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


  THE ROLE OF THE INTERAGENCY PROGRAM OFFICE IN VA ELECTRONIC HEALTH 
                          RECORD MODERNIZATION

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

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                 OF THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      THURSDAY, SEPTEMBER 13, 2018

                               __________

                           Serial No. 115-78

                               __________

       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                    
35-832 PDF                  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

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                      JIM BANKS, Indiana, Chairman

MIKE COFFMAN, Colorado               CONOR LAMB, Pennsylvania, Ranking 
JACK BERGMAN, Michigan                   Member
                                     SCOTT PETERS, California

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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                      Thursday, September 13, 2018

                                                                   Page

The Role Of The Interagency Program Office In VA Electronic 
  Health Record Modernization....................................     1

                           OPENING STATEMENTS

Honorable Jim Banks, Chairman....................................     1
Honorable Conor Lamb, Ranking Member.............................     3

                               WITNESSES

Dr. Lauren Thompson, Director, Interagency Program Office, U.S. 
  Department of Defense..........................................     4
    Prepared Statement...........................................    27
        Accompanied by:

    Dr. Helga Rippen, Deputy Director, Interagency Program 
        Office, U.S. Department of Veterans Affairs

John Windom, Acting Chief Health Information Officer and Program 
  Executive Officer, Office of Electronic Health Record 
  Modernization, U.S. Department of Veterans Affairs.............     5
Carol Harris, Director of IT Acquisition Management Issues, U.S. 
  Government Accountability Office...............................     7
    Prepared Statement...........................................    29

 
  THE ROLE OF THE INTERAGENCY PROGRAM OFFICE IN VA ELECTRONIC HEALTH 
                          RECORD MODERNIZATION

                              ----------                              


                      Thursday, September 13, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                   Subcommittee on Technology Modernization
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 2:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Jim Banks 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Banks, Coffman, Bergman, Roe, 
Lamb, and Peters.

            OPENING STATEMENT OF JIM BANKS, CHAIRMAN

    Mr. Banks. Good afternoon. The Subcommittee will come to 
order. Thank you all for being here today for the first hearing 
of the Subcommittee on Technology Modernization.
    I would first like to thank Chairman Roe for entrusting me 
with this responsibility. I have spent much of the past 2 
months studying VA's EHR modernization and the Military Health 
System GENESIS Program and meeting the people working on both 
of those efforts.
    I never expected that electronic health records would be 
such a major part of my service in the House of 
Representatives. However, I do appreciate the central role they 
play in the quality of health care delivery to every 
servicemember, veteran, and practically every citizen in this 
country.
    I am also well aware of the stakes. EHR modernization is 
inextricably linked to VA's ongoing reform efforts. If 
successful, it will be one of the lynchpins of a more 
responsive, agile, and efficient VA. If mismanaged, I fear a 
daunting and disappointing setback.
    That is why this Subcommittee is so important. Very rarely 
has a body of the Congress been dedicated to oversight of one 
program from its inception. Far too often, we only take an 
interest in a government project when it has already become a 
public scandal. This time it must be much different.
    I commit to digging into the details and asking the 
difficult questions. I commit to bringing the EHR modernization 
into public view. VA is asking veterans to invest their trust 
and all taxpayers to invest a huge amount of their dollars. The 
public deserves to know what is happening.
    I would also like to thank Ranking Member Lamb for being my 
partner in this effort. We intend to set an example for how 
well bipartisan oversight can work, even in 2018, when we 
dispense with petty political games. Sometimes a big government 
bureaucracy is like a freight train lumbering down the tracks. 
The course may become dangerous, and the people driving the 
train may even realize it; but the track was expensive to set, 
and no one wants to alter it. Sometimes that train, that 
bureaucracy needs some external help to course correct. That is 
this Subcommittee's role.
    VA's EHR modernization is still at the beginning of the 
beginning, but a great deal has happened since June 26, this 
Committee's last hearing on the subject. More is known now. We 
know there will be disputes within the VA and other agencies. 
We know leadership is crucial to resolve those disputes. We 
also know that EHR modernization must be people centric. The 
system must be designed from the bottom up and reflect what 
veterans and health care providers actually need.
    We have learned so many lessons from MHS GENESIS' early 
mistakes. There is a great deal though that we still do not 
know. We do not know if in any significant level of detail what 
will happen and when in VA's EHR modernization. We do not know 
precisely how the Cerner Millennium system will be structured 
and configured.
    The Department is still deep in its planning to flesh out 
its schedule and fill in those blanks. VistA, other systems, 
and VHA's processes are tightly interconnected. Once the 
changes begin, we do not know what disruptions may result. We 
also do not know what possibilities the future holds.
    The EHR modernization promises native interoperability and 
data, reams of clinical data to make veterans health care more 
effective. It is important to take time and plan how to harness 
that. We are here today to discuss specifically the role of the 
Interagency Program Office. What is the IPO, and why does it 
matter?
    VA's EHR modernization and the Defense Health Agency's MHS 
GENESIS Program must succeed together. That requires 
cooperation. There will be debates, sometimes disagreements, 
and decisions that must be made. There will be countless 
actions every single day which must be coordinated between the 
two programs.
    Who makes sure all of that happens? Personalities will 
change, but what is the constant? Maybe the two agencies work 
together seamlessly at all times; maybe not. If not, Congress 
expects the IPO to bridge the gaps. Congress created the IPO in 
the 2008 NDAA to act as the single point of accountability for 
DoD and VA to rapidly develop and implement EHR systems or 
capabilities to achieve full interoperability--the single point 
of accountability.
    The IPO has been many things over the past 10 years, a 
coordinating body for standards, the builder of an integrated 
EHR system, which was quickly abandoned, a contributor to the 
Joint Legacy Viewer, and the facilitator of interoperability 
when the two Departments decided to modernize their EHR systems 
separately.
    But the IPO has never truly been the single point of 
accountability. After trying practically everything else under 
the sun over the past 10 years, VA and DoD have come to the 
last remaining, hopefully best, solution to implement the same 
commercial EHR. This is exactly what the IPO was intended for.
    The question is, though, after so many twists and turns 
over the years and the expansions and contractions of its 
mission, whether the IPO is up to the task. And if not, how do 
we make it up to the task?
    With that, I yield to Ranking Member Lamb for his opening 
statement.

        OPENING STATEMENT OF CONOR LAMB, RANKING MEMBER

    Mr. Lamb. Thank you, Mr. Chairman.
    I also would like to thank Chairman Banks and Dr. Roe as 
well for how well they have worked with me and my staff as we 
get started here.
    To use Mr. Banks' analogy, my focus is on the passengers on 
that train. The veterans themselves have to remain our primary 
focus. They need to get where they are going in a timely and 
safe manner, and everything that we do here will be about 
making sure that their care is at the highest standard of 
health care worldwide, and that is what this project needs to 
serve.
    So, along the way, we should do whatever it takes to get 
them to the destination, whether its change course or lighten 
the load or add additional fuel or hire new engineers. Whatever 
it is has to be on the table so that we can get the mission 
accomplished.
    This Committee, in my brief experience in Congress, has 
lived up to its reputation as the last frontier of 
bipartisanship in Congress, and that is largely thanks, I 
think, to Dr. Roe's leadership. He has established a culture in 
this Committee that I am very proud to be part of, and I think 
that you will see that reflected in the work of this 
Subcommittee as well. So thank you very much to you, gentlemen.
    I think that this project has great promise, and in 
addition to the care of our veterans, we need to focus on 
accountability. That is something that I have seen can be 
difficult to track in an agency as large and complex as VA, but 
I know we can do it, and I know there is some great people 
there trying to do the job.
    I want to thank Mr. Windom for already meeting with my 
staff to lay out some of the organizational chart. And just 
like you would at the start of any military mission, I think 
part of our goal here today is to establish exactly who is 
accountable for what part of the mission and how quickly they 
will be able to get that done.
    So, with that, I am ready to begin. Thank you, Mr. 
Chairman.
    Mr. Banks. Thank you, Ranking Member Lamb.
    I now would like to welcome our first and only panel who 
are seated at the witness table. On the panel, we have the 
Director of the Interagency Program Office, Dr. Lauren 
Thompson, representing the Department of Defense. She is 
accompanied by the Deputy Director of the Interagency Program 
Office, Dr. Helga Rippen, representing the Department of 
Veterans Affairs.
    We also have Mr. John Windom, the Acting Chief Health 
Information Officer and Program Executive Officer for the 
Office of EHR Modernization in the Department of Veterans 
Affairs.
    Finally, we have Ms. Carol Harris, the Director of IT 
Acquisition Management Issues at the Government Accountability 
Office.
    As will be the Subcommittee's practice, I ask the witnesses 
to please stand and raise your right hand.
    [Witnesses sworn.]
    Mr. Banks. Thank you, and let the record reflect that all 
witnesses have answered in the affirmative. You may be seated.
    And, Dr. Thompson, you are recognized for 5 minutes.

                  STATEMENT OF LAUREN THOMPSON

    Ms. Thompson. Chairman Roe, Chairman Banks, Ranking Member 
Lamb, and distinguished Members of the Subcommittee, thank you 
for the opportunity to testify before you today.
    I'm honored to represent the Department of Defense as the 
Director of the DoD/VA Interagency Program Office. And I'm 
accompanied, as you mentioned, by Dr. Helga Rippen, the VA 
executive in our office as the Deputy Director of the 
Interagency Program Office.
    The mission of the IPO is to lead and coordinate the 
adoption of and contribution to national health data standards 
to ensure interoperability across the DoD, the VA, and private-
sector health care providers. The DoD and VA represent two of 
our Nation's largest health systems. Providing high-quality 
health care to servicemembers, veterans, and their families is 
one of the IPO's highest priorities, and health data 
interoperability is essential to improving the care delivered.
    The IPO is a collaborative entity comprised of staff from 
both the DoD and the VA who have technical expertise in health 
data standards and interoperability. The IPO serves as a 
central resource for the DoD and VA monitoring industry best 
practices and providing technical guidance to facilitate health 
data exchange.
    IPO team members work closely with the Office of the 
National Coordinator for Health Information Technology and the 
Department of Health and Human Services, as well as with 
standards development organization, such as Health Level-7 and 
others, to support the identification, implementation, and 
evolution of national standards associated with both the DoD 
and VA EHRs.
    These activities are vital to providing the building blocks 
for interoperability across the Departments. In April 2016, the 
Departments with the IPO's support met the requirements of the 
fiscal year 2014 National Defense Authorization Act, certifying 
to Congress that their systems were interoperable with an 
integrated display of data.
    Currently, the Departments share more than 1.5 million data 
elements daily. More than 415,000 DoD and VA clinicians are 
able to view real-time data of more than 16 million patients 
who have received care in the DoD and the VA through the Joint 
Legacy Viewer.
    The IPO plays an important role in monitoring DoD and VA 
interoperability efforts as well. The IPO established a health 
data interoperability metrics dashboard to identify Department-
specific targets for transactional metrics and trends, which 
are routinely shared with Congress.
    The IPO has also implemented the recommendations of the 
Government Accountability Office regarding outcome-oriented 
metrics to provide a basis for assessing and reporting on 
interoperability progress. We work collaboratively with the 
Departments on this.
    The IPO also serves as a focal point for collaboration 
across DoD and VA in their EHR modernization efforts. The IPO 
has been actively supporting the Departments with the 
development of a governance process to enable them to make 
joint decisions regarding common aspects of EHR. The IPO will 
facilitate the governance process, provide expertise and 
guidance in implementing best practices, and capture artifacts 
needed for decision-making.
    DoD and VA are working to further enhance interoperability 
through the implementation of the same electronic health record 
system. The IPO will continue to work with the Departments as 
well as the Office of the National Coordinator for Health 
Information Technology and industry partners to ensure that 
collectively we are advancing interoperability throughout the 
health care industry.
    Enabling health information exchange and interoperability 
between EHR systems across DoD, VA, and private sector will 
serve as the foundation for patient-centric health care, 
seamless care transitions, and improved care for our 
servicemembers, veterans, and their families. The IPO remains 
committed to this mission.
    Thank you for the opportunity to speak with you today. I am 
happy to answer any questions you may have regarding the IPO 
and ongoing work of the DoD and VA in regards to their 
modernization efforts. Thank you.

    [The prepared statement of Lauren Thompson appears in the 
Appendix]

    Mr. Banks. Thank you, Dr. Thompson.
    Mr. Windom, you are now recognized for 5 minutes.

