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


  180-DAY REVIEW OF THE ELECTRONIC HEALTH RECORD MODERNIZATION PROGRAM

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

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                 OF THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION
                               __________

                      WEDNESDAY, NOVEMBER 14, 2018
                               __________

                           Serial No. 115-80
                               __________

       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
                    
35-834                    WASHINGTON : 2019                      
                     
                     
                                          
                     
                     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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                      Wednesday, November 14, 2018

                                                                   Page

180-Day Review Of The Electronic Health Record Modernization 
  Program........................................................     1

                           OPENING STATEMENTS

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

                               WITNESSES

Mr. John Windom, Executive Director, Office of Electronic Health 
  Record Modernization, U.S. Department of Veterans Affairs......     3
    Prepared Statement...........................................    25
        Accompanied by:

    Dr. Laura Kroupa, Acting Chief Medical Officer, Office of 
        Electronic Health Record Modernization, U.S. Department 
        of Veterans Affairs

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

    Mr. Travis Dalton, President of Government Services, Cerner


 
  180-DAY REVIEW OF THE ELECTRONIC HEALTH RECORD MODERNIZATION PROGRAM

                              ----------                              


                      Wednesday, November 14, 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 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Jim Banks 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Banks, Coffman, Bergman, and Lamb.
    Also Present: Representative Roe.

            OPENING STATEMENT OF JIM BANKS, CHAIRMAN

    Mr. Banks. Good morning.
    The Subcommittee will come to order.
    Thank you all for being here today for the second hearing 
of the Subcommittee on Technology and Modernization on the 
electronic health record.
    It has been almost exactly 180 days since the VA awarded 
the Cerner contract and began the Electronic Health Record 
Modernization, EHRM, program. We are here today to get a status 
report.
    Federal agencies brief congressional committees on programs 
in private nearly every day. However, for this particular 
program, I believe it should periodically happen in public.
    A lot has happened since May: The Office of EHRM has mostly 
taken shape. VA formed councils of health care providers to vet 
Cerner EHR and its workflows. Cerner has begun traveling to the 
initial implementation sites in Spokane and Seattle and has 
assessed their readiness. Cerner has studied the suitability of 
Military Health System Genesis, the Defense Department's Cerner 
EHR, as the baseline for VA. And VA has begun infrastructure 
upgrades at the first medical centers.
    At some point next year, implementation will begin in 
earnest in Spokane and Seattle. The structure is mostly in 
place, but there is an enormous number of dots to connect. 
High-level organizational questions are still not settled. The 
workflow councils have a series of meetings spanning much of 
next year in which to hash out how the system should be 
configured.
    VA has over 1,200 distinct decisions to make, often 
necessitating coordination with DoD. The infrastructure 
upgrades, many of which will entail digging trenches and 
ripping out walls, will need to line up with the implementation 
schedule.
    Practical problems, from the mundane to the esoteric, will 
undoubtedly arise. VA has already run into some. For example, 
nearly all of the computers in Spokane and Seattle are 
reportedly incompatible with Cerner and are being replaced.
    We are moving into the middle of the beginning. VA has 
outlined the program, identified the next steps, and generally 
called out the dependencies and risks. What comes next is 
detailed plans and schedules. Only then will we truly know what 
to expect and what VA has bought.
