the VistA modules to the Cerner system's 
capabilities to identify the VistA components that are expected to be 
replaced by the Cerner system. The analysis identified 131 (92 percent) 
of the 143 VistA modules and 32 (91 percent) of the 35 applications 
that are expected to be replaced by the Cerner system. For example, the 
analysis determined that the Care Management and Mental Health modules 
would be replaced by the new system.
    EHRM program officials also undertook a subsequent, broader 
analysis to identify, among other things, the scope of VistA, as well 
as the department's other health IT systems that could also be replaced 
by the Cerner system. These other systems include, for example, 
dentistry and oncology applications. As part of this analysis, the 
department combined data from the VA Systems Inventory, the VistA 
Document Library, the VA Monograph, and other sources to identify the 
health information technology environment at a typical VA medical 
center.
    The resulting analysis of VA's health IT environment identified a 
total of 330 applications that support health care delivery at a 
medical center, of which 119 applications (approximately 36 percent) 
have been identified as having similar functionality as a capability of 
the Cerner system. Further, 128 of the 330 applications are identified 
as VistA applications. Of the 128 applications designated as VistA, 58 
(approximately 45 percent) have been identified as having similar 
functionality as a capability of the Cerner system, including pharmacy, 
laboratory, and scheduling capabilities.
    In addition to the analyses discussed above, VA has taken steps to 
understand differences in VistA at individual facilities. Specifically, 
according to EHRM officials, representatives from VA and Cerner have 
visited 17 VA medical facilities to conduct preliminary site 
assessments. The intent of these assessments is to obtain a broad 
perspective of the current state of the systems, applications, 
integration points, reporting, and workflows being utilized at 
individual facilities. These site visits identified VistA customization 
that may be site specific. The identification of such site specific 
customization is intended to help Cerner plan for implementation of its 
system at each location. According to EHRM program officials, full site 
assessments that are planned at each location in preparation for 
implementation of the Cerner system are expected to identify the full 
extent of VistA customization.

VA's Preparations for Transitioning from VistA to the Cerner System Are 
    Ongoing

    Since the former VA Secretary announced in June 2017 that the 
department would acquire the same electronic health record system as 
DoD, VA has taken steps to position the department for the transition 
to the new system. These actions, which are ongoing, have included 
standardizing VistA, assessing the department's approach to increasing 
interoperability, establishing governance for the new program and the 
framework for joint governance with DoD, and preparing initial program 
plans.

Standardizing VistA
    VA's goal is for all instances of VistA being used in its medical 
facilities to be standardized where practical. Such standardization is 
intended to better position the department to switch to the Cerner 
system. To increase standardization, the VistA Evolution program has 
been focused over the last 5 years on standardizing a core set of VistA 
modules related to interoperability which, according to the department, 
accounts for about 60 percent of VistA.
    In addition, the program has focused on identifying software that 
is common to each VistA instance. VA refers to this collection of 
standard software as the gold instance. As part of its effort to 
standardize VistA, VA has implemented a process to compare the system 
at each site with the gold instance. Sites that are identified as 
having variations from the gold instance must apply for a waiver to 
gain approval for continuing to operate a non-standard VistA instance. 
OI&T and VHA assess the waivers, which may be approved if a site needs 
non-standard functionality that is deemed critical to that site. 
Alternatively, waivers are not approved if the assessment determines 
that a site's needs can be met by reverting to the gold instance of 
VistA.

Assessing the Approach to Increasing Interoperability
    VA has identified increased interoperability as a key expected 
outcome of its decision to switch from VistA to the Cerner system. To 
ensure that the contract with Cerner will improve interoperability with 
community care providers (i.e., non-VA and third party providers), the 
former VA Secretary announced in December 2017 that the department had 
taken a ``strategic pause'' on the electronic health record acquisition 
process. During the pause, an independent study was undertaken to 
assess the approach to interoperability with the new acquisition. \14\ 
The assessment made recommendations to improve imported data, address 
data rights and patient safety risks, and improve data access for 
patients. VA agreed with all of the resulting recommendations and, 
according to EHRM program officials, included provisions in the 
contract with the Cerner Corporation to address the recommendations.
---------------------------------------------------------------------------
    \14\ The MITRE Corporation coordinated the assessment and reported 
related recommendations in the VA EHRM Request for Proposal 
Interoperability Review Report on Jan. 31, 2018.