                    STATEMENT OF JOHN WINDOM

    Mr. Windom. Good afternoon, Chairman Banks, Ranking Member 
Lamb, and distinguished Members of the Subcommittee.
    Dr. Roe, good afternoon.
    Thank you for the opportunity to testify on the VA's effort 
to modernize our electronic health record, commonly referred to 
as an EHR.
    First, I want to take the time to personally thank each of 
the Members of the Subcommittee for your ongoing and really 
unwavering support EHRM. Without your support, VA would not be 
able to move forward on this critical initiative.
    The Department is committed to providing the best care for 
our Nation's veterans, especially access to complete medical 
record. The new EHR system will improve access to quality care 
and enable the seamless transfer of health data as 
servicemembers transition from the Active Duty to veteran 
status.
    On June 5, 2017, VA announced its decision to replace 
VistA, its legacy system, which is unsustainable and cannot 
deliver critical capabilities to meet the evolving needs of the 
health care market. Through this decision, VA is working to 
adopt the same EHR solution as the Department of Defense 
allowing patient data to reside in a single hosting site 
utilizing a single common system.
    The ultimate outcome of this initiative will enable the 
sharing of health information, improve care, delivery, and 
coordination, and provide clinicians with data and tools to 
support patient safety. VA took several additional steps to 
ensure this acquisition meets the needs of the veterans and the 
clinicians who care for our veterans while also being a good 
steward of the taxpayers' dollars by capitalizing on DoD 
synergies.
    VA conducted an interoperability assessment and worked with 
leading health care organizations who recently implemented new 
EHR systems. These steps were critical in identifying and 
reducing potential gaps in VA's EHR contract.
    On May 17, 2018, VA awarded a contract to Cerner to 
leverage an existing commercial solution to achieve 
interoperability within VA, between VA and DoD, and between VA 
and community care providers. This contract contains the 
necessary conditions fostering innovation and evolving 
commercial technologies.
    VA also ordered the first three task orders that include 
project management, IOC site assessments, and data hosting. I 
want to highlight these important aspects of the EHR 
modernization effort, which will contribute to the overall 
success of the program.
    First, VA's implementation strategy will take several years 
to deploy and will be an evolving process as technology 
advances. VA's approach involves deploying the solution at IOC 
sites to identify problems and correct them before deploying to 
additional sites. The IOC sites will further hone governance, 
configuration management, and solidify processes overall.
    Secondly, VA has developed a change management strategy 
that involves users in the field earlier in the processes to 
determine their needs and quickly alleviate concerns. 
Furthermore, EHRM has established clinical councils that 
include nurses, doctors, and other end users from the field to 
support configuration of workflows.
    Finally, VA and DoD are working closely together to advance 
transparency through governance from an interagency decision-
making perspective through the DoD/VA Interagency Program 
Office. The Department's leadership, including myself, meets at 
least monthly to verify working group strategies and course 
correct if necessary.
    By learning from DoD, VA will be able to proactively 
address challenges and further reduce potential risk at VA's 
IOC sites. As challenges arise throughout the deployment, VA 
will work urgently to mitigate the impact of veterans' health 
care.
    We established a program office to provide oversight to the 
new EHR implementation. The office is staffed with the 
appropriate functional, technical, and subject-matter experts 
to enforce adherence to cost schedule and performance 
objectives, as well as quality objectives. This transformation 
will support the Department's effort to modernize the VA's 
health systems and ensure VA is a source of pride for our 
veterans, beneficiaries, employees, and taxpayers.
    Mr. Chairman, this concludes my opening statements. I am 
happy to answer any questions that you or the Members of the 
Subcommittee may have, and, again, thank you for this 
opportunity.
    Mr. Banks. Thank you, Mr. Windom.
    Ms. Harris, you are now recognized for 5 minutes.

                   STATEMENT OF CAROL HARRIS

    Ms. Harris. Chairman Banks, Ranking Member Lamb, and 
Members of the Subcommittee, thank you for inviting us to 
testify today on DoD and VA's Interagency Program Office and 
its role in VA's Electronic Health Record Modernization 
Program. As requested, I'll briefly summarize our prior work on 
the establishment and evolution of the IPO over the last 
decade.
    As you know, VA and DoD operate two of the Nation's largest 
health care systems, which provide coverage to millions of 
veterans and Active Duty servicemembers and their 
beneficiaries. Both Departments have long recognized the need 
for shared health information systems and capabilities, the 
benefits of which include making patient information more 
readily available and reducing medical mistakes. To this end, 
the IPO was established by law to act as a single point of 
accountability for DoD and VA system interoperability efforts.
    Unfortunately, this office has not come close to fulfilling 
this objective. Between 2008 and 2010, we issued a series of 
reports detailing how VA and DoD have not yet fully executed 
their plan to set up the IPO. For example, key leadership 
positions were either vacant or being filled on an interim 
basis, and the office was not yet carrying out critical IT 
management responsibilities in the areas of performance 
measurement, project planning, and schedule.
    Accordingly, we recommended, among other controls, the IPO 
develop a project plan and detailed integrated master schedule. 
And while the Departments agreed with the recommendation, their 
subsequent actions were incomplete and the IPO remained 
ineffectual.
    In 2009, the IPO was rechartered and assigned 
responsibility for establishing a virtual lifetime electronic 
record for servicemembers and veterans. In February 2011, we 
reported that the office had not developed an improved 
integrated master schedule, master program plan, or performance 
metrics for this initiative. We noted if these deficiencies 
were not corrected, VA and DoD's ability to effectively deliver 
capabilities to support their joint health IT needs would be 
uncertain.
    As such, we recommended that the Departments address these 
management weaknesses. The Departments agreed with the 
recommendation but did not take action, and thus, the IPO's 
ability to effectively deliver this initiative continues to be 
hampered.
    In March 2011, the Secretaries of VA and DoD committed the 
two Departments to developing a common integrated electronic 
health record system. To oversee this new effort, in October 
2011, the IPO was rechartered yet again to give it increased 
authority and expanded responsibilities for leading the 
integrated system effort.
    However, in February 2013, VA and DoD abandoned their plans 
for the system. We reported on this decision and found that the 
Departments had not addressed management barriers for effective 
collaboration on their joint health IT efforts. Among other 
things, VA and DoD did not provide the IPO with controls over 
essential resources, such as funding and staffing.
    In addition, the Departments diffuse their responsibility 
for achieving integrated health records, thus undermining the 
office's intended role as a single point of accountability. We 
recommended that the Departments ensure the IPO has authority 
over dedicated resources, developing interagency processes, and 
making decisions over the Departments' interoperability 
efforts. Again, the Departments agreed with the recommendation, 
but no action was taken.
    In June 2017, the VA announced that it planned to acquire 
the same commercial electronic health record system that DoD 
has been acquiring. VA has since established a program 
management office and drafted high-level plans for governance 
of the electronic health record implementation.
    Program officials have noted the governance bodies will not 
be finalized until next month, and the officials have not yet 
indicated what role, if any, the IPO is to have in the 
governance process. As such, we are recommending that VA 
clearly define the role and responsibilities of the IPO within 
the governance plans for acquisition of the new system.
    Because the IPO has historically been ineffective in 
increasing interoperability and the VA has largely ignored our 
previous recommendations, the Department has made limited 
progress. In order for VA to successfully acquire the same 
system as DoD, the Department must expeditiously and 
effectively implement this recommendation.
    That concludes my statement. I look forward to addressing 
your questions.

    [The prepared statement of Carol Harris appears in the 
Appendix]