    I would like to take this occasion to address some 
persistent questions and clarify some jargon.
    First, community provider interoperability has always been 
the elephant in the room. VA-DoD interoperability is very 
important, but VA is much farther behind in exchanging records 
with its community partners. There are many helpful tools, like 
health information exchanges, but no out-of-the-box EHR system 
completely solves this problem. No matter which EHR VA 
selected, more work would be needed to achieve interoperability 
with community health systems.
    The VA has been actively grappling with this challenge for 
over a year now. The delays in awarding a contract were a 
result.
    Now, some in the media see the, quote, ``Mar-a-Lago crowd'' 
behind every unexplained or unfavorable development. I can't 
speak to that. What I do know is that community 
interoperability is a very real problem, and for $16 billion, 
VA had better solve it.
    The result of months of reviews by some of the best experts 
money can buy was language written into the contract concerning 
data standards, data rights, and future obligations of Cerner 
to advance interoperability. Not quite an answer, but paths to 
an answer.
    It all means nothing if VA and Cerner do not follow through 
though. I am not ready to sound the alarm yet, but I have heard 
very little about this subject since taking on this role. I 
have expressed my concern about what seems to be a loss of 
focus on innovation.
    Secondly, there was a spirited debate between VA and DoD 
about what, quote, ``single common system,'' end quote, means. 
As the debate progressed, it became clear that their ability to 
interoperate seamlessly hinged on it.
    Some thought it meant are both departments merely need to 
install the Cerner EHR or perhaps the same version of the EHR. 
That is apparently not enough. In the industry jargon, they 
must have a single instance.
    That means both departments have to pull their patient data 
from the same database, which means the two implementations 
have to be joined at the hip. It raises the stakes. It is 
important to put this reality out in the open and early.
    Thirdly, I expect there will be a lot of discussion this 
morning about standardization. That means VHA eliminating 
needless variations in how different facilities deliver care. 
It is a goal throughout health care, but not all 
standardization is the same. I am concerned VA may not be 
standardizing against any well-defined goal, instead 
standardizing by default. It is not possible to accommodate 
what every single doctor and nurse wants, but the people 
running the EHRM program need to understand what they want and 
why.
    Relatedly, I expect to hear the term ``Cerner best 
practices.'' ``Cerner best practices'' means out-of-the-box, 
standard EHR functionality. More best practices mean fewer 
variations.
    Finally, we are going to discuss risk. Some risks are 
specific to this particular EHR transition. However, other 
risk, probably more risk, would be the same regardless of the 
EHR system chosen. The fact is unwinding VistA is much more 
difficult than installing any EHR in its place.
    I have high expectations, though, for the VA. I believe in 
transparency and reality. Frankly, the more I have learned 
about the EHRM program, the more daunting it has become. But 
this discussion inevitably becomes about doing anything or 
doing nothing. Doing anything is hard; doing nothing is easy.
    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 have many questions 
but no opening statement, so I will yield back.
    Mr. Banks. Thank you, Ranking Member Lamb.
    I would now like to welcome our first and only panel, who 
are seated at the witness table.
    On the panel, we have the Executive Director of the VA 
Office of Electronic Health Record Modernization, Mr. John 
Windom. He is accompanied by the office's Acting Chief Medical 
Officer, Dr. Laura Kroupa, and his Chief Technology Integration 
Officer, Mr. John Short. Additionally, we have Mr. Travis 
Dalton, president of Cerner government services.
    I ask the witnesses to please stand and raise your right 
hands.
    [Witnesses sworn.]
    Mr. Banks. Let the record reflect that all witnesses have 
answered in the affirmative.
    You may take a seat.
    The Subcommittee has asked Mr. Dalton to be present to 
answer Members' questions, not to present a formal statement. 
Therefore, Mr. Windom will present the only opening statement.
    Mr. Windom, you are now recognized for 5 minutes.

