[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VA ELECTRONIC HEALTH RECORD MODERNIZATION: THE BEGINNING OF THE
BEGINNING
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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
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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
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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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
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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
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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.
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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.
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\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
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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.
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\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
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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.
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\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.
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\15\ GAO, Information Technology: Opportunities for Improving
Acquisitions and Operations, GAO-17-251SP (Washington, D.C.: April 11,
2017).
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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\
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\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.
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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.
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\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.
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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.
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\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.
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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.
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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.
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\21\ See, for example, Carnegie Mellon Software Engineering
Institute, Capability Maturity Modelr Integration for Acquisition
(CMMI-ACQ), Version 1.3 (November 2010).
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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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