    Mr. Banks. Thank you, Ms. Harris.
    The written statements of Dr. Thompson and Ms. Harris will 
be entered into the hearing record. Mr. Windom was unable to 
submit written testimony for this hearing.
    We will now proceed to questioning, and I yield to myself 
to begin questioning.
    To start with, Mr. Windom, I have to start by asking you 
about the leadership turnover in the Office of EHR 
Modernization. You might recall that this was my first question 
for the Full Committee's June EHR hearing, so I hope this isn't 
becoming a--somewhat of a pattern moving forward.
    But in the immediate aftermath of Ms. Morris' resignation 
on August 24, you were appointed the Acting Chief Health 
Information Officer in her place. Our understanding at that 
time was VA intended to conduct a search to fill the position 
and that you would at some point return to your previous role 
as program executive officer. Has that changed?
    Mr. Windom. Sir, the--I've been with the effort since its 
inception, including in uniform, as part of the drafting of the 
determination and findings that drove this process. So I've 
been with the VA for approximately 17 months in and out of 
uniform.
    The departure of Genevieve Morris really impacted no 
continuity issues within our office. The Deputy Secretary, who 
recently has come on board and I've been interacting with 
daily, we're assessing the overall organizational structure. 
From our perspective, we feel like we have no gaps in 
leadership.
    We have the full support of VHA and OI&T in augmenting the 
present OEHRM, Office of Electronic Health Record 
Modernization, and therefore, we feel like we, at this point in 
time, have no gaps in leadership or in subject-matter 
expertise.
    I'm more than--was more than involved in the day-to-day 
operations for the past 17 months even as Genevieve Morris 
assumed the helm for approximately 1 month. So, sir, I guess I 
would offer to you that we expect turnover--that's kind of the 
way things go, not only in the Federal space but in the normal 
commercial workspace--and that, you know, we wish Genevieve 
Morris the best.
    And in the same vein, you know, our chief medical officer 
who departed, again, family wanted to be on the West Coast. We 
have Dr. Laura Kroupa who immediately stepped in from the CMIO 
role into the CMO role. She's been with us for 17 months, fully 
understands her requirements. Again, we kind of pride ourselves 
on no single points of failure, people being willing and ready 
to step up. So, sir, that's where--that would be what I offer 
as a response.
    Mr. Banks. Appreciate that.
    Mr. Windom, as well, the Office of EHR Modernization has a 
chief medical officer position and a chief technology officer 
position, in other words, a physician executive and a general 
IT executive. Health informatics is somewhat different. It 
blends the two competencies. Do you believe it is valuable to 
have a health informaticist as the leader or one of the leaders 
at your office?
    Mr. Windom. Yes, sir, absolutely. I think your--the term--
the use of the word ``leader'' is the critical piece. I pride 
myself on knowing what I don't know and knowing what I do know. 
And we've got an incredible subject-matter base throughout the 
VA portfolio for me to access, including support contracts in 
Booz Allen Hamilton and other access to other consultants where 
we can draw on the expertise on a moment's notice.
    Mr. Banks. So, with that, is there anyone working in the 
Office of EHR Modernization who has managed an EHR 
implementation in a large health system to its completion?
    Mr. Windom. Sir, the--we have subject-matter experts that 
are being provided to us by Booz Allen Hamilton as part of our 
support contract that are delivering who have done just what 
you've just--you've captured, which is work in EHR 
implementation from start to finish. And so I'm comfortable 
with the support we have from the commercial--
    Mr. Banks. So it's a yes?
    Mr. Windom [continued].--environment. So that is a yes.
    Mr. Banks. Okay.
    Mr. Windom. Do we have the expertise on the government 
side? I would offer limited.
    Mr. Banks. Okay. All right. Mr. Windom, your position in 
MHS GENESIS in the Defense Health Management System's 
Modernization Office was as the program manager. Is that 
correct?
    Mr. Windom. Yes, sir, that's correct.
    Mr. Banks. Okay. And when did you hold that position?
    Mr. Windom. I held it from October 2013 through--I departed 
in November/December of two thousand and--my years are running 
together. I'm getting older--2015, so approximately 3 years, 
sir.
    Mr. Banks. So what--what were--can you tell us then what 
were some of the other leadership positions at MHS GENESIS in 
addition to that one?
    Mr. Windom. My primary position was the program manager, so 
I report--
    Mr. Banks. What were some other positions that existed?
    Mr. Windom. I'm sorry, sir. Would you please repeat that?
    Mr. Banks. Within the organization.
    Mr. Windom. Well, we've had chief engineer. We had system 
engineers. We've had testing leads, obviously a functional 
lead, chief medical officer. We had a, you know, a technical 
lead and a CIO/engineer, system engineer. We had no role called 
a CHIO, chief health informatics officer. That seems to be an 
evolving role in the commercial--
    Mr. Banks. All right. I don't mean to cut you off. Before I 
yield to the Ranking Member, do you believe the chief health 
information officer position is necessary and beneficial, yes 
or no?
    Mr. Windom. I have been unable to find in any 
implementations in the commercial the naming of a chief health 
information officer. I find that that skill set is offered from 
our CMIO community and from our informatics community in 
general.
    So, to answer to your question, I believe that the 
leadership role is the fundamental and most important element 
of this bringing together the requisite expertise to deliver to 
the mission.
    Mr. Banks. Thank you. My time has expired.
    I yield to Ranking Member Lamb for his questions.
    Mr. Lamb. Thank you, Mr. Chairman.
    Mr. Windom, who do you believe is the person within VA who 
is primarily accountable for the success of this project?
    Mr. Windom. Sir, my ego would say me, but reality is the 
DefSec, Mr. Jim Byrne. I report to him as mandated by, you 
know, the various elements of--from congressional mandates 
regarding who should oversee the funding of this project. So my 
ego, my accountability, in reality, his accountability, and I 
think that relationship is--supports that.
    Mr. Lamb. Thank you.
    Now, could you just tell me succinctly, what do you view as 
the role of the IPO when it comes to the actual successful 
implementation of this project?
    Mr. Windom. The IPOs, sir, is--I think is a--the 
facilitator between DoD and VA. When I say that, I mean clearly 
DoD has a mission set of requirements. VA has a mission set of 
requirements. It's impossible as we execute our day-to-day 
operations to be absolutely aware of what's going on in the DoD 
portfolio, and I believe vice versa.
    I think the importance of the IPO is that they do have the 
visibility under both portfolios and therefore can facilitate 
or bridge the gaps of understanding between the organizations 
and to ensure that we are aware and in tune as to what, if you 
will, are problems that are being countered, lessons learned 
being shared, things along that line. So I would offer a 
facilitator between the two organizations and support of 
overall success, mission success for both organizations.
    Mr. Lamb. And so it sounds like you view it as--and this is 
just a yes-or-no question so I can move on. Do you view it 
mainly as their responsibility to provide information to you?
    Mr. Windom. I believe it's not only information but also 
consult, guidance as appropriate, and also recommendations and, 
if you will, endorsement of good ideas, So the full spectrum, 
sir.
    Mr. Lamb. Okay. Do you believe that the IPO has decision-
making authority over you with respect to any aspect to this 
project?
    Mr. Windom. I do not believe that.
    Mr. Lamb. Okay. Thank you.
    Dr. Thompson, same question for you. Can you just define 
for me very succinctly what you view the role of the IPO to be 
in this project?
    Ms. Thompson. Thank you for the question, sir.
    The IPO serves in a convening role, a coordinating role. We 
facilitate the information sharing from the experiences of the 
DoD's MHS GENESIS deployment at initial sites to the VA and 
conversely information from the VA as their program is being 
developed to share with the DoD.
    We do, as I had indicated in my opening statement, we have 
been working in collaboration with both Departments, been 
developing a process for governing, how decisions will get made 
as they arise, where there are--when decisions need to be made 
regarding the common electronic health record that is able--
that has evolved since the VA made their announcements to 
purchase the same system as the DoD.
    Mr. Lamb. But do you think that you have the decision-
making authority to establish how that governance structure 
looks, or would you agree with Mr. Windom that you're basically 
making recommendations to both entities?
    Ms. Thompson. At this point in time, we make 
recommendations. We do not have the decision-making authority.
    Mr. Lamb. Okay. Thank you.
    Now, Ms. Harris, having heard both of those answers, can 
you fill us in in the time remaining, do you think that there's 
a further definition of IPO that needs to happen, or are there 
shortcomings in what we've heard here today?
    Ms. Harris. Well, according to the law, the IPO is supposed 
to be the single point of accountability, so that would include 
responsibility, authority, and decision-making 
responsibilities. So I think that how they've responded is in 
conflict with the expectations set out by law.
    Mr. Lamb. And would you agree that, as of right now, it 
appears that we lack a single accountable individual person or 
group who will be accountable for the joint success of this 
project, meaning the actual interoperability that we're trying 
to achieve between the two agencies?
    Ms. Harris. That is correct, yes.
    Mr. Lamb. Okay. Thank you, Mr. Chairman. I yield back.
    Mr. Banks. Thank you. I now yield to the Full Committee 
Chairman of the House Veterans Affairs Committee, Dr. Phil Roe, 
for 5 minutes.
    Mr. Roe. Thank you, Mr. Chairman.
    I'm going to give a little history lesson here, and then 
we'll go with questions. I remember sitting here, and I think 
maybe Mr. Coffman was here, when we spent $1 billion of 
taxpayers' money to try to get VistA and AHLTA to speak to each 
other, and it was a failure. And I think that's--was 
astonishing to me that we could get rid of $1 billion and 
accomplish not anything.
    That was several years ago when you all went through Mr.--
when it went through the chronology as Ms. Thompson did. I 
don't want to do that again. I think Secretary Panetta and 
Shinseki sat right at that dais and said: We failed.
    We then--I think the decision was made by the DoD and then 
our previous VA Secretary to move on and try to have the same 
system. I thought that was a good decision that was made.
    One of the things that I want to get into, and I think it's 
very important what both the Ranking Member and the Chairman 
have said, is about who's in charge--you know, who's in charge 
of this thing. And I'm going to quote the Yogi Berra: If you 
don't know where you're going, you might end up someplace else.
    And that's my fear that if we don't have somebody in 
charge, that that's going to happen. And so we need to 
establish that this--today when we leave here who can the 
Chairman and the Ranking Member contact when they need to know 
something about this program.
    And I took the--I've implemented the electronic health 
record system, and it is difficult. And every VA hospital I go 
to, I try to explain to them that this--and talk to the people 
and to veterans that this is going to be hard and you've got to 
be patient with the providers and the hospital when this 
implementation takes place.
    And I know from our visit out at Fairchild and Madigan--I 
know the Chairman has been out there--it was less than smooth, 
to be kind. And, Mr. Windom, you mentioned any time you put 
EHRs in, it slows you down. There's no question about it. I 
found myself sitting at 8 o'clock at night, 9 o'clock at night, 
entering data in the computer from my day's work, a really fun 
thing to be doing.
    And I know you mentioned here that you would look at a hit 
of 10 percent. I think you're going to have to look, if you 
look at Madigan, a much bigger hit in productivity, and that 
has slowed them down initially 50 percent. And they had to hire 
a number of people to get up to speed.
    And one of my concerns is, is all this at this 30,000-foot 
level is fine, but there's a nurse and a doctor and a health 
care people out there that are seeing a patient. And if they 
hit a blind canyon, what do they do? Because there's six other 
people waiting to see them right then.
    And apparently what happened when DoD was putting this out, 
they had to call a number here in D.C., and, you know, it was 
1-800, hold, and ``We'll get back to you, and there are 1,000 
people in front of you,'' and yet there's a provider out there 
that they were fearful that they would put inaccurate data in 
and so forth and actually harm patients.
    Can we be assured that the training--and what I found out 
was--I didn't care about all that. What I cared about: Can I 
negotiate this electronic system and get this data in there 
accurately, because after I'm long gone somebody is going to be 
looking at this data making clinical decisions based on the 
patient's well-being?
    Can we be assured that there will be adequate--Cerner has 
been in our office. Can we be assured that there will be help 
there for those providers, and have we talked to those 
providers instead of putting a top-down approach? Have we found 
out what they want and what works at their hospital after this 
initial rollout? And, Dr. Thompson, you or Mr. Windom, either 
can take those questions.
    Mr. Windom. Thank you, Dr. Roe.
    The 10 percent number, I'm not sure. We have articulated, I 
think, at various aspects anywhere from 10 to 50 percent 
understanding that there are inefficiencies introduced by 
business transformations, and our job is to be preemptive and 
proactive.
    And I think we are, with the support of VHA, in making sure 
that we have strategies that augment the workforces that are 
there as part of our implementation strategies. I think that's 
a key element, and we will continue to monitor those. I can--
yes, sir.
    Mr. Roe. No. I'll tell you what really--when I was at 
Fairchild, what really got me was they had taken a year to put 
10,000 healthy people--and VA have healthy people. Most of them 
are not. And what--the data that was entered--was entered into 
the record was very basic data, and you had to use the Joint 
Legacy Viewer to get into the weeds.
    And we need--in other words, we were going to have to run 
that system parallel until, I guess, for 70 years or 90 years 
until every veteran who went in there was gone. And then I 
thought: Well, that's a disaster. If we've got to run two 
systems to be able to have an EHR, that defeats the purpose of 
it.
    So can we be assured that all of that data will be moved 
onto one system so that, at one point in time, we can cut the 
lights off on the old and be totally beholden to the new one 
with that data backed up and shared somewhere?
    Mr. Windom. Yes, sir. It is our intent to migrate all data 
into the healthy intent platform that Cerner manages. We will 
have complete access to data and still own the data. So that's 
absolutely our strategy. I think you hit the nail on the head 
in a myriad of ways, and I think you hit the nail on the head 
when you said this is hard.
    And so we are going to continue to leverage our partnership 
with DoD. We're going to continue to learn from that, and we're 
going to continue to do the absolute best we can not to impact 
that important care being delivered to our veterans.
    So I can't disagree with any of your remarks, sir, other 
than we're learning by the day, and we're going to continue to 
develop our implementation and integration strategies to 
minimize that impact on our veterans and on the clinicians that 
serve our veterans. So--
    Mr. Roe. I yield back, and hopefully, we'll have a second 
round.
    Mr. Banks. Thank you, Chairman Roe.
    I now yield 5 minutes to Mr. Peters.
    Mr. Peters. Thank you, Mr. Chairman. I am glad that we're 
having our first Technology Modernization Subcommittee hearing 
today. And sorry I'm covering two hearings, so I didn't--I 
wasn't able to catch all the testimony. But I'm looking forward 
to working with my colleagues here to make sure that veterans 
remain the priority throughout the project.
    I served my first two terms on the Armed Services 
Committee. This is my third term, and I'm honored to serve on 
the Veterans Committee. One of the things I always wondered and 
laypeople always wondered was why you'd have two electronic 
health records for that set of people. Every single veteran 
comes from the Department of Defense. So we scratched our head 
about this, and we all understood there was kind of standoff 
between the DoD and the VA in terms of how they wanted to 
approach it.
    So I recognize that the IPO, the Interagency Program 
Office, provides an important role in sharing information. But 
I think Mr. Lamb's questioning showed pretty clearly that 
there's really no one there to break the ties or resolve the 
differences. It seems to me that the same kinds of differences, 
whether they're cultural or historical, exist today as they did 
when I came in.
    I guess my question for Ms. Thompson or Dr. Thompson is: 
You had mentioned that the IPO, the DoD, and the VA planned to 
set up governance bodies to oversee the effort. How would--what 
would those look like, and how would the bodies differ from the 
current process? And then I'm going to ask Ms. Harris to 
address the same issue, what you think it should look like. Dr. 
Thompson.
    Ms. Thompson. Thank you for the question.
    So, first, let me point out that there are existing joint 
governance bodies in place today, and we intend to use those 
bodies to the extent that we can. What we are proposing as new 
bodies are specific to making decisions about the configuration 
of the electronic health record that will be implemented at the 
sites in both Departments.
    What we are proposing are three bodies, a joint functional 
governance board and a joint technical governance board and a 
joint decision-making board. The premise of the governance is 
that the decisions are made at the lowest level possible. We 
have clinicians working together side by side today, technical 
experts working side by side today to help determine the path 
forward and solve problems.
    When they cannot agree, then only at that point would a 
decision be escalated to respectively either a functional 
governance board or technical governance board. And we fully 
believe that those bodies will be able to come to agreement, 
and only if they can't would those decisions then be escalated 
to a decision board which would be comprised of those in the 
Departments with the authority to make decisions regarding the 
configuration of the electronic health record.
    Mr. Peters. Ms. Harris.
    Ms. Harris. Sir, I think, based on the IPO's past history, 
I think it's evident that they never had the clout to either 
mediate and resolve the issues between VA and DoD as it relates 
to interoperability. So I think when it comes to the law itself 
of having a single point of accountability, the IPO was never 
set up to succeed there because neither of the Departments were 
willing to relinquish control.
    Mr. Peters. Right.
    Ms. Harris. I think in terms of what you would see in 
leading organizations,--what they have shown based on our past 
work is that you have a single executive level entity that is 
the point of accountability, and it's just one body as opposed 
to multiple bodies, and it has to be at that executive level.
    So that's something that we would expect to see, you know, 
moving forward when VA and DoD establish their joint 
governance. Certainly I would expect to see it at a minimum at 
the Deputy Secretary level, you know, VA's Deputy Secretary and 
his counterpart at the DoD leading this joint executive entity.
    Mr. Peters. Do you anticipate that the joint effort would 
actually have new decision-making authority that would bind 
both agencies?
    Ms. Harris. That would--I mean, in order to be the single 
point of accountability, they would have to have decision-
making authority in order to be able to arbitrate issues and 
make decisions so that if compromises are necessary--
    Mr. Peters. Yeah.
    Ms. Harris [continued].--that they have the authority to 
make those decisions. That's essential.
    Mr. Peters. And is that something that we've seen in other 
agencies? Is there a model for this that we can borrow?
    Ms. Harris. Unfortunately, we've never seen it work well 
when we've seen those joint collaborative efforts. I mean, 
there's a reason IT is difficult. And certainly, you know, when 
you're talking about the two largest health care networks in 
the Nation, I mean, it compounds that complexity. However, we--
    Mr. Peters. Well, I would just--I'm out of time, but I 
would just offer that either the President has to do this or 
the Congress has to do this, because I don't think this thing 
gets created without some action by us. And the only people--
the only person that both agencies report to now is the 
President of the United States. And if--I think also Congress 
would have a role to create such an agency as well. So I 
think--I look forward to the current--the coming work. Thank 
you. I yield back.
    Mr. Banks. Thank you.
    I now yield 5 minutes to Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    Ms. Harris, from a Government Accountability Office 
standpoint, if you were to look at how we wasted $1 billion and 
got nowhere on this interoperability of health records, isn't 
it that you had two large Federal entities with neither--both 
considered to be coequals with neither one in charge and people 
in the middle, you know, trying to negotiate with them 
unsuccessfully, is that--does that characterize where we are--
where we were?
    Ms. Harris. Yes. I think that in the past situations what 
we've seen historically is that when everyone is responsible, 
no one's responsible. And so I think that's what has led us to 
where we are today since, you know, we've had these subsequent 
interoperability initiatives, including the integrated 
electronic health records initiative between DoD and VA, and 
unfortunately, because of the lack of collaboration on the part 
of both Departments, that's why we're here today.
    Mr. Coffman. So now what we have going is creative, 
strengthen this IPO to hopefully move forward. I think you 
still have two big coequals out there. I'm not sure that the 
results are going to be different. Isn't it better--wouldn't it 
be better for--to make a decision, whether by the Congress of 
the United States or preferably the executive branch that would 
put one of these two players in charge to say either it is the 
DoD or VA, and the other player certainly is going to have 
input, but it's going to have to follow whatever--if DoD is the 
lead agency, then DoD is going write this thing, and VA is 
going to have to follow or vice versa.
    But to have--I think to have the IPO with the expectation 
that these two big players--that life is going to be different, 
I'm not sure life is going to be different. And I worry that 
we're going to waste another $1 billion on this.
    And so I would--I think to my colleagues, and would love to 
get your input on this, wouldn't it be better--I mean, if we 
look back, clearly--this would be--if either DoD or VA were in 
charge of this, and we're not coequals, I think this would be 
done by now. I don't think we waste $1 billion. I'd love your 
input on that.
    Ms. Harris. Well, I think that--I think, number one, if the 
IPO continues the way that it is operating today, we are going 
to continue to have dysfunction in moving forward, and 
unfortunately, you know, we want to prevent that.
    We have not done work on MHS GENESIS, so I can't speak to 
the DoD side, and so I wouldn't be able to weigh in on whether 
DoD or VA should be taking the lead. I think that's something 
that the Departments should discuss as they define the roles of 
joint governance moving forward for their two implementation 
efforts.
    Again, I--perhaps Mr. Windom might have some perspectives 
as well, but I think that's something that the Departments have 
to negotiate amongst themselves.
    Mr. Coffman. Mr. Windom.
    Mr. Windom. Sir, I would offer that our governance is 
evolving. It's impossible to create a governance structure that 
can--handles all matters that may arise. As a matter of fact, 
we think we have a notional governance structure that is being 
tested through use cases as to how it would function and render 
decisions that you speak to. I think we are working through 
that process right now.
    Again, the mission set went from a JOV-dominated element 
for interoperability to now two EHRs that are going to make us 
interoperable. That's a new mission set. That's a new oversight 
responsibility, and I think we're working through those 
challenges, sir. And I think we will have a governance 
structure that works. And as you know, any business 
transformation typically involves challenges with governance. 
So we will continue to work that, sir. We understand.
    Mr. Coffman. So where I might disagree is you said we will 
have a--it will evolve, and we will have a governance structure 
that will work. And I think given the restraints that you're 
under, I think that that's pretty optimistic, and I think it's 
good. That's leadership on your part.
    However, that still doesn't define the fact that we don't 
have a lead agency in charge. I still think there is a role for 
an--the IPO with the lead agency in charge. But I--you know, I 
think we owe it to the taxpayers, we owe it to our Active Duty 
and our veterans to get this right, and I believe that we've 
got to define that somebody who's going to be the lead agency--
one of these two that's going to be the lead agency here.
    Mr. Chairman, I yield back.
    Mr. Banks. Thank you.
    I now yield 5 minutes to General Bergman.
    Mr. Bergman. Thank you, Mr. Chairman.
    Thanks to everybody for being here.
    Now, as I look at the timeline here on the documents 
presented, it kind of goes, you know, back to the future. In 
January 2008, when we, Congress, created the Interagency 
Program Office, I was still in command of the Marine Corps 
Reserve. And in April of 2009, when work on the virtual 
lifetime electronic record began, I was still in command. Okay.