                    STATEMENT OF JOHN WINDOM

    Mr. Windom. Thank you, Mr. Chairman, Ranking Member.
    Congressman Roe, thank you for joining us as well.
    Good morning, Chairman. Thanks, Ranking Member Lamb and 
distinguished Members of this Subcommittee. Thank you for the 
opportunity to testify on the status of VA's efforts to 
modernize our electronic health record, or EHR.
    I am accompanied by Dr. Kroupa, the Office of Electronic 
Health Record Modernization, or EHRM's, Acting Chief Medical 
Officer, and Mr. John Short, OEHRM's Technology Integration 
Officer.
    First, I want to take time to personally thank each of the 
Members of the Subcommittee for your continued support and 
shared commitment to the program's success. Because of your 
ongoing support, VA has been able to adhere to the 
implementation schedule while being a good steward of the 
taxpayers' dollars.
    As you are well aware, VA's current EHR system, VistA, is 
unsustainable and cannot deliver critical capabilities to meet 
the evolving needs of the health care market. Through the EHR 
modernization effort, or EHRM, VA is working to provide 
veterans with access to a complete medical record by adopting 
the same EHR solution as DoD, allowing patient data to reside 
in a single hosting site, using a single common system. This 
will enable the seamless transfer of health data as 
servicemembers transition from Active Duty to veteran status to 
allow us to leverage an existing commercial solution to achieve 
interoperability within the VA, between the VA and DoD, and 
between VA and community care providers.
    VA's multiyear implementation strategy will evolve as 
technology advances. It includes deploying the solution at 
initial operating capability sites to identify problems and 
correct them before deploying to additional sites. As 
challenges arise throughout the deployment, VA will work 
swiftly to mitigate potential impacts to veterans' health care.
    Since VA provided testimony on EHRM before the Full 
Committee in June 2018, VA has accomplished several key 
milestones I want to highlight.
    First, VA awarded three additional task orders that include 
data migration, enterprise interface development, functional 
baseline design and development, and IOC deployment.
    Secondly, in June 2018, VA established OEHRM to provide 
oversight to the implementation. The office will ensure VA 
successfully deploys and maintains the new EHR solution and the 
health IT tools dependent upon it.
    Additionally, in July 2018, VA and Cerner conducted a 
current-state review at VA's IOC sites. This provided VA with 
details of each site's specific as-is states and how it aligns 
with commercial standards to implement the proposed state.
    Furthermore, because VA is committed to closely aligning 
its workflows with commercial best practices, it commissioned 
Cerner to complete a baseline assessment of how closely DoD's 
EHR solution aligns with these practice. Cerner provided VA 
with the analysis in September 2018, which revealed DoD's new 
EHR is, in general, in alignment with commercial best 
practices.
    Also in September, VA held its model validation event, 
where it began the national and local workflow development 
processes for the new EHR solution. During this event, there 
were a series of working sessions designed to examine Cerner 
commercial-recommended workflows against VA's. This enables VA 
to configure its workflows to best meet the needs of our 
veterans while also implementing commercial best practices.
    Finally, VA established 18 EHR councils, primarily 
comprised of clinicians in the field, to enable the 
configuration of national standardized clinical and business 
workflows.
    To ensure the appropriate VA and DoD coordination, there 
remains an emphasis on transparency throughout the integrated 
governance both within and across VA. At an interagency level, 
VA and DoD are committed to instituting optimal organizational 
design that prioritizes accountability and advances synergy 
between VA and DoD.
    The Department has established an interagency working group 
which meets regularly to review use cases and collaborate on 
best practices to ensure interoperability objectives are 
achieved between VA and the DoD. By learning from the DoD, VA 
is able to proactively address challenges and further reduce 
potential risk at VA's IOC sites.
    Mr. Chairman, this concludes my opening statement. I am 
happy to answer any questions that you or the Members of the 
Subcommittee may have, and thank you very much for the 
opportunity.
    Sir, I want to add some additional remarks with my time. 
There's been a number of articles posted. I look forward to 
answering whatever questions or concerns that have you 
regarding those articles.
    I just want to remind you, you know, Chairman, you're a 
naval officer. I've served 34 years in the Navy. I have 
performed on teams, I have supported teams, I've led teams. We 
are building a team in VA.
    I have an uncle, Wendell Davis, who just entered into 
hospice in the VA St. Louis Medical Center, has about 10 days 
left. This is not only personal, it's important to our 
veterans, which I am one of. We remain committed to fulfill the 
objectives of the VA and what you've charged us to do.
    Thank you.

    [The prepared statement of John Windom appears in the 
Appendix]