Establishing a Program Office and Governance
    Our prior work has identified strong agency leadership support and 
governance as factors that can increase the likelihood of a program's 
success. \15\ Such leadership and governance can come from the 
establishment of an effective program management organization and a 
related governance structure.
---------------------------------------------------------------------------
    \15\ GAO, Information Technology: Opportunities for Improving 
Acquisitions and Operations, GAO-17-251SP (Washington, D.C.: April 11, 
2017).
---------------------------------------------------------------------------
    VA has taken steps to establish a program management office and 
drafted a structure for technology, functional, and joint governance of 
the electronic health record implementation. Specifically, in January 
2018, the former VA Secretary established the EHRM Program Executive 
Office (PEO) that reports directly to the VA Deputy Secretary. 
According to EHRM program officials, this office supported the contract 
negotiations with the Cerner Corporation and is expected to continue to 
manage the program going forward.
    Program officials stated that the office is beginning the process 
of hiring full-time employees. In addition, to support the program 
office, the department has awarded a contract for project management 
support and has also reassigned a number of VA staff to the PEO.
    Further, VA has drafted a memorandum that describes the role of 
governance bodies within VA, as well as governance intended to 
facilitate coordination between DoD and VA. For example, according to 
the draft memorandum, within VA, the EHRM Steering Committee is 
expected to provide strategic direction for the efforts while 
monitoring progresses toward goals and advising the Secretary on the 
progress and performance of the EHRM efforts. This Committee is to 
include the Deputy Secretary, the Undersecretary for Health, and the 
Chief Information Officer, among others, and is to meet quarterly or as 
necessary to make its reports to the Secretary.
    Additionally, according to EHRM program documentation, VA is in the 
process of establishing a Functional Governance Board, a Technical 
Governance Board, and a Governance Integration Board comprised of 
program officials intended to provide guidance; coordinate with DoD, as 
appropriate; and inform the Steering Committee. Further, a joint 
governance structure between VA and DoD has been proposed that would be 
expected to leverage existing joint governance facilitated by the DoD/
VA Interagency Program Office. \16\
---------------------------------------------------------------------------
    \16\ The National Defense Authorization Act for Fiscal Year 2008 
(Pub. L. No. 110-181, Sec. 1635 (2008)) called for DoD and VA to set up 
an interagency program office. This office is intended to function as 
the single point of accountability for ensuring that electronic health 
records systems or capabilities allow for full interoperability of 
health care-related information between DoD and VA.
---------------------------------------------------------------------------
    Nevertheless, while the department's plans for governance of the 
EHRM program provide a framework for high-level oversight for program 
decisions moving forward, EHRM officials have noted that the governance 
bodies will not be finalized until October 2018.

Preparing Initial Program Plans
    Program planning is an activity for ensuring effective management 
of key aspects of an IT program. These key aspects include 
identification of the program's scope, responsible organizations, 
costs, and schedules.
    VA has prepared initial program plans, including a preliminary 
timeline for deploying the new electronic health record system to its 
medical facilities. The department also has a proposed 90-day schedule 
that depicts key program activities currently underway now that the 
contract has been awarded. For example, the department's preliminary 
plans include an 8-year deployment schedule beginning with planned 
implementation at initial sites within 18 months of October 1, 2018.
    According to the executive director for the EHRM program, the 
department also intends to complete a full suite of planning and 
acquisition management documents to guide the program. These documents 
include, for example, a life cycle cost estimate, a data migration 
plan, a change management plan, and an integrated master schedule to 
establish key milestones over the life of the project. EHRM PEO 
officials have stated that the department intends to complete the 
development of its initial plans for the program within 30 to 90 days 
of awarding the contract (between mid-June and mid-August 2018), and 
intends to update those plans as the program matures. The plans are to 
be reviewed during the milestone reviews identified in the department's 
formal project management framework.