    So I didn't really think about it in that depth until we 
were sitting here today, and you look at how fast time flies. 
I'm not sure which goes faster, the time or the $1 billion out 
the door. Okay. The point is we cannot recover time ever. We as 
a Committee, we as a Congress could, you know, put more money 
into a program. We can always do that, but is that the right 
answer for this Committee, who you've heard said several 
different ways, works bipartisan. Are we throwing good money 
after the bad?
    And I guess what I was, you know, hoping for is to hear 
some level of testimony that instills confidence in us that 
we're not writing one check after another and dropping it into 
a black hole because, in the end, what we're talking about is 
creating a health record when a young man or woman comes into 
the military and having it be their final health record, if you 
will, when they are at the end of their time on this Earth. I 
don't see it.
    So, having said that, let's talk a little about--I'd like 
to hear from you as to some of the whys we're not. In fact, I 
took a note that, Mr. Windom, you said joint governance is 
evolving. Evolving, okay, there's a lot of things that evolve. 
Do you or any--would any of you at the table be willing to 
venture a statement, making a statement as to, are you 
satisfied with the rate of evolution? Anybody could answer.
    Mr. Windom. Sir, I'm very satisfied with the rate of 
evolution. And this is why I say it's evolving, is that the as-
is state of the enterprise within VA is different than the as-
is state of the enterprise within DoD. We've acquired the same 
commercial electronic health record, and now we're 
understanding the gaps between how we sought to implement and 
how DoD is implementing.
    And so those gaps have to be reconciled, and they have to 
be reconciled through governance. We've got site surveys that 
are ongoing that are discovering new things within the 
framework of the VA environment that have to be also taken into 
consideration.
    Our job is to deliver more capabilities than is presently 
being delivered within the VA as is DoD's. We didn't buy a new 
system to implement the same thing. And so there is some cross-
pollinization. There is some hard work that has to be done. 
There's some hard--
    Mr. Bergman. Let me ask you a question--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued]. --because I don't want you to run 
out my time.
    Mr. Windom. No. No problem, sir.
    Mr. Bergman. Okay. And the point of this is we talk about 
vying--you know, you've got two big dogs vying for control, in 
some ways, of a project. What can Congress do--what can 
Congress do to set the stage for--I don't care if it's you 
agree in the joint governance that DoD is going to have it for 
the first year, and then you're going to do a handoff with a 
baton and hand it to the VA for the second year, don't care, 
because as we evolve, the situation is still there; people in 
positions change. Is there something that Congress or through 
the Veterans' Affairs Committee can actually do through 
legislative process to actually jump start this evolution?
    Mr. Windom. Sir, I think you did jump start it when you 
provided $782 million in the year of execution, fiscal year 
2018. And so we are very respectful of your investment in us. 
And so I think you have to let us--
    Mr. Bergman. Are you guys going to be able to then as 
hopefully will--you know, most of us will be back here to look 
you in the eye a year from now and get accountability up, you 
know, update as far as the--where we are?
    Mr. Windom. Sir, that's the only way I know how to do it. I 
spent 30 years in the military. Cost, schedule, performance 
objectives have been at the forefront of any program that I've 
worked in or led, and so I expect to be held to the same 
standard. So we look forward to giving you and presenting you 
with the data that supports our adherence and exceeding of 
cost, schedule, and performance objectives or rationale why we 
didn't. So we look forward to that scrutiny, sir.
    Mr. Bergman. The point is I look forward to being here and 
whether it be in the Technology Committee or whether it be in 
the Oversight Investigation Committee--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--because we've got things moving 
to a small extent. And I see I'm over my time, and I yield 
back. But we need to keep the sense of urgency at all levels 
moving forward.
    Mr. Windom. Yes, sir.
    Mr. Bergman. Thank you, Mr. Chairman.
    Mr. Windom. Thank you, sir.
    Mr. Banks. Thank you. We will now proceed to a second round 
of questioning, and I will begin.
    Mr. Windom, this is a diagram--is it on the screen? Yes. 
Okay. This is a diagram from your office depicting VA's 
Committees, boards, and councils, and DoD's equivalents that 
oversee the EHR modernization. Can you please take a moment to 
explain what these are, what they do, and how they interact 
with each other?
    Mr. Windom. Sir, I can't really see the screen, but I think 
I have the boxes memorized. So at the lower level we've got 
technical and functional governance boards. Again, Dr. Thompson 
mentioned for us governance to be successful, things have to be 
resolved at the lowest level. Okay.
    If everything has to be elevated to an executive council or 
a government integration board, then we're really not 
succeeding. So really it's the clinicians talking to the 
clinicians, the technicians talking to the technicians. And you 
see, other than the names being changed, we pretty much mirror 
on the VA side what DoD is doing in the name of TSWGs and other 
things.
    So really those four layers of governance that allow pass 
of resolution--thank you. Now I've got to put on my glasses. So 
the Steering Committee at the top is chaired by the DefSec. The 
Governance Integration Board, No. 2, is chaired by me, and it's 
bringing together the CMO and the CTO for elements that they 
were under--unable to adjudicate at the lower level. And then 3 
and 4 reflect the functional and the technical governance board 
that I indicated chaired by the CMO and the CTO respectively. 
And then you have that lowest level of governance where we hope 
at the functional level and the technical level, which is No. 
5, things are really being resolved. The more we have to 
elevate, the less we are succeeding.
    Mr. Windom. There's absolutely no way. We will have 
thousands of governance elements, and I hope to having risen to 
block No. 1 only a handful for the executive levels like the 
DepSec and VHA and the CIO. Because, again, that is going to be 
a slower, arduous process where things can get resolved in 
block No. 5 at a more efficient--and those are the people that 
are being called upon to execute using the new HR, and so, sir, 
that's--an explanation of the left side.
    Mr. Banks. I need to move on.
    Dr. Thompson, the middle of the diagram there's a box, 
marked, quote, ``facilitated by IPO.'' Can you please explain 
what these boards are that the IPO facilitates, and how does 
your office do that?
    Ms. Thompson. These are the three boards that I mentioned 
that are not in place yet but that we are proposing be put into 
place. A joint technical board, a joint functional board, and a 
joint decision board. The proposal is that the IPO serve as the 
executive secretariat for these boards as we serve in that 
capacity for other joint bodies. In that role, we would take 
responsibility for planning the meetings and developing the 
process and capturing decisions that are made at the meeting, 
ensuring that the artifacts are captured and that the decisions 
made at the meetings are communicated appropriately.
    So, in effect, we would be managing the proceedings of 
these meetings, bringing together the appropriate people, the 
decisionmakers.
    Mr. Banks. Could you elaborate on when they would be 
established?
    Ms. Thompson. We are in the final stages of formalizing a 
proposal to our Joint Executive Committee, which is co-chaired 
by the Deputy Secretary of the VA and the Undersecretary for 
Personnel and Readiness. It is our hope to be able to bring 
that before them for consideration in the near future.
    Mr. Banks. What is the near future?
    Ms. Thompson. Within the next few months.
    Mr. Banks. Okay.
    Ms. Harris, the middle portion of this diagram, where the 
IPO coordinates between the DoD and VA, has existed for some 
time. Isn't that correct?
    Ms. Harris. Yes, that's correct.
    Mr. Banks. Okay. How well, Ms. Harris, has this structure 
performed in the past and how well has the IPO been able to 
drive interoperability projects between the two Departments?
    Ms. Harris. The IPO, based on history, has demonstrated 
they have not had the clout to be able to, again, mediate and 
resolve the issues between the two Departments. So the 
performance of the IPO has been relatively lackluster, but 
there is an important role for the IPO. I mean, they play a 
critical role in identifying interoperability standards, and 
they certainly have a role to play in measuring the progress 
and performance of interoperability between the two 
Departments. So certainly there is a role for the IPO to play.
    However, you know, based on what we see here, I mean, they 
are not acting as the single point of accountability, again as 
called for by statute. So I think, you know, one of the things, 
going back to one of the earlier questions of what Congress 
could potentially do, one thought for consideration would be to 
relieve the IPO of the legislative requirement to act as a 
single point of accountability. I think that, again, when you 
look at leading organizations, that single point of 
accountability should be at the executive level.
    And one of the things that strikes me, when you look at 
this org chart, I mean, you count the number of boxes. There 
are at least 16 boxes here, which shows that accountability has 
been so diffused so that when wheels fall off the bus, you 
can't point to a single entity who is responsible, and that is 
a problem. And so, again, focusing on a single point of 
accountability is critical in moving forward to make sure that 
interoperability is functional.
    Mr. Banks. Thank you.
    My time is expired. I now yield 5 minutes to Ranking Member 
Lamb.
    Mr. Lamb. Thank you, Mr. Chairman.
    So, Dr. Thompson, the proposal that you've laid out of the 
three bodies, you used the term ``executive secretariat.'' Do 
you agree with Ms. Harris that that is--that is inconsistent 
with the statutory mission of IPO being a single point of 
accountability? Do you agree that those two things are not 
consistent with each other?
    Ms. Thompson. In practice today, we do not function as a 
single point of accountability. Our approach is to--is 
collaborative in nature, to convene the decisionmakers of the 
Departments and facilitate a decision in that way. And I do 
believe we've been very effective in doing that.
    Mr. Lamb. Okay, so you do agree, then, that the way you're 
functioning today and the way you would function under this 
proposal would not be consistent with the statutory objective 
of being a single point of accountability?
    Ms. Thompson. Not in regards to electronic health record 
modernization. We have served in that capacity in regards to 
moving forward interoperability in health data exchange.
    Mr. Lamb. Would your office be capable of fulfilling the 
statutory mission if given something that it doesn't have right 
now?
    Ms. Thompson. We would be more than willing to fulfill that 
role. We are not currently staffed or resourced to fulfill that 
function as I would envision it would need to be if we were to 
serve in that capacity.
    Mr. Lamb. And what is it that you would need in order to 
serve in that capacity?
    Ms. Thompson. We would likely need additional people to 
support the function.
    Mr. Lamb. Okay. Any idea how many people?
    Ms. Thompson. I would not want to take a guess at that. I'd 
be happy to take that for the record and get back to you.
    Mr. Lamb. Okay, I would appreciate that.
    Do you agree that, under the proposal you've discussed 
here, with the three bodies, it doesn't appear that in that 
proposal there is anyone who is an arbiter between DoD and VA. 
Is that right?
    Ms. Thompson. There is not a single individual. Our 
approach is for all of these bodies to be co-chaired by a DoD 
and a VA decisionmaker.
    Mr. Lamb. Right. But there would essentially be an even 
number of--of votes.
    Ms. Thompson. There's not--
    Mr. Lamb. And if it was 1 to 1--
    Ms. Thompson. There's not an individual who is a 
tiebreaker.
    Mr. Lamb. Right, okay.
    Mr. Windom, are you aware of this proposal, of the three 
bodies?
    Mr. Windom. Yes, sir, I am.
    Mr. Lamb. Okay. Any thoughts on how that could work?
    Mr. Windom. Sir, I believe that the use cases that we've 
been running through this process have been yielding successes. 
So, again, my commitment is: Extremely dynamic environment. We 
will continue to assess our governance structure to make it as 
efficient as we possibly can. And so, at this point in time, I 
would offer, I think, that is a very viable governance 
structure, sir.
    Mr. Lamb. So, correct me if I'm wrong, I just want to sum 
it up. Do I have it right that your view is basically that this 
is kind of being worked out on the fly, day to day, through the 
testing and examinations that you guys are doing, and you're 
raising issues to DoD as they come up? Is that a fair way of 
saying it?
    Mr. Windom. I would say, we started governance--this 
governance discussion well over--almost a year ago. And so as 
discoveries are made, this is being refined. Again, we're in--
    Mr. Lamb. What is being refined, though? Because this 
proposal of the three bodies does not exist yet, as far as I 
can tell, so--
    Mr. Windom. No. It--which is one of the refinements that 
have been made is the need for these three bodies as we 
adjudicate issues between DoD and VA.
    Mr. Lamb. Right.
    Mr. Windom. Again--
    Mr. Lamb. But right now that is not happening in any formal 
way. That's kind of what I'm asking you. Seems like it's 
happening on--
    Mr. Windom. Not in a formal way, you're correct, sir. It 
is. And I guess I want to make a comment about the GAO's 
comments and Ms. Harris' comment, is that there's 16 boxes on 
there because there are a myriad of mission sets, that there's 
no single body that is qualified from technical to clinical 
perspective. Our job is to manage those and have elevation 
opportunities through the give and through the executive 
council to resolve things that are unable to be resolved at the 
lowest level. What I can't impress upon the Committee enough is 
that governance has to be successful at the lowest possible 
level. Things can't rise to the superior level on every matter.
    Mr. Lamb. Thank you.
    Mr. Chairman, I yield back.
    Mr. Banks. Thank you.
    I yield 5 minutes to Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    And a couple things, everyone--every Member on this dais 
has been in the military, and we all understand the command 
structure. I understand--and when I had my little two silver 
bars and then finally got a little--I would have to absolute 
him every time because he had three stars. I got that. There's 
nobody that we have as a three-star here.
    And what I think Mr. Coffman is concerned with in his 
question, his concern is we're going to have another Denver 
fiasco if we don't have somebody that the buck stops here. And 
we had a $600 million project end up being a $2 billion 
project. This would be a $40 billion if we triple the cost of 
this thing. So that's why it is absolutely critical--and Ms. 
Harris has said over and over again--the private sector where I 
came from, whoever signed the check was in charge. They were 
the ones that were responsible, either to the shareholders or 
to the partners in the group to make those decisions.
    And what I see coming here is we've got to get that worked 
out, whether it's someone from the executive branch or--and I 
would argue that the VA has different needs than the DoD does. 
Those are different systems. They serve different patients. And 
the VA system is gargantuan compared to what the DoD is doing. 
So I think that should be taken into consideration when you're 
working out this command or this guidance structure. So that's 
just my two cents' worth on that.
    If we haven't learned anything today, I think we've learned 
that, that we're going to end up in a Denver if we don't 
decide--or somebody--where the buck stops.
    And, Mr. Windom, I totally agree: Everything doesn't need 
to go to the boss. There needs to be somebody, like I said, at 
the provider side, to help them navigate this. They don't need 
to call you for that, to find out how to get this button 
punched to get there. So I got that. One of the things that I 
would like to know and I think it's critically important, 
clinically, that you said that you--Mr. Windom, you said it was 
your intent to get to a single system, but there was no 
commitment to that. Are we committed to get off the legacy 
system and into this one single system?
    Mr. Windom. Sir, absolutely, committed.
    Mr. Roe. Okay.
    Mr. Windom. The pivot strategy is an important piece of 
this. Again, I think everyone knows that we have to run these 
systems in parallel for a period of time. My job is to drive 
down the amount of time we have to run these systems 
simultaneously. That's taxpayers' money being expended.
    We want to move--IOC is critical. We're going to be 
assessing during IOC what things can be deployed sooner, what 
things can be deployed out of sequence, to facilitate turning 
things off, sir, as you're alluding to. Absolutely, we want to 
pivot from the existing legacy systems to the new her, but we 
want to do it without disrupting care or introducing 
efficiency--inefficiencies in the care of veterans. So we have 
to be judicious.
    Sir, I've heard you say a number of times, the schedule 
won't drive us. We have to do what's right. We have to be 
committed to our veterans every step of the way. And that's 
what we're going to deliver to you, is a pivot strategy and 
then execute to that strategy, that, in fact, takes care of our 
veterans.
    Mr. Roe. Where I see the--this is just my view after 
listening to this today. Where I see the IPO as, is that when 
you go to Bremerton and Madigan and you find out that the 
pharmacy has been slowed up, and that that they can pass that--
this is what happened when we rolled this out. This is what you 
shouldn't do, or this is what you should do to ramp up to avoid 
the slowdowns that occur. That--I don't think they need to be 
involved in every decision going on.
    But somebody, just like when Dr. Shulkin said we're going 
to use the Cerner System, one person made that decision. It was 
a gigantic decision, but when he took advice from a lot of 
people--but one person had to sit down and sign his or her name 
to that document so they could get it done. And there needs to 
be a buck-stops-here person in this organization, I think, so 
that those things we learned in Spokane and Seattle, the IPO 
can pass all that information along very well.
    But I don't think they need to be--they need to be a flow 
of information and best practices, not the person that says: 
Here, no, we're not going to do that.
    And there needs to be that person out there, so that 
backstop out there somewhere.
    I yield back.
    Mr. Banks. Mr. Coffman?
    Mr. Coffman. Thank you, Mr. Chairman.
    I just want to--I just don't think this is doable. I just--
I think that we're going to undergo the same problem unless we 
change. And I get that we plussed up the IPO to try and make a 
difference. I just don't think it's going to make enough of a 
difference at the end of the day that we are going to be 
efficient in terms of resolving this issue of interoperability. 
I think we're going to waste more taxpayer dollars in getting 
to where we need to go.
    I think from day 1, we made a terrible mistake, the prior 
administration and continued by this administration in not 
saying to both of these major players, the Department of 
Defense and the Department of Veterans Affairs, one of you is 
in charge, and the other one can have input, and the IPO can 
certainly serve as a vehicle for that input. But by not doing 
that, we've created this consensus situation where we hope that 
it's going to get done, but we don't know that it's going to 
get done.
    So I would hope that this Committee would take a hard look 
at this organizational structure and say whether or not one of 
these two agencies ought to be in charge, ought to be the lead 
agency, and then let's move forward from there.
    I yield back, Mr. Chairman.
    Mr. Banks. General Bergman?
    Mr. Bergman. Thank you, Mr. Chairman.
    Dr. Thompson, you used a phrase that sent chills up my 
spine when the question was asked, what do you need, and it 
was: more people.
    Okay. You didn't know how many, that's okay. But there's 
a--at least when I was spending my time in DoD, the answer that 
sent chills up a lot of spines then was the answer to every 
problem was: Give us more people, more money, more time, and 
we'll get you a solution.
    So, you know, the point is, I think we really, really, 
really--I don't care who does it--we need to get realistic with 
the fact that that is not an answer that is going to energize 
what it is we're trying to accomplish. Because when you add 
more people to a situation, you get a chart, an org chart, 
that, as we've already kind of alluded to here, does not feel 
like it reports to anybody, or anybody's in charge. And you 
spend--waste a lot of time with reorganizing ourselves just 
because there's been a little, you know, a little change.
    But let me ask you a question. You know, the GAO had 
previously recommended that the IPO have authority over budget 
and staff, over interagency processes and over decision-making 
for interoperability in both Departments. VA and DoD accepted 
the recommendations but never really implemented them. We know 
that. It seems that the IPO itself is not able to implement 
such recommendations. Is it a lack of authority to exercise 
more authority? Who can implement whatever recommendations are 
out there?
    Ms. Thompson. I joined the IPO in 2015. Those 
recommendations were made prior to my tenure with the IPO. So I 
can't speak specifically to the reasons why, at that time, 
those recommendations were not put into place. As we've been 
rechartered, we have a much smaller footprint, very much 
focused on health data standards and interoperability, and 
that's where we have been focused. If there's a decision made 
that the IPO should take on a different function, I think we 
would need to consider what it would take for us to perform 
that function.
    I don't believe today we are configured to support a single 
point of accountability as is being suggested here today. We 
would be happy to step into that role. I don't believe we're 
positioned for it properly today.
    Mr. Bergman. So let's say for the sake of discussion that 
we had folks like the Under Secretary of Defense for 
Acquisition, Technology, and Logistics, AT&L, and ultimately 
maybe the Secretary of Defense and maybe the Secretary of 
Veterans Affairs and the Deputy Secretary for Veterans Affairs, 
do you think if we got them in the room, knowing some of the 
personalities involved with that group, that they could come 
out with an org chart that would show responsibility for what 
actions? I mean, do we have to leave it to the heads to send a 
wire diagram down, or I mean, can that actually be done at your 
level in a prioritized manner?
    Ms. Thompson. We would be happy to do that if that is asked 
of us.
    Mr. Bergman. Okay, in other words, so if basically told to 
do something, you'll do it?
    Ms. Thompson. Yes, sir.
    Mr. Bergman. Okay, well, I guess we need to figure out--
yeah, yeah. So--yeah. In fact, the doctor and I are practicing 
the vulcan mind meld here, because my next question was, Ms. 
Harris, what do you think?
    Ms. Harris. As currently chartered and resourced, the 
office would not be able to function as an effective means for 
joint governance. So things would have to change, both in terms 
of staffing and resources.
    However, in addition, I think the root cause of why the IPO 
has been ineffective over the past decade is because it has had 
no authority or influence over the actions of the large and 
powerful organizations within DoD and VA that have 
responsibility for the Departments' electronic health record 
programs.
    Mr. Bergman. Okay, thank you.
    And, Mr. Chairman, I'll yield back the rest of my time.
    Mr. Banks. Thank you.
    I have one final brief question, which I will ask, and then 
I will defer to my colleagues on the Committee if they, too, 
might have a brief question before we conclude.
    Dr. Thompson, I recently visited the Seattle VA Medical 
Center, as you already know. I learned that personnel there had 
not been able to visit the nearby military health system 
facilities where Cerner has been implemented. It is my 
understanding, though, that they will now be permitted to do 
that. Is that correct?
    Ms. Thompson. Yes, that--that is correct.
    Mr. Banks. Okay, thank you.
    Do any of my colleagues--Ranking Member Lamb? Dr. Roe?
    Mr. Roe. One very quick.
    Ms. Harris, as we discussed this governance structure, do 
you think there should be one person, one entity, where the 
buck stops?
    Ms. Harris. Yes, sir.
    Mr. Roe. Okay, thank you.
    I yield back.
    Mr. Banks. Anybody else?
    Okay. Well, thank you once again to our witnesses for your 
testimony. If there are no further questions, the panel is now 
excused.
    This afternoon, we have heard a great deal about leadership 
and governance. The VA needs leaders to establish the 
governance, but the governance must be enduring because 
individual leaders will come and go. Unfortunately, we have 
seen far too much of that turnover in the early months of this 
program. The IPO, or the Interagency Program Office, is one of 
the few aspects of her modernization that is mandated by law. 
That means that it has a very important and permanent role to 
play in governance.
    Most everyone here today agrees the IPO needs to do more. 
My hope is DoD and VA will hash out what that looks like and 
come to mutual agreement. I am willing to give them additional 
time to do that, but I will not wait forever. The key decisions 
that will determine her modernization's future and prospects 
for success are being made over the next several months. I am 
skeptical of Congress imposing solutions, but we also have to 
keep the train safe on the tracks.
    Thank you to all of you again for your participation in 
today's hearing.
    I'd also like to thank the staff for helping make this a 
very productive first hearing of this Subcommittee.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    And, without objection, so ordered.
    The hearing is now adjourned.