    Mr. Banks. Thank you, Mr. Windom.
    I'll begin the questioning.
    Mr. Windom, let's begin with a budget and the cost 
estimate. Please let me know if I have the following facts 
correct. As a result of this Cerner contract being awarded 
later than planned, you had $205 million unspent in fiscal year 
2018. Is that correct?
    Mr. Windom. Yes, sir, that's correct.
    Mr. Banks. So, with the infrastructure upgrades, will they 
proceed more gradually than originally planned? Is that 
correct?
    Mr. Windom. Sir, more gradually--what we're seeking to do--
and I've got my Chief Technology Officer here with me, and he 
can respond in greater detail.
    What we're seeking to do is ensure that we balance the 
implementation appropriately of our infrastructure readiness 
plans such that we are not too far out in front of ourselves 
with regard to user adoption. The last thing we want to do is 
invest and then something become obsolete, so our timing is 
critical.
    So the answer to your question is we've got an 
infrastructure plan that will support our implementation 
objectives--
    Mr. Banks. Got it.
    Mr. Windom [continued].--with the proper timing, sir.
    Mr. Banks. Got it.
    So, because of that, compared to the original November 2017 
estimate, you are now forecasting $214 million less in fiscal 
year 2019 and $236 million less in fiscal year 2020. So, 
conversely, in later years, the infrastructure costs will run 
slightly higher than originally estimated, all together about 
$204 million more through fiscal year 2027. Would you say 
that's correct?
    Mr. Windom. I would say that's correct, sir.
    Mr. Banks. So I need you to help me on this one. In spite 
of all that underrun, your total estimate over 10 years went 
up, has already gone up before any real work actually begins, 
by about $350 million, from roughly $15.8 billion to $16.1 
billion. How can that be?
    Mr. Windom. Sir, when we originally briefed you on that 10-
year lifecycle cost estimate, we in no way included the VA 
government employee costs. We made that clear with the asterisk 
noted in our original estimates. Those estimates for the 
support we need from a VA employee requirement are now included 
in those estimates. So what you're looking at primarily are 
employee staff salary numbers.
    Mr. Banks. Got it. That's what I thought you would say. So 
I find it hard to believe that such a basic part of running the 
program, government salaries, could have been overlooked. But 
even if I accept that at face value, it's an enormous amount of 
money.
    So, if we figure they are senior GS-15 employees, which I 
understand many of the folks in your office are, and we include 
their cost of benefits, $350 million buys roughly 2,000 full-
time employees. Now, there are less than 300 people working in 
the EHR Modernization Office. So am I mistaken here? What am I 
missing?
    Mr. Windom. Sir, $350 million, by my simple math, equates 
to about $35 million a year over 10 years.
    We were very much up front, as we executed the strategy 
associated with the D&F, that we were not taking the time to 
fully calculate the VA employee costs during this timeframe in 
order to move aggressively toward our goal of awarding the 
contract.
    What we have recently come back to you with is what we 
think are some very reasonable numbers with regards to program 
employee requirements, approximately 269 overall government 
employees.
    And so, you know, the expertise that we need, I've said 
before in previous hearings, we've got to have physicists to 
grade physics tests; we have to have highly qualified subject 
matter experts to grade the implementation efforts of Cerner. 
Those people in the industry cost money.
    And so we will continue to be judicious with taxpayers' 
money. We hope through efficiencies learned through IOC we will 
drive down those costs. But what I have provided you is a 
realistic estimate such that we can plan accordingly.
    Mr. Banks. All right. I appreciate that, but let's explore 
another explanation for this budget increase.
    You are now estimating that the project management office 
support costs will go up between $50 million and $90 million 
every year through fiscal year 2027. That comes out to about a 
$583 million increase over the life of the project. These are 
the contractor costs to staff your office, principally a 
contract with Booz Allen Hamilton. Is that correct?
    Mr. Windom. That's correct, sir.
    Mr. Banks. So the Booz Allen contract is already in place 
for a period of 5 years. Is this a big increase to the Booz 
Allen contract, or are we talking about even more support 
contracts?
    Mr. Windom. Sir, the numbers that you're looking at are 
intertwined. There is no distinguishing. Our number remains for 
the life of the contract in support of Booz Allen's support 
approximately $120 million to $125 million. The numbers that 
you're seeing are support of executive councils, workflow 
management and development processes, alignment processes, and 
also effectively a satellite command activity we're going to 
need to have in the Pacific Northwest.
    The numbers, again, are what we know today. The great thing 
about IT is it continues to evolve. There are going to be 
efficiencies gained that we just can't forecast at this point. 
We will be looking at those numbers very keenly, very astutely 
over the coming years to ascertain whether the budget 
requirements have remained the same or we need to adjust 
accordingly.
    There's advancements in technology that are forthcoming 
that we expect to drive down those numbers. But what I wanted 
to give you was an honest perspective, sir, and that's what 
I've given you.
    Mr. Banks. Thank you.
    My time has expired. I yield 5 minutes to the Ranking 
Member, Mr. Lamb.