Critical Factors Underlying Successful Major Acquisitions

    Our prior work has determined that successfully overcoming major IT 
acquisition challenges can best be achieved when critical success 
factors are applied. \17\ Specifically, we reported in 2011 on common 
factors critical to the success of IT acquisitions, based on seven 
agencies having each identified the acquisition that best achieved the 
agency's respective cost, schedule, scope, and performance goals. \18\ 
These factors remain relevant today and can serve as a model of best 
practices that VA could apply to enhance the likelihood that the 
acquisition of a new electronic health record system will be 
successfully achieved.
---------------------------------------------------------------------------
    \17\ GAO-12-7.
    \18\ The seven departments and associated successful IT investments 
are the Department of Commerce, Decennial Response Integration System; 
Department of Defense, Global Combat Support System-Joint Increment 7; 
Department of Energy, Manufacturing Operations Management Project; 
Department of Homeland Security, Western Hemisphere Travel Initiative; 
Department of Transportation, Integrated Terminal Weather System; 
Department of the Treasury, Customer Account Data Engine 2; and 
Department of Veterans Affairs, Occupational Health Record-keeping 
System.
---------------------------------------------------------------------------
    Among the agencies' seven IT investments, agency officials 
identified nine factors as having been critical to the success of three 
or more of the seven investments. These nine critical success factors 
are consistent with leading industry practices for IT acquisition. The 
factors are:

      Active engagement of senior officials with stakeholders.
      Qualified and experienced program staff.
      Support of senior department and agency executives.
      Involvement of end users and stakeholders in the 
development of requirements.
      Participation of end users in testing system 
functionality prior to formal end user acceptance testing.
      Consistency and stability of government and contractor 
staff.
      Prioritization of requirements by program staff.
      Regular communication maintained between program 
officials and the prime contractor.
      Sufficient funding.

    Officials for all seven selected investments cited active 
engagement with program stakeholders-individuals or groups (including, 
in some cases, end users) with an interest in the success of the 
acquisition-as a critical factor to the success of those investments. 
Agency officials stated that stakeholders, among other things, reviewed 
contractor proposals during the procurement process, regularly attended 
program management office sponsored meetings, were working members of 
integrated project teams, \19\ and were notified of problems and 
concerns as soon as possible. In addition, officials from two 
investments noted that actively engaging with stakeholders created 
transparency and trust, and increased the support from the 
stakeholders.
---------------------------------------------------------------------------
    \19\ The Office of Management and Budget defines an integrated 
project team as a multi-disciplinary team led by a project manager 
responsible and accountable for planning, budgeting, procurement, and 
life-cycle management of the investment to achieve its cost, schedule, 
and performance goals. Team skills include budgetary, financial, 
capital planning, procurement, user, program, architecture, earned 
value management, security, and other staff as appropriate.
---------------------------------------------------------------------------
    Additionally, officials for six of the seven selected investments 
indicated that the knowledge and skills of the program staff were 
critical to the success of the program. This included knowledge of 
acquisitions and procurement processes, monitoring of contracts, large-
scale organizational transformation, Agile software development 
concepts, \20\ and areas of program management such as earned value 
management and technical monitoring.
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    \20\ Agile software development is not a set of tools or a single 
methodology, but a philosophy based on selected values, such as 
prioritizing customer satisfaction through early and continuous 
delivery of valuable software; delivering working software frequently, 
from every couple of weeks to every couple of months; and making 
working software the primary measure of progress.
---------------------------------------------------------------------------
    Finally, officials for five of the seven selected investments 
identified having the end users test and validate the system components 
prior to formal end user acceptance testing for deployment as critical 
to the success of their program. Similar to this factor, leading 
guidance recommends testing selected products and product components 
throughout the program life cycle. \21\ Testing of functionality by end 
users prior to acceptance demonstrates, earlier rather than later in 
the program life cycle, that the functionality will fulfill its 
intended use. If problems are found during this testing, programs are 
typically positioned to make changes that would be less costly and 
disruptive than ones made later in the life cycle.
---------------------------------------------------------------------------
    \21\ See, for example, Carnegie Mellon Software Engineering 
Institute, Capability Maturity Modelr Integration for Acquisition 
(CMMI-ACQ), Version 1.3 (November 2010).
---------------------------------------------------------------------------
    Use of the critical success factors described above can serve as a 
model of best practices for VA. Application of these acquisition best 
practices presents opportunities for the department to increase the 
likelihood that its planned acquisition of a new electronic health 
record system will meet its cost, schedule, scope, and performance 
goals.
    In conclusion, VA continued to obligate billions of dollars for its 
VistA system. Recently, the department has undertaken important 
analyses to better understand the scope of the system and identify 
capabilities that can be provided by the Cerner electronic health 
record system it is acquiring. VA has additional key activities 
underway, such as establishing program governance and EHRM program 
planning. Based on these preliminary observations and as the department 
continues its activities to transition from VistA to the Cerner 
electronic health record system, critical success factors can serve as 
a model of best practices that VA could apply to enhance the likelihood 
that the acquisition of the new system will be successfully achieved. 
While it is early in VA's acquisition of the Cerner system, it will be 
important for the department to leverage all available opportunities to 
ensure that its transition to a new system is carried out in the most 
effective manner possible. Our experience has shown that challenges can 
successfully be overcome through using a disciplined approach to IT 
acquisition management.
    Chairman Roe, Ranking Member Walz, and Members of the Committee, 
this concludes 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, 
please contact David A. Powner at (202) 512-9286 or [email protected]. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this testimony statement. GAO 
staff who made key contributions to this statement are Mark Bird 
(Assistant Director), Jennifer Stavros-Turner (Analyst in Charge), John 
Bailey, Rebecca Eyler, Jacqueline Mai, Scott Pettis, and Charles 
Youman.