    [Whereupon, at 3:22 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

               Prepared Statement of Dr. Lauren Thompson
    Chairman Banks, Ranking Member Lamb, and distinguished Members of 
the Subcommittee, thank you for the opportunity to testify before you 
today. I am honored to represent the Department of Defense (DoD) as the 
Director of the DoD/Veterans Affairs (VA) Interagency Program Office 
(IPO).The mission of the DoD/VA IPO is to lead and coordinate the 
adoption of and contribution to national health data standards to 
ensure health data interoperability among DoD, VA, and private sector 
healthcare worldwide. To give you a bit of history about the IPO, the 
Fiscal Year 2008 National Defense Authorization Act (NDAA) directed the 
DoD and VA to develop and implement electronic health record (EHR) 
systems or capabilities that allow for full interoperability of 
personal health care information between the DoD and the VA and 
directed the establishment of the IPO to guide both Departments in 
their efforts. In January 2009, the IPO completed its first charter, 
sharing its mission and functions with respect to attaining 
interoperable electronic health data. In March 2011, both secretaries 
of Defense and VA instructed the DoD and VA to develop a single, 
jointly integrated electronic health record.
    When the Departments decided to pursue the modernization of 
individual systems in 2014, the DoD decided to replace its older system 
by purchasing a new, commercial off-the-shelf solution and the VA 
decided to modernize its existing Veterans Health Information Systems 
and Technology Architecture (VistA) health information system. In 
December 2013, the IPO was rechartered to lead the efforts of the DoD 
and VA to implement national health data standards for interoperability 
and to establish, monitor, and approve clinical and technical standards 
for the integration of health data between both Departments and the 
private sector.

INTEROPERABILITY AND DATA SHARING

    The DoD and VA represent two of our nation's largest healthcare 
systems. Currently, the Departments share more than 1.5 million data 
elements daily, and more than 415,000 DoD and VA clinicians are able to 
view the real-time records of the more than 16 million patients who 
have received care from both Departments.
    Providing high-quality healthcare to service members, veterans, and 
their families is one of the IPO's highest priorities, and health data 
interoperability is essential to improving the care delivered. In April 
2016 the Departments, with the IPO's help, met a requirement of the 
Fiscal Year 2014 NDAA, certifying to Congress that their systems are 
interoperable with an integrated display of data. While the Departments 
met the required objectives, interoperability is a spectrum wherein 
data sharing and functionality can continually improve.
    The two Departments currently share health records through the 
Defense Medical Information Exchange (DMIX) program, which includes the 
Joint Legacy Viewer, a health information portal that aggregates data 
from across multiple data sources to provide read access to medical 
information across multiple government and commercial data sources. As 
a result, the Departments increased patient data accessed through Joint 
Legacy Viewer more than fivefold; including the over 1.5 million data 
elements shared daily between the DoD and VA combined.