    Mr. Lamb. Thank you, Mr. Chairman.
    Dr. Kroupa, welcome, first of all. Thank you for joining 
us. I wanted to ask you a little about the workflow councils. 
Can you just kind of describe to me in layman's terms your 
understanding of how those are going to work and the clinician 
involvement?
    Dr. Kroupa. Certainly.
    So we've formed 18 clinical councils. Each of those 
councils are centered around a type of clinical care. So we 
have a provider council, we have a nursing council, you know, 
laboratory councils. There are different clinical themes.
    Each of those councils have a mix of field staff and 
central office staff. Basically 60 percent of the folks on 
these councils are folks who see patients, who are out in the 
medical centers. But we also have central office staff, who 
understand national policy and direction.
    These councils have been meeting on a weekly basis for 
several months. They attended the model validation event in 
September, and they just got back from the first workshop in 
Kansas City, workshop 1.
    Mr. Lamb. Okay. And after the councils--so you're saying 
they meet every week?
    Dr. Kroupa. They meet by phone virtually.
    Mr. Lamb. And after that, what happens to the information 
that's exchanged? I guess, who is that information flowing to?
    Dr. Kroupa. So each council has an administrator, a project 
manager. There's folks from Cerner that are also part of those 
meetings. So after the first workshop, they all got together in 
a room, they made decisions, they got educated on the system. 
And they have a whole set of activities that they are going to 
be doing over the next 6 weeks in preparation for the next 
workshop.
    So they have different sprints where they talk about a 
certain type of activity, and then they have their input into 
that, and then they come back and refine it and refine it until 
everybody is satisfied with the output of that work. So they 
have a series of eight workshops total that they will be doing 
over the course of this next year.
    Mr. Lamb. And in those workshops, are they--what is it 
precisely that they're talking to each other about? Are they 
looking at EHR examples, or are they more talking about their 
existing workflow?
    Dr. Kroupa. So the workshops are led by Cerner staff, who 
present them with Cerner best practices, and they have a set of 
decisions that they have to make. In fact, I think we know that 
we have 2,760 decisions to make over the course of these 
workshops. And then there is a tool that they use to track all 
the decisions that are made so that that is what leads to the 
configuration of the electronic health record.
    And in these councils we also have included Department of 
Defense staff to help us understand the decisions that they've 
made and the decisions that they've had and bring that 
knowledge into the room.
    Mr. Lamb. Okay. And are the councils full? Like, do you 
have full participation right now?
    Dr. Kroupa. Yes. In fact, we had--we are very engaged, very 
enthusiastic staff. And, really, we filled up the Cerner room 
when we were there for the workshop. So there is no problem 
with getting our clinical staff involved, and we have a list of 
folks who are waiting to be rotated in.
    Mr. Lamb. And the clinical staff, are they clinicians from 
the three test sites, or are they just from everywhere in the 
VA system?
    Dr. Kroupa. They're from everywhere in the VA system, but 
VISN 20, which is the IOC site, has a representative on every 
council.
    Mr. Lamb. Okay. So those 18 councils, are they divided kind 
of by, like, subject area? Is that what you're saying?
    Dr. Kroupa. Correct.
    Mr. Lamb. Okay. Got it. All right.
    Mr. Dalton, can you just describe for me, if you know, the 
information coming out of these councils that is then being 
taken by Cerner, what is Cerner doing with that sort of on a 
weekly, monthly basis at this point?
    Mr. Dalton. Certainly. First of all, I'd just like to say 
thank you for the opportunity to be here on behalf of Cerner.
    Mr. Lamb. Sure.
    Mr. Dalton. It's an honor and a pleasure to do that. I've 
led our government business since 2011, so I've had the 
opportunity to be along for the entirety of the journey with 
DoD and VA. So I appreciate the opportunity to be here.
    The other thing I would note related to the councils was 
that there is also outside representation from leading academic 
and other institutions, so these are not just Cerner points of 
view and inputs. We're getting a variety of inputs from a 
multitude of folks across the industry that use different 
systems, and I think that's important to note. We welcome that 
input as part of this process.
    Mr. Lamb. Can you give me some examples of the institutions 
involved?
    Mr. Dalton. I think some of the leading institutions--Dr. 
Kroupa?
    Dr. Kroupa. I know we have folks from Yale as one 
institution. We have some of the bigger health care systems 
that have implemented Cerner across the country are also part 
of it.
    Mr. Lamb. Got it.
    Mr. Dalton. Yeah. And those councils--
    Mr. Lamb. My time is up. We can come back to this in 
another round. I don't want to--thank you, Mr. Chairman.
    Mr. Banks. The chair recognizes the Chairman of the Full 
House Veterans' Affairs Committee, Dr. Phil Roe.
    Mr. Roe. Thank you. And, Mr. Chairman, I'm sorry Mr. 
Coffman and I didn't get the memo on the striped tie this 
morning the rest of you have on.
    You know how strongly I feel about the EHR modernization 
and what a priority it's been for us in the Committee and for 
patient care.
    It means a great deal of scrutiny for the VA leadership, 
and a few years ago that scrutiny would've probably been 
decidedly unwelcome, and they would've been not shy about 
telling us so. But to Secretary Wilkie and his team's credit, 