GAO HIGHLIGHTS

Why GAO Did This Study

    VA provides health care services to almost 9 million veterans and 
their families and relies on its health information system-VistA-to do 
so. However, the system is more than 30 years old, is costly to 
maintain, and does not support interoperability with DoD and private 
health care providers. Since 2001, VA has pursued multiple efforts to 
modernize the system. In June 2017, VA announced plans to acquire the 
same system-the Cerner system-that DoD is implementing.
    GAO was asked to summarize preliminary observations from its 
ongoing review of VistA and the department's efforts to acquire a new 
system to replace VistA. Specifically, the statement summarizes 
preliminary observations regarding (1) costs incurred for the system 
and related activities during the last 3 fiscal years; (2) key 
components that comprise VistA and are to be replaced; and (3) actions 
VA has taken to prepare for its transition to the Cerner system. The 
statement also discusses common factors critical to the success of IT 
acquisitions that GAO has previously identified.
    GAO reviewed its prior reports on the VistA modernization and on 
critical success factors of major IT acquisitions. GAO also reviewed 
records of obligations for VistA for fiscal years 2015, 2016, and 2017; 
analyzed VA documentation that describes the scope of VistA, and 
reviewed program documentation.

What GAO Found

    According to the Department of Veterans Affairs (VA), the Veterans 
Health Information Systems and Technology Architecture (VistA) and 
related costs, as approximated by funding obligations, were 
approximately $1.1 billion, $899 million, and $946 million in fiscal 
years 2015, 2016 and 2017, respectively. These obligations total about 
$3.0 billion over 3 years to support the system. As identified by the 
department, the obligations were to cover the costs for three programs 
(VistA Evolution, Interoperability, and Virtual Lifetime Electronic 
Record Health) and other supporting investments for activities such as 
networks and infrastructure sustainment. The following table provides a 
summary of the total VistA and VistA-related obligations.
    Obligations for the Veterans Health Information Systems and 
Technology Architecture (VistA) for Fiscal Years 2015 through 2017, as 
identified by the Department of Veterans Affairs
    SET TABLE HERE
    GAO's preliminary results indicate that VA is working to define 
VistA and identify system components to be replaced by the new system. 
However, according to VA officials, there is no single information 
source that fully defines the scope of VistA. This situation is partly 
due to differences in VistA at various facilities. In the absence of a 
complete definition of VistA, program officials have taken a number of 
steps to define the system's scope and identify the components that the 
new system will replace. These steps have included conducting analyses, 
performing preliminary site (medical facility) assessments, and 
planning for a detailed assessment of each site where the new system 
will be deployed.
    Since VA announced in June 2017 that the department would acquire 
the same electronic health record system as the Department of Defense 
(DoD), GAO's preliminary results indicate that VA has begun taking 
actions to prepare for the transition from VistA. These actions have 
included standardizing VistA, clarifying the department's approach to 
interoperability, establishing governance for the new program and the 
framework for joint governance with DoD, and preparing initial program 
plans. VA is early in its effort to transition from VistA to the Cerner 
system and the department's actions are ongoing.
    In 2011, GAO reported on nine common factors critical to the 
success of major IT acquisitions. Such factors include ensuring active 
engagement of senior officials with stakeholders and having qualified, 
experienced program staff. These critical success factors can serve as 
a model of best practices that VA could apply to enhance the likelihood 
that the acquisition of a new electronic health record system will be 
successfully achieved.