    COLLABORATIVE DATA STANDARDS

    Today, working closely with the Office of the National Coordinator 
for Health Information Technology (ONC) and standards development 
organizations, the IPO supports the identification, implementation, and 
evolution of the national standards associated with both Departments' 
Electronic Health Records. These activities are vital to continue 
providing the building blocks necessary for the Departments to expand 
and improve their health data interoperability, both across the 
Departments and with private healthcare providers.
    The IPO is a collaborative entity, comprised of approximately 30 
staff members from both the DoD and VA who have technical expertise in 
health data standards and information sharing.
    Assisting the Departments with their interoperability and 
Electronic Health Record modernization milestones, the IPO serves as a 
central resource for the DoD and VA as they develop, adopt, and update 
a technical framework that is clinically driven to align identified 
standards with approved use cases. To that end, the IPO monitors 
industry best practices and provides technical guidance to facilitate 
health data exchange between the Departments and with private 
healthcare providers. The IPO also serves as a conduit for the 
Departments' engagement with the Office of the National Coordinator for 
Health Information Technology and standards development organizations 
to facilitate knowledge sharing on a national level. The IPO is 
integrated into the Office of the National Coordinator for Health 
Information Technology's planning for a national health IT ecosystem 
and is a key contributor to the Office of the National Coordinator for 
Health Information Technology's Interoperability Standards Advisory, a 
process that identifies standards to advance nationwide Health IT 
interoperability.

METRICS MONITORING

    The IPO also plays an important role in monitoring DoD and VA 
interoperability efforts.
    Specifically, the IPO established a Health Data Interoperability 
Metrics Dashboard to identify Department-specific targets for 
transactional metrics and trends, routinely shared with Congress.
    In addition to these efforts, and in conjunction with the 
Departments, the IPO implemented the Government Accountability Office's 
(GAO) recommendations that the DoD and VA adopt outcome-oriented 
metrics to provide a basis for assessing and reporting on the health 
data interoperability progress, which resulted in the DoD/VA IPO Health 
Outcome-Oriented Metrics Roadmap. The IPO continues to foster the 
development of metrics in collaboration with the Health Executive 
Committee's Health Data Sharing Business Line sub-workgroups, based on 
the Joint Interoperability Strategic Plan use cases, developing metrics 
for Separating Service Members and Integrated Disability Evaluation 
System, Patient Empowerment, Transitions of Care, and Population 
Health.

ELECTRONIC HEALTH RECORD COLLABORATION

    In July 2015, the DoD awarded a contract to the Leidos Inc. to 
deliver a modern, secure, and connected Electronic Health Record. The 
Leidos Partnership for Defense Health team consists of four core 
partners, Leidos Inc., as the prime integrator, and three primary 
partners in Cerner Corporation, Accenture, and Henry Schein Inc. The 
commercial electronic health record system, MHS GENESIS, provides a 
state of the market commercial off the shelf solution.
    Throughout 2017, the DoD achieved major milestones, deploying MHS 
GENESIS to Fairchild Air Force Base, Naval Health Clinic Oak Harbor, 
Naval Hospital Bremerton, and Madigan Army Medical Center, all in the 
state of Washington. The DoD plans to deploy MHS GENESIS to more than 
9.4 million beneficiaries and 205,000 medical personnel and staff by 
the end of 2023.
    In June 2017, VA announced its plans to adopt the same Electronic 
Health Record system as the DoD, and on May 17, 2018, VA signed a 
contract with Cerner Corporation. Both Departments using the same 
electronic health record system will ultimately result in a single 
software baseline and enable seamless care between them without the 
exchange and reconciliation of data between two separate systems. This 
decision will, over time, solve the problem of moving patient health 
record data between the Departments, as there will be a single, common 
clinical system. This decision is another step toward advancing 
Electronic Health Record adoption across the nation and is in the best 
interest of our service members, veterans, and their families.
    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. As a 
result, the IPO's role in facilitating collaboration between the DoD 
and VA is more vital than ever before. The IPO has been actively 
supporting the Departments with the development of a governance process 
to enable them to make joint decisions regarding common aspects of the 
Electronic Health Record solution. This process will involve multiple 
layers, from Department-level governance within the DoD and VA, to the 
interagency coordination and collaboration through working groups and 
committees that is already underway and facilitated by the IPO, to 
joint DoD/VA Electronic Health Record Modernization governance bodies. 
We expect these governance bodies to be in place by 2019.
    The joint Electronic Health Record Modernization governance bodies 
will focus on adjudicating only those issues that cannot be agreed upon 
through the existing interagency structures. The IPO will support the 
governance process, host meetings, manage information collection, and 
communicate assessments, meeting materials, action items, and 
decisions. The IPO will provide expertise and guidance implementing 
best practices and ensure a common standard operating procedure for 
capturing the artifacts needed to support decision-making by the 
Electronic Health Record Modernization governance bodies. The IPO will 
also be responsible for managing, organizing, and communicating 
decisions made by the governance bodies. However, the IPO will not 
redefine Departmental processes or function as a decision authority.

CONCLUSION

    The field of health data is constantly evolving. With the DoD and 
VA further enhancing interoperability through the implementation of the 
same Electronic Health Record, the IPO must continue collaboration with 
the Office of the National Coordinator for Health Information 
Technology and industry partners to ensure that the DoD and VA map 
their data to the latest national standards, and that the Office of the 
National Coordinator for Health Information Technology and the private 
sector can continue to learn from our experience.
    The IPO is fully committed to assisting the DoD and VA as they 
continue their modernization.
    Enabling health information exchange between systems in DoD, VA, 
and the private sector will serve as the foundation for a patient-
centric healthcare experience, seamless care transitions, and improved 
care for our service members, veterans, and their families.
    Again, thank you for this opportunity, and I look forward to your 
questions.

                                 ------
                 Prepared Statement of Carol C. Harris
ELECTRONIC HEALTH RECORDS

Clear Definition of the Interagency Program Office's Role in VA's New 
    Modernization Effort Would Strengthen Accountability

    Chairman Banks, Ranking Member Lamb, and Members of the 
Subcommittee:

    Thank you for the opportunity to participate in today's hearing on 
the Department of Defense (DoD) and Department of Veterans Affairs (VA) 
Interagency Program Office and the office's role regarding VA's 
Electronic Health Record Modernization (EHRM) program. As you know, 
these departments operate two of the nation's largest health care 
systems, which provide coverage to millions of veterans and active duty 
service members and their beneficiaries. The use of information 
technology (IT) is crucial to helping the departments effectively serve 
the nation's veterans and, each year, the departments spend billions of 
dollars on information systems and assets.
    Both VA and DoD have long recognized the importance of advancing 
the use of shared health information systems and capabilities to make 
patient information more readily available to their health care 
providers, reduce medical errors, and streamline administrative 
functions. Toward this end, the two departments have an extensive 
history of working to achieve shared health care resources. \1\ Over 
many years, however, the departments have experienced challenges in 
managing a number of critical initiatives related to modernizing major 
systems. Such initiatives include modernizing VA's electronic health 
information system--the Veterans Health Information Systems and 
Technology Architecture (VistA).
---------------------------------------------------------------------------
    \1\ Since the 1980s, VA and DoD have entered into many types of 
collaborations to provide health care services-including emergency, 
specialty, inpatient, and outpatient care-to VA and DoD beneficiaries, 
reimbursing each other for the services provided. These collaborations 
vary in scope, ranging from agreements to jointly provide a single type 
of service to more coordinated "joint ventures," which encompass 
multiple health care services and facilities and focus on mutual 
benefit, shared risk, and joint operations in specific clinical areas.
---------------------------------------------------------------------------
    To expedite the departments' efforts to exchange electronic health 
care information, Congress included in the National Defense 
Authorization Act for Fiscal Year 2008, provisions that required VA and 
DoD to jointly develop and implement electronic health record systems 
or capabilities and to accelerate the exchange of health care 
information. \2\ The act also required that these systems or 
capabilities be compliant with applicable interoperability \3\ 
standards, implementation specifications, and certification criteria of 
the federal government.
---------------------------------------------------------------------------
    \2\ Pub. L. No. 110-181, Sec.  1635, 122 Stat. 3, 460-463 (2008).
    \3\ According to the National Defense Authorization Act for Fiscal 
Year 2014, interoperability is the ability of different electronic 
health records systems or software to meaningfully exchange information 
in real time and provide useful results to one or more systems. See 
Pub. L. No. 113-66, Div. A, Title VII, Sec.  713, 127 Stat. 672, 794-
798 (Dec. 26, 2013).
---------------------------------------------------------------------------
    Further, the act established a joint Interagency Program Office to 
act as a single point of accountability for the electronic health care 
exchange efforts. The office was given the function of implementing, by 
September 30, 2009, electronic health record systems or capabilities 
that would allow for full interoperability of personal health care 
information between the departments.
    In addition, the act included a provision that GAO report on the 
progress that VA and DoD have made in achieving the goal of fully 
interoperable personal health care information. Our reports in response 
to this requirement included information on the departments' efforts to 
set up the joint Interagency Program Office. \4\ We also subsequently 
produced reports that have discussed the Interagency Program Office in 
relation to VA's efforts to develop a lifetime electronic health record 
capability for servicemembers and veterans, \5\ develop a joint 
electronic record capability with DoD \6\, and promote increased 
electronic health record system interoperability. \7\
---------------------------------------------------------------------------
    \4\ GAO, 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); Electronic Health Records: DoD's and 
VA's Sharing of Information Could Benefit from Improved Management, 
GAO-09-268 (Washington, D.C.: Jan. 28, 2009); Electronic Health 
Records: DoD and VA Efforts to Achieve Full Interoperability Are 
Ongoing; Program Office Management Needs Improvement, GAO-09-775 
(Washington, D.C.: July 28, 2009); and Electronic Health Records: DoD 
and VA Interoperability Efforts Are Ongoing; Program Office Needs to 
Implement Recommended Improvements, GAO-10-332 (Washington, D.C.: Jan. 
28, 2010).
    \5\ GAO, Electronic Health Records: DoD and VA Should Remove 
Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-
265 (Washington, D.C.: Feb. 2, 2011).
    \6\ GAO, Electronic Health Records: VA and DoD Need to Support Cost 
and Schedule Claims, Develop Interoperability Plans, and Improve 
Collaboration, GAO-14-302 (Washington, D.C.: Feb 27, 2014).
    \7\ GAO, Electronic Health Records: Outcome-Oriented Metrics and 
Goals Needed to Gauge DoD's and VA's Progress in Achieving 
Interoperability, GAO-15-530 (Washington, D.C.: Aug 13, 2015).
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    At your request, my testimony today summarizes findings from our 
prior work that examined the establishment and evolution of the 
Interagency Program Office over the last decade. The testimony also 
discusses the roles this office has played in VA's and DoD's efforts to 
increase interoperability and electronic health record capabilities, 
and any challenges the office has faced in doing so.
    In developing this testimony, we relied on our previous reports and 
testimonies related to the Interagency Program Office, as well as VA's 
and DoD's electronic health record system programs and modernization 
efforts. \8\ We also incorporated information on the departments' 
actions in response to recommendations we made in our previous reports. 
In addition, we discussed this testimony with the Executive Director of 
VA's EHRM office. The reports cited throughout this statement include 
detailed information on the scope and methodology of our prior reviews.
---------------------------------------------------------------------------
    \8\ GAO, VA IT Modernization: Preparations for Transitioning to a 
New Electronic Health Record System Are Ongoing, GAO-18-636T 
(Washington, D.C.: June 26, 2018); 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); Electronic 
Health Records: VA's Efforts Raise Concerns about Interoperability 
Goals and Measures, Duplication with DoD, and Future Plans, GAO-16-807T 
(Washington, D.C.: July 13, 2016); GAO-15-530; GAO-14-302; Electronic 
Health Records: Long History of Management Challenges Raises Concerns 
about VA's and DoD's New Approach to Sharing Health Information, GAO-
13-413T (Washington, D.C.: Feb 27, 2013); GAO-11-265; GAO-10-332; GAO-
09-775; GAO-09-268; and GAO-08-954.
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    We conducted the work on which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

Background

    Historically, patient health information has been scattered across 
paper records kept by many different caregivers in many different 
locations, making it difficult for a clinician to access all of a 
patient's health information at the time of care. Lacking access to 
these critical data, a clinician may be challenged in making the most 
informed decisions on treatment options, potentially putting the 
patient's health at risk.
    The use of technology to electronically collect, store, retrieve, 
and transfer clinical, administrative, and financial health information 
has the potential to improve the quality and efficiency of health care. 
Electronic health records are particularly crucial for optimizing the 
health care provided to military personnel and veterans. While in 
active military status and later as veterans, many DoD and VA 
personnel, along with their family members, tend to be highly mobile 
and may have health records residing at multiple medical facilities 
within and outside the United States.
    VA and DoD operate separate electronic health record systems that 
they rely on to create and manage patient health information. In 
particular, VA currently uses its integrated medical information 
system--VistA--which was developed in-house by the department's 
clinicians and IT personnel and has been in operation since the early 
1980s. \9\ Over the last several decades, VistA has evolved into a 
technically complex system comprised of about 170 modules that support 
health care delivery at 170 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.
---------------------------------------------------------------------------
    \9\ VistA began operation in 1983 as the Decentralized Hospital 
Computer Program. In 1996, the name of the system was changed to VistA.
---------------------------------------------------------------------------
    For its part, DoD relies on its Armed Forces Health Longitudinal 
Technology Application (AHLTA), which comprises multiple legacy medical 
information systems that were developed from commercial software 
products and customized for specific uses. For example, the Composite 
Health Care System (CHCS), which was formerly DoD's primary health 
information system, is used to capture information related to pharmacy, 
radiology, and laboratory order management. In addition, the department 
uses Essentris (also called the Clinical Information System), a 
commercial health information system customized to support inpatient 
treatment at military medical facilities.
    In July 2015, DoD awarded a contract for a new commercial 
electronic health record system to be developed by the Cerner 
Corporation. Known as MHS GENESIS, this system is intended to replace 
DoD's existing AHLTA system. The transition to MHS GENESIS began in 
February 2017 and implementation is expected to be complete throughout 
the department in 2022.