                                 ---------
                        Statement For The Record

                   Project Management Institute (PMI)

Letter dated: June 22, 2018

    The Honorable Phil Roe, M.D.
    Chairman
    U.S. House Committee on Veterans Affairs
    335 Cannon House Office Building

    The Honorable Tim Walz
    Ranking Member
    U.S. House Committee on Veterans Affairs
    335 Cannon House Office Building
    Building Washington, DC 20515

    Dear Chairman Roe and Ranking Member Walz:

    On behalf of our half million members and certification holders in 
the United States, the Project Management Institute (PMI) appreciates 
the opportunity to submit information to today's U.S. House of 
Representatives Committee on Veterans Affairs hearing entitled ``VA 
Electronic Health Record Modernization: The Beginning of the 
Beginning.''
    As the world's leading not-for-profit professional association for 
the project, program and portfolio management profession, PMI works 
with Congress to improve the Federal government's ability to 
effectively manage its portfolios of projects and programs.
    As the Department of Veterans Affairs (VA) embarks on the country's 
largest electronic health records (EHR) modernization project, PMI 
looks forward to working with the Committee and its new Technology 
Modernization Subcommittee to ensure that project, program and 
portfolio management leading practices are leveraged as one of the many 
crucial factors necessary to meet the Committee's objective of ensuring 
``veterans and taxpayers are protected during the transition.''
    Within that context, PMI is pleased to share its perspective on how 
project, program and portfolio management standards, workforce 
development, and executive sponsorship lead to greater organizational 
success and less wasteful Federal government spending.

Standards
    The importance of adopting leading project, program and portfolio 
management practices is difficult to overstate. PMI's Pulse of the 
Professionr 2018 survey reveals that 9.9% of every dollar is wasted due 
to poor project performance-that's $99 million for every $1 billion 
invested The data further shows that when proven project, program and 
portfolio management practices are implemented, projects and programs 
meet their original goals and business intent far more often than those 
without.
    Nationwide and globally, thousands of organizations-from small 
businesses and Fortune-level companies, to state and Federal government 
agencies-across all industries, manage their portfolios of projects and 
programs using the widely-accepted American National Standards 
Institute (ANSI) standards for project, program and portfolio 
management.
    Within Federal agencies, ANSI standards and frameworks allow for 
better performance tracking, promote flexibility and agility, foster 
transparency and accountability, and ensure compliance with existing 
statutes and Office of Management and Budget (OMB) guidance (including 
Public Law 104-113, the ``National Technology Transfer and Advancement 
Act of 1995;'' Public Law 114-264, ``The Program Management Improvement 
and Accountability Act,'' and OMB Circular No. A-119 Revised). Further, 
the U.S. Government Accountability Office (GAO) uses these ANSI 
standards as benchmarks in its evaluations, including those examining 
VA projects and programs.
    PMI's Pulse of the Professionr 2018 survey confirms that when 
organizations have mature value delivery capabilities, including the 
incorporation of ANSI-accredited standardized practices, project and 
program performance improves significantly:

      23% more projects and programs are completed on time
      20% fewer projects and programs are deemed failures
      18% more projects and programs are completed within 
budget
      14% fewer projects and programs suffer from scope creep
      13% more projects and programs meet their business goals 
and strategic intent

    Effectively leveraging standards is even more critical for 
organizations engaging in highly-complex and highly-technical projects 
and programs, such as the VA EHR modernization project. As the 
Committee and Subcommittee thoughtfully carries out its oversight 
responsibilities, PMI encourages efforts to ensure the EHR project-and 
all VA projects and programs-are executed with ANSI standards as the 
foundation of their process considerations.

Workforce development
    In today's environment of digital transformation, project, program 
and portfolio managers are the bridges that connect organizational 
strategy to implementation. As a result, there is a widening gap 
between employers' need for these skilled workers and the availability 
of qualified professionals to fill those roles. This gap is 
particularly acute within Federal agencies, where there has been a 
dramatic increase in the number of jobs requiring project-oriented 
skills taking place at the same time many professionals are retiring 
from the workforce.
    To deliver their portfolios of projects and programs more 
effectively and efficiently, Federal agencies, including the VA, need 
skilled, certified project, program and portfolio managers. These 
important stewards of taxpayer dollars require a unique set of 
technical competencies, detailed in the PMI Project Manager Competency 
Development Framework-Third Edition, combined with leadership skills 
and strategic and business management expertise, as embodied in the PMI 
Talent Triangle.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Within the VA, the VA Acquisition Academy (VAAA) has been 
recognized as an industry leader for its training and development 
efforts, including its Program Management School. The VAAA provides 
best-in-class training for project and program managers, both within 
the VA and government-wide. Upon completion, participants receive the 
Federally-recognized FAC-P/PM certification, which also meets the 
training requirements for PMI's industry-benchmark Program Management 
Professional (PMPr) certification.
    One example of the VAAA's effectiveness in recent years, is the 
Health Care Program Executive Office (PEO) established within the 
Veterans Health Administration (VHA). The VHA implemented the VAAA's 
Enterprise Program/Project Management Training Model within their PEO, 
which resulted in $390 million in program savings, as documented in VA 
Office of Inspector General report, ``Audit of Savings Reported under 
the Office of Management and Budget's Acquisition Savings Initiative.''
    As the VA ramps up its EHR modernization project, the Committee and 
Subcommittee should ensure that all project and program management 
professionals working on the effort have the technical, leadership, and 
business management skills required to successfully deliver on behalf 
of our Nation's veterans.

Executive sponsorship
    Leadership support for projects and programs is priceless. Actively 
engaged executive sponsors help organizations bridge the communications 
gap between influencers and implementers to significantly increase 
collaboration and support, boost project and program success rates, and 
reduce risk.
    PMI analysis shows that the dominant driver of project and program 
success is an actively engaged executive sponsor. PMI's Pulse of the 
Professionr 2018 survey found that organizations with a higher 
percentage of projects and programs with actively engaged sponsors 
(more than 80%) report 40% more successful projects than those with a 
lower percentage of projects with executive sponsors (less than 50%). 
We see that effective sponsors use their influence within an 
organization to actively overcome challenges by communicating alignment 
to strategy, removing roadblocks, and driving organizational change. 
With this consistent engagement and support, project and program 
momentum will stay steady and success is more likely.
    Strong executive sponsorship is critical to addressing the 
following persistent project and program management challenges:

      Ensuring project and program managers have the resources 
necessary for successful execution
      Providing leadership in the use of best practices and 
disciplined project and program management to reduce acquisition and 
procurement costs
      Empowering project and program managers to assess 
potential failures to achieve cost, schedule or performance parameters 
and direct corrective action;
      Ensuring that major acquisitions have adequate, 
experienced and dedicated project and program managers with relevant 
training and certification
      Requiring that organizations adopt widely-accepted 
project, program and portfolio management best practices and standards
      Maintaining certification standards for all project and 
program managers

    Executive sponsors also enabler a culture of project and program 
delivery excellence. PMI research and thought leadership finds that 
executives who emphasize project and program awareness, alignment, and 
accountability, often create and reinforce most productive project and 
program management cultures. Within this context, it is recommended 
that the Committee and Subcommittee ensure the assignment and active 
engagement of the VA EHR modernization project executive sponsor(s) at 
the various stages and levels of the initiative, which will 
significantly improve the likelihood of a successful project outcome.

Conclusion
    Thank you again for the opportunity to highlight the importance of 
project, program and portfolio management leading practices to 
delivering on the promise of the VA EHR modernization project, and VA 
projects and programs more broadly.
    PMI shares the Committee's commitment to the men and women who 
bravely served in our armed forces. That's why PMI supports veterans, 
Active duty military, National Guard/Reserve, retirees and spouses as 
they seek to transition into civilian project management careers. With 
today's job market demanding highly qualified and skilled individuals, 
PMI and our nationwide network of local chapters work with our veterans 
to transfer the leadership and management skills they perfected while 
serving our country into well-paying project management oriented roles 
for leading employers nationwide.
    For more information on how PMI works with transitioning military 
veterans and their families, please visit http://www.pmi.org/military.
    In closing, PMI stands ready to work with the Committee, the new 
Subcommittee, and the VA to ensure the success of the VA EHR 
modernization project. If you have any questions, please contact Jordon 
Sims (202-772-3598 / [email protected]) or Tommy Goodwin (202-772-
3592 / [email protected]) from PMI's Washington, DC office. Thank 
you.

    Sincerely,

    Mark A. Langley
    President and Chief Executive Officer

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