Interoperability: An Overview

    The sharing of health information among organizations is especially 
important because the health care system is highly fragmented, with 
care and services provided in multiple settings, such as physician 
offices and hospitals, that may not be able to coordinate patient 
medical care records. Thus, a means for sharing information among 
providers, such as between DoD's and VA's health care systems, is by 
achieving interoperability.
    The Office of the National Coordinator for Health IT, \10\ within 
the Department of Health and Human Services, has issued guidance, \11\ 
describing interoperability as:
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    \10\ The Office of the National Coordinator for Health IT is 
responsible for overseeing the certification of electronic health 
record technology, including establishing technical standards and 
certification criteria for it. Additionally, the Office of the National 
Coordinator is charged with formulating the federal government's health 
IT strategy and coordinating related policies, programs, and 
investments.
    \11\ Office of the National Coordinator for Health IT, Connecting 
Health and Care for the Nation: A Shared Nationwide Interoperability 
Roadmap Final Version 1.0. The definition of interoperability used in 
the Roadmap is derived from the Institute of Electrical and Electronics 
Engineers definition of interoperability.

    1.the ability of systems to exchange electronic health information 
---------------------------------------------------------------------------
and

    2. the ability to use the electronic health information that has 
been exchanged from other systems without special effort on the part of 
the user.

    Similarly, the National Defense Authorization Act for Fiscal Year 
2014 \12\ defines interoperability, per its use in the provision 
governing VA's and DoD's electronic health records, as ``the ability of 
different electronic health records systems or software to meaningfully 
exchange information in real time and provide useful results to one or 
more systems.'' Thus, in these contexts, interoperability allows 
patients' electronic health information to be available from provider 
to provider, regardless of where the information originated.
---------------------------------------------------------------------------
    \12\ Pub. L. No. 113-66, Div. A, Title VII, Sec.  713, 127 Stat. 
672, 794-798 (Dec. 26, 2013).
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    Achieving interoperability depends on, among other things, the use 
of agreed-upon health data standards \13\ to ensure that information 
can be shared and used. If electronic health records conform to 
interoperability standards, they potentially can be created, managed, 
and consulted by authorized clinicians and staff across more than one 
health care organization, thus providing patients and their caregivers 
the information needed for optimal care. Information that is 
electronically exchanged from one provider to another must adhere to 
the same standards in order to be interpreted and used in electronic 
health records, thereby permitting interoperability. \14\
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    \13\ Health data standards are one component that can be used to 
facilitate health information exchange and interoperability. Such 
standards consist of languages and technical specifications that, when 
adopted by multiple entities, facilitate the exchange of health 
information. Health data standards include, for example, standardized 
language for prescriptions and for laboratory testing.
    \14\ GAO, Electronic Health Records: HHS Strategy to Address 
Information Exchange Challenges Lacks Specific Prioritized Actions and 
Milestones, GAO-14-242 (Washington, D.C.: Mar. 24, 2014); and 
Electronic Health Record Programs: Participation Has Increased, but 
Action Needed to Achieve Goals, Including Improved Quality of Care, 
GAO-14-207 (Washington, D.C.: Mar. 6, 2014).
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    In the health IT field, standards may govern areas ranging from 
technical issues, such as file types and interchange systems, to 
content issues, such as medical terminology. \15\ On a national level, 
the Office of the National Coordinator has been assigned responsibility 
for identifying health data standards and technical specifications for 
electronic health record technology and overseeing the certification of 
this technology.
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    \15\ Developing, coordinating, and agreeing on standards are only 
parts of the processes involved in achieving interoperability for 
electronic health records systems or capabilities. In addition, 
specifications are needed for implementing the standards.
---------------------------------------------------------------------------
    In addition to exchanging the information, systems must be able to 
use the information that is exchanged. Thus, if used in a way that 
improves providers' and patients' access to critical information, 
electronic health record technology has the potential to improve the 
quality of care that patients receive and to reduce health care costs. 
For example, with interoperability, medical providers have the ability 
to query data from other sources while managing chronically ill 
patients, regardless of geography or the network on which the data 
reside.

VA and DoD Have a Long History of Efforts to Achieve Electronic Health 
    Record Interoperability

    Since 1998, DoD and VA have relied on a patchwork of initiatives 
involving their health information systems to exchange information and 
increase electronic health record interoperability. These have included 
initiatives to share viewable data in existing (legacy) systems; link 
and share computable data between the departments' updated health data 
repositories; develop a virtual lifetime electronic health record to 
enable private sector interoperability; implement IT capabilities for 
the first joint federal health care center; and jointly develop a 
single integrated system. Table 1 provides a brief description of the 
history of these various initiatives.
[GRAPHIC] [TIFF OMITTED] T5832.001

    In addition to the initiatives mentioned in table 1, DoD and VA 
previously responded to provisions in the National Defense 
Authorization Act for Fiscal Year 2008 directing the departments to 
jointly develop and implement fully interoperable electronic health 
record systems or capabilities in 2009. \16\ The act also called for 
the departments to set up the Interagency Program Office to be a single 
point of accountability for their efforts to implement these systems or 
capabilities by the September 30, 2009, deadline.
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    \16\ Pub. L. No. 110-181, Sec.  1635, 122 Stat. 3, 460-463 (2008).

The Interagency Program Office Has Not Functioned as the Single Point 
    of Accountability for VA and DoD's Efforts to Increase Electronic 
---------------------------------------------------------------------------
    Health Record Interoperability

    The Interagency Program Office has been involved in the various 
approaches taken by VA and DoD to increase health information 
interoperability and modernize their respective electronic health 
record systems. These approaches have included development of the 
Virtual Lifetime Electronic Record (VLER) and a new, common integrated 
electronic health record (iEHR) system. However, although the 
Interagency Program Office has led efforts to identify data standards 
that are critical to interoperability between systems, the office has 
not been effectively positioned to be the single point of 
accountability as called for in the National Defense Authorization Act 
for Fiscal Year 2008. Moreover, the future role of the office with 
respect to VA's current electronic health record modernization program 
is uncertain.

The Interagency Program Office Became Operational, but Was Not 
    Positioned to Be the Single Point of Accountability for Achieving 
    Interoperability

    Although VA and DoD took steps to set up the Interagency Program 
Office, the office was not positioned to be the single point of 
accountability for the departments' efforts to achieve electronic 
health record interoperability by September 30, 2009. When we first 
reported on its establishment in July 2008, VA and DoD's efforts to set 
up the office were still in their early stages. \17\ Leadership 
positions in the office were not yet permanently filled, staffing was 
not complete, and facilities to house the office had not been 
designated. Further, the implementation plan for setting up the office 
was in draft and, although the plan included schedules and milestones, 
the dates for several activities (such as implementing a capability to 
share immunization records) had not yet been determined, even though 
all capabilities were to be achieved by September 2009.
---------------------------------------------------------------------------
    \17\ GAO-08-954.
---------------------------------------------------------------------------
    We concluded that without a fully established program office and a 
finalized implementation plan with set milestones, the departments 
could be challenged in meeting the required date for achieving 
interoperability. Accordingly, we recommended that the departments give 
priority to fully establishing the office by putting in place permanent 
leadership and staff, as well as finalizing the draft implementation 
plan. Both departments agreed with this recommendation.
    We later reported in January 2009 that VA and DoD had continued to 
take steps to set up the Interagency Program Office. \18\ For example, 
the departments had developed descriptions for key positions within the 
office. In addition, the departments had developed a document that 
depicted the Interagency Program Office's organizational structure; 
they also had approved a program office charter to describe, among 
other things, the mission and functions of the office.
---------------------------------------------------------------------------
    \18\ GAO-09-268.
---------------------------------------------------------------------------
    However, we pointed out that VA and DoD had not yet fully executed 
their plan to set up the office. For example, among other activities, 
they had not filled key positions for the Director and Deputy Director, 
or for 22 of 30 other positions identified for the office.
    Our report stressed that, in the continued absence of a fully 
established Interagency Program Office, the departments would remain 
ineffectively positioned to assure that interoperable electronic health 
records and capabilities would be achieved by the required date. Thus, 
we recommended that the departments develop results-oriented 
performance goals and measures to be used as the basis for reporting 
interoperability progress. VA and DoD agreed with our recommendation.
    Nevertheless, in a subsequent July 2009 report, we noted that the 
Interagency Program Office was not effectively positioned to function 
as a single point of accountability for the implementation of fully 
interoperable electronic health record systems or capabilities between 
VA and DoD. \19\ While the departments had made progress in setting up 
the office by hiring additional staff, they continued to fill key 
leadership positions on an interim basis. Further, while the office had 
begun to demonstrate responsibilities outlined in its charter, it was 
not yet fulfilling key IT management responsibilities in the areas of 
performance measurement (as we previously recommended), project 
planning, and scheduling, which were essential to establishing the 
office as a single point of accountability for the departments' 
interoperability efforts. Thus, we recommended that the departments 
improve the management of their interoperability efforts by developing 
a project plan and a complete and detailed integrated master schedule. 
VA and DoD stated that they agreed with this recommendation.
---------------------------------------------------------------------------
    \19\ GAO-09-775.
---------------------------------------------------------------------------
    In our January 2010 final report in response to the National 
Defense Authorization Act for Fiscal Year 2008, we noted that VA and 
DoD officials believed they had satisfied the act's September 30, 2009, 
requirement for full interoperability by meeting specific 
interoperability-related objectives that the departments had 
established. \20\ These objectives included: refine social history 
data, share physical exam data, and demonstrate initial document 
scanning between the departments.
---------------------------------------------------------------------------
    \20\ GAO-10-332.
---------------------------------------------------------------------------
    Additionally, the departments had made progress in setting up their 
Interagency Program Office by hiring additional staff, including a 
permanent director. In addition, consistent with our recommendations in 
the three previously mentioned reports, the office had begun to 
demonstrate responsibilities outlined in its charter in the areas of 
scheduling, planning, and performance measurement.
    Nevertheless, the office's efforts in these areas did not fully 
satisfy the recommendations and were incomplete. Specifically, the 
office did not have a schedule that included information about tasks, 
resource needs, or relationships between tasks associated with ongoing 
activities to increase interoperability. Also, key IT management 
responsibilities in the areas of planning and performance measurement 
remained incomplete. We reiterated that, by not having fulfilled key 
management responsibilities, as we had previously recommended, the 
Interagency Program Office continued to not be positioned to function 
as a single point of accountability for the delivery of the future 
interoperable capabilities that the departments were planning.

The Interagency Program Office Was to Be the Single Point of 
    Accountability for Establishing a Lifetime Electronic Record for 
    Servicemembers and Veterans, but VA and DoD Did Not Develop 
    Complete Plans for the Effort

    Although the Interagency Program Office charter named the office as 
the single point of accountability for the initiative, the office did 
not have key plans to define and guide the effort. In April 2009, the 
President announced that VA and DoD would work together to define and 
build VLER to streamline the transition of electronic medical, 
benefits, and administrative information between the two departments. 
VLER was intended to enable access to all electronic records for 
service members as they transition from military to veteran status, and 
throughout their lives. Further, the initiative was to expand the 
departments' health information sharing capabilities by enabling access 
to private sector health data.
    Shortly after the April 2009 announcement, VA, DoD, and the 
Interagency Program Office began working to define and plan for the 
VLER initiative. Further, the office was rechartered in September 2009 
and named as the single point of accountability for the coordination 
and oversight of jointly approved IT projects, data, and information 
sharing activities, including VLER.
    In our February 2011 report on the departments' efforts to address 
their common health IT needs, we noted that, among other things, the 
Interagency Program Office had not developed an approved integrated 
master schedule, master program plan, or performance metrics for the 
VLER initiative, as outlined in the office's charter. \21\ We noted 
that if the departments did not address these issues, their ability to 
effectively deliver capabilities to support their joint health IT needs 
would be uncertain. Thus, we recommended that the Secretaries of VA and 
DoD strengthen their efforts to establish VLER by developing plans that 
would include scope definition, cost and schedule estimation, and 
project plan documentation and approval. Although the departments 
stated they agreed with this recommendation, they did not implement it.
---------------------------------------------------------------------------
    \21\ GAO-11-265.

The Interagency Program Office Was Responsible for the Development of a 
    Joint Electronic Health Record System for VA and DoD, but the 
---------------------------------------------------------------------------
    Office Was Not Positioned for Effective Collaboration

    The Interagency Program Office was assigned responsibility for the 
development of an electronic health record system that VA and DoD were 
to share. However, the departments did not provide the office with 
control over the resources (i.e., funds and staff) it needed to 
facilitate effective collaboration.
    In March 2011, the Secretaries of VA and DoD committed the two 
departments to developing the iEHR system, and in May 2012 announced 
their goal of implementing it across the departments by 2017. To 
oversee this new effort, in October 2011, VA and DoD re-chartered the 
Interagency Program Office to give it increased authority, expanded 
responsibilities, and increased staffing levels for leading the 
integrated system effort. The new charter also gave the office 
responsibility for program planning and budgeting, acquisition and 
development, and implementation of clinical capabilities. However, in 
February 2013, the Secretaries of VA and DoD announced that they would 
not continue with their joint development of a single electronic health 
record system.
    In February 2014, we reported on the departments' decision to 
abandon their plans for iEHR. \22\ Specifically, we reported that VA 
and DoD had not addressed management barriers to effective 
collaboration on their joint health IT efforts. For example, the 
Interagency Program Office was intended to better position the 
departments to collaborate, but the departments had not implemented the 
office in a manner consistent with effective collaboration. 
Specifically, the Interagency Program Office lacked effective control 
over essential resources such as funding and staffing. In addition, 
decisions by the departments had diffused responsibility for achieving 
integrated health records, potentially undermining the office's 
intended role as the single point of accountability.
---------------------------------------------------------------------------
    \22\ GAO-14-302.
---------------------------------------------------------------------------
    We concluded that providing the Interagency Program Office with 
control over essential resources and clearer lines of authority would 
better position it for effective collaboration. Further, we recommended 
that VA and DoD better position the office to function as the single 
point of accountability for achieving interoperability between the 
departments' electronic health record systems by ensuring that the 
office has authority (1) over dedicated resources (e.g., budget and 
staff), (2) to develop interagency processes, and (3) to make decisions 
over the departments' interoperability efforts. Although VA and DoD 
stated that they agreed with this recommendation, they did not 
implement it.

The Interagency Program Office Subsequently Took Steps to Improve 
    Interoperability Measurement and Additional Actions Are Planned

    In light of the departments' not having implemented a solution that 
allowed for seamless electronic sharing of medical health care data, 
the National Defense Authorization Act for Fiscal Year 2014 included 
requirements pertaining to the implementation, design, and planning for 
interoperability between VA and DoD's separate electronic health record 
systems. Among other things, the departments were each directed to (1) 
ensure that all health care data contained in VA's VistA and DoD's 
AHLTA systems complied with national standards and were computable in 
real time by October 1, 2014, and (2) deploy modernized electronic 
health record software to support clinicians while ensuring full 
standards-based interoperability by December 31, 2016.
    In August 2015, we reported that VA and DoD, with guidance from the 
Interagency Program Office, had taken actions to increase 
interoperability between their electronic health record systems. \23\ 
Among other things, the departments had initiated work focused on near-
term objectives, including standardizing their existing health data and 
making them viewable by both departments' clinicians in an integrated 
format. The departments also developed longer-term plans to modernize 
their respective electronic health record systems. For its part, the 
Interagency Program Office issued guidance outlining the technical 
approach for achieving interoperability between the departments' 
systems.
---------------------------------------------------------------------------
    \23\ GAO-15-530.
---------------------------------------------------------------------------
    However, even with the actions taken, VA and DoD did not certify by 
the October 1, 2014, deadline established in the National Defense 
Authorization Act for Fiscal Year 2014 for compliance with national 
data standards that all health care data in their systems complied with 
national standards and were computable in real time.
    We also reported that the departments' system modernization plans 
identified a number of key activities to be implemented beyond December 
31, 2016--the deadline established in the act for the two departments 
to deploy modernized electronic health record software to support 
clinicians while ensuring full standards-based interoperability. 
Specifically, DoD had issued plans and announced the contract award for 
acquiring a modernized system to include interoperability capabilities 
across military operations. VA had issued plans describing an 
incremental approach to modernizing its existing electronic health 
records system. These plans--if implemented as described--indicated 
that deployment of the new systems with interoperability capabilities 
would not be completed across the departments until after 2018.
    With regard to its role, the Interagency Program Office had taken 
steps to develop process metrics intended to monitor progress related 
to the data standardization and exchange of health information 
consistent with its responsibilities. For example, it had issued 
guidance that calls for tracking metrics, such as the percentage of 
data domains within the departments' current health information systems 
that are mapped to national standards.
    However, the office had not yet specified outcome-oriented metrics 
and established related goals that are important to gauging the impact 
that interoperability capabilities have on improving health care 
services for shared patients. As a result, we recommended that VA and 
DoD, working with the Interagency Program Office, take actions to 
establish a time frame for identifying outcome-oriented metrics, define 
goals to provide a basis for assessing and reporting on the status of 
interoperability-related activities and the extent to which 
interoperability is being achieved by the departments' modernized 
electronic health record systems, and update Interagency Program Office 
guidance to reflect the metrics and goals identified.
    Subsequently, we reported that VA and DoD had certified in April 
2016 that all health care data in their systems complied with national 
standards and were computable in real time. \24\ However, VA 
acknowledged that it did not expect to complete a number of key 
activities related to its electronic health record system until 
sometime after the December 31, 2016, statutory deadline for deploying 
modernized electronic health record software with interoperability.
---------------------------------------------------------------------------
    \24\ GAO-16-807T.
---------------------------------------------------------------------------
    Further, in following up on implementation of the recommendations 
in our August 2015 report, we found that VA, DoD, and the Interagency 
Program Office had addressed the recommendations in full by updating 
guidance to include goals and objectives and an approach to developing 
metrics that would improve the departments' ability to report on the 
status of interoperability activities.

The Interagency Program Office's Role in Governing VA's New Electronic 
    Health Record System Acquisition Is Uncertain

    In June 2017, the former VA Secretary announced a significant shift 
in the department's approach to modernizing the department's electronic 
health record system. 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. 
\25\
---------------------------------------------------------------------------
    \25\ In July 2015, DoD awarded a $4.3 billion contract for a 
commercial electronic health record system developed by Cerner, to be 
known as MHS GENESIS. The transition to the new system began in 
February 2017 in the Pacific Northwest region of the United States and 
is expected to be completed in 2022. The former Secretary of Veterans 
Affairs signed a "Determination and Findings," to justify use of the 
public interest exception to the requirement for full and open 
competition, and authorized VA to issue a solicitation directly to 
Cerner. A "Determination and Findings" means a special form of written 
approval by an authorized official that is required by statute or 
regulation as a prerequisite to taking certain contract actions. The 
"Determination" is a conclusion or decision supported by the 
"Findings.'' The findings are statements of fact or rationale essential 
to support the determination and must cover each requirement of the 
statute or regulation. FAR, 48 C.F.R. Sec.  1.701.
---------------------------------------------------------------------------
    Accordingly, the department awarded a contract to Cerner in May 
2018 for a maximum of $10 billion over 10 years. Cerner is to replace 
VistA with a commercial electronic health record system. This new 
system is to support a broad range of health care functions that 
include, for example, acute care, clinical decision support, dental 
care, and emergency medicine. When implemented, the new system will be 
expected to provide access to authoritative clinical data sources and 
become the authoritative source of clinical data to support improved 
health, patient safety, and quality of care provided by VA.
    Deployment of the new electronic health record system at three 
initial sites is planned for within 18 months of October 1, 2018, \26\ 
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.
---------------------------------------------------------------------------
    \26\ The three initial deployment sites are the Mann-Grandstaff, 
American Lake, and Seattle VA Medical Centers.
---------------------------------------------------------------------------
    As we testified in June 2018, VA has taken steps to establish a 
program management office and has drafted a structure for technology, 
functional, and joint governance of the electronic health record 
implementation. \27\ Specifically, in January 2018, the former VA 
Secretary established the Electronic Health Record Modernization (EHRM) 
program office that reports directly to the VA Deputy Secretary.
---------------------------------------------------------------------------
    \27\ GAO-18-636T.
---------------------------------------------------------------------------
    Further, VA has drafted a memorandum that describes the role of 
governance bodies within VA, as well as governance intended to 
facilitate coordination between the department and DoD. 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 and coordinate with DoD, as appropriate. Further, a 
joint governance structure between VA and DoD has been proposed that 
would be expected to leverage existing joint governance facilitated by 
the Interagency Program Office.
    Nevertheless, while VA'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. Accordingly, the officials 
have not yet indicated what role, if any, the Interagency Program 
Office is to have in the governance process.

Conclusions

    The responsibilities of the Interagency Program Office have been 
intended to support the numerous approaches taken by VA and DoD to 
increase health information interoperability and modernize their 
respective electronic health record systems. Yet, while the office has 
led key efforts to identify data standards that are critical to 
interoperability between systems, the office has not been effectively 
positioned to be the single point of accountability originally 
described in the National Defense Authorization Act for Fiscal Year 
2008. Further, the future role of the Interagency Program Office 
remains unclear despite the continuing need for VA and DoD to share the 
electronic health records of servicemembers and veterans. In 
particular, what role, if any, that the office is to have in VA's 
acquisition of the same electronic health record system that DoD is 
currently acquiring is uncertain.

Recommendation for Executive Action

    We are making the following recommendation to VA:

    The Secretary of Veterans Affairs should ensure that the role and 
responsibilities of the Interagency Program Office are clearly defined 
within the governance plans for acquisition of the department's new 
electronic health record system. (Recommendation 1)

    Chairman Banks, Ranking Member Lamb, and Members of the 
Subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions that you may have at this time.

GAO Contact and Staff Acknowledgments

    If you or your staffs have any questions about this testimony, 
please contact Carol C. Harris, Director, Information Technology 
Acquisition Management Issues, at (202) 512-4456 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 testimony are Mark Bird 
(Assistant Director), Jennifer Stavros-Turner (Analyst in Charge), 
Rebecca Eyler, Jacqueline Mai, Scott Pettis, and Charles Youman.

                             GAO HIGHLIGHTS

What GAO Found

    Since its establishment in 2008, the Department of Defense (DoD) 
and Department of Veterans Affairs (VA) Interagency Program Office has 
been involved in various approaches to increase health information 
interoperability. However, the office has not been effectively 
positioned to function as the single point of accountability for the 
departments' electronic health record system interoperability efforts. 
For example,

      Between July 2008 and January 2010, GAO issued reports on 
VA's and DoD's efforts to set up the office, which highlighted steps 
the departments had taken, but also identified deficiencies, such as 
vacant leadership positions and a lack of necessary plans. GAO 
recommended that the departments improve management of their 
interoperability efforts by developing a project plan and results-
oriented performance goals and measures.
      In April 2009, the Interagency Program Office was 
assigned responsibility for establishing a lifetime electronic record 
for servicemembers and veterans, called the Virtual Lifetime Electronic 
Record. GAO reported in February 2011 that, among other things, the 
office had not developed and approved an integrated master schedule, a 
master program plan, or performance metrics for the initiative, as 
outlined in the office's charter. Accordingly, GAO recommended that the 
departments correct these deficiencies to strengthen their efforts to 
establish the Virtual Lifetime Electronic Record.
      In March 2011, VA and DoD committed to jointly developing 
a new, common integrated electronic health record system and empowered 
the Interagency Program Office with increased authority, expanded 
responsibilities, and increased staffing levels for leading the 
integrated system effort. However, in February 2013, the departments 
abandoned their plan to develop the integrated system and stated that 
they would again pursue separate modernization efforts. In February 
2014, GAO reported on this decision and recommended that VA and DoD 
take steps to better position the office to function as the single 
point of accountability for achieving interoperability between the 
departments' electronic health record systems.

    VA and DoD stated that they agreed with the above GAO 
recommendations. However, in several cases the departments' subsequent 
actions were incomplete and did not fully address all recommendations.
    In June 2017 VA announced that it planned to acquire the same 
electronic health record system that DoD has been acquiring. GAO 
testified in June 2018 that a governance structure had been proposed 
that would be expected to leverage existing joint governance 
facilitated by the Interagency Program Office. At that time, VA's 
program officials had stated that the department's governance plans for 
the new program were expected to be finalized in October 2018. However, 
the officials have not yet indicated what role, if any, the Interagency 
Program Office is to have in the governance process. Ensuring that the 
role and responsibilities of the office are clearly defined within 
these governance plans is essential to VA successfully acquiring and 
implementing the same system as DoD.
    View GAO-18-696T. For more information, contact Carol C. Harris at 
(202) 512-4456 or [email protected].
    Highlights of GAO-18-696T, a testimony before the Subcommittee on 
Technology Modernization, Committee on Veterans' Affairs, House of 
Representatives

ELECTRONIC HEALTH RECORDS

Clear Definition of the Interagency Program Office's Role in VA's New 
    Modernization Effort Would Strengthen Accountability

Why GAO Did This Study

    The National Defense Authorization Act for Fiscal Year 2008 
included provisions that VA and DoD jointly develop and implement 
electronic health record systems or capabilities and accelerate the 
exchange of health care information. The act also required that these 
systems be compliant with applicable interoperability standards. 
Further, the act established a joint Interagency Program Office to act 
as a single point of accountability for the efforts, with the function 
of implementing, by September 30, 2009, electronic health record 
systems that allow for full interoperability.
    This testimony discusses GAO's previously reported findings on the 
establishment and evolution of the Interagency Program Office over the 
last decade. In developing this testimony, GAO summarized findings from 
its reports issued in 2008 through 2018, and information on the 
departments' actions in response to GAO's recommendations.

What GAO Recommends

    GAO recommends that VA clearly define the role and responsibilities 
of the Interagency Program Office in the governance plans for 
acquisition of the department's new electronic health record system.

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