they've been engaging with the Subcommittee constructively. And 
I told the Secretary, I said, if we don't get this right, you 
and I need to go in the witness protection program, and I hope 
they hold a couple of spots for us.
    I've been watching the EHR modernization plan to come 
together the last year and a half, and during Secretary 
Shulkin's tenure there was an intensive look at 
interoperability. Now, I expressed my concern about 
transferring all patient data, and that became obvious when I 
was at Spokane a while ago. VA seems to have worked through 
those issues and understands what capabilities Cerner provides 
out of the box and what additional work will have to take 
place. But this by no means is interoperability with the 
community providers, and we know that's not easy.
    Again and again, we turn to a basic question like how the 
VA system will be situated with respect to MHS Genesis and how 
the clinical standardization is going to proceed. I'm a little 
uncomfortable about that. Ideally, those questions would have 
been answered first. That being said, as long as they are 
thoroughly and transparently answered before Cerner starts 
installing the EHR in Seattle and Spokane, the situation should 
be manageable.
    Now, Dr. Kroupa, typically after EHR implementation, the 
medical practice suffers a large productivity hit. I know when 
we put ours in our office, the way we solved that problem was 
the doctors just stayed late at night entering the data well 
into the night. And we know there's about a 40- or 50-percent 
temporary reduction in efficiency and capacity; that's pretty 
normal.
    There have been discussions at the VA about designing the 
Cerner implementation to limit the productivity hit 10 percent. 
Do you think that's possible?
    Dr. Kroupa. Well, I agree that that is one of biggest 
things that we need to consider as we look forward here. We are 
looking at all the different possibilities in terms of what the 
percentage will be. We're making active plans to mitigation the 
loss in productivity that will occur during training and go-
live.
    We have a committee that is headed up by VHA that is 
looking at various strategies. Some of the things we're looking 
at are using our telehealth capacity to see patients. So while 
the folks that are at the IOC sites are getting trained and 
getting used to the system, we're looking at bringing in 
temporary staff to help see patients while the staff at the 
sites are also involved. We're looking at how we can use the 
community resources if there's a decrease in capacity. A 
variety of mitigation strategies.
    And we also have a very, very robust change management 
training strategy so that staff will be able to quickly, you 
know, get accustomed to the record and be able to regain their 
productivity quickly.
    Mr. Roe. Well, I've been warning VA groups when I go to see 
them that this is going to happen. And we already have a 
shortage of staff at the VA, medical staff. This is going to be 
a big hit for the Spokane region. We know what happened in 
DoDat Madigan. We know what's happened there already.
    So I think that's something we have to plan for. And I hope 
you are doing that. And I just wonder how you are going to be 
able to do that, whether you're going to--and the other thing I 
wanted to know is, from DoD to VA, to Mr. Lamb's questions, 
what have we learned from there that's transferrable--and 
maybe, Mr. Dalton, you can answer this--to VA?
    Because--and the other part of question is, I know the 
people--I know when we put it in our own office, implemented 
it, the people implementing it knew very well. But are you 
getting the information out to the worker bees, the people who 
are actually going to be using it at the site? The people 
implementing it will know very well. They'll have had weeks and 
months and maybe a year or so of training on it. But the person 
actually doing the care and the nurses and the doctors, are 
they going to be brought up to speed in time to do this? 
Because this is a big, big process you're going through.
    Mr. Dalton. Thank you, sir. I appreciate the question.
    Yeah, we learned some hard lessons with DoD. There's no 
doubt about that. I think transformation is always hard and 
it's always difficult.
    We're doing things, a lot of things, differently here. So 
we're engaging with the sites early and often. So one of the 
things that we've done is a current-state review and 
assessment. That's an activity here we didn't do with the DoD.
    We're also doing eight workshops, so we're doing more 
workshops up front. We're doing more of an iterative process, 
where we are getting regular design review and we're making 
sure that it's understood what those decisions are that are 
being made.
    This is a provider-led process. We have 18 councils with a 
variety of input. They're also assisting us, to the earlier 
question, with validation of workflow done to date by the DoD, 
new workflows that we need for VA. And then they're assisting 
with validation of those elements.
    And then several other things, too, sir, around training. 
We've created 100- to 400-level courses for the VA based on 
workflow, not based on just the function that you serve but 
based on the workflow, the entirety of the workflow. We've got 
a VA play domain that we're introducing that will allow folks 
to get in early and have access and a better understanding.
    And then Cerner will be providing the help desk support 
direct and also ongoing sustainment in the VISNs and at the 
VAMCs.
    Mr. Roe. Let me give you one--
    Mr. Dalton. Yes, sir.
    Mr. Roe. I know my time's expired, but I want to say one 
other thing before I finish, is that what you have to have to 
make this implement and work correctly is that when a provider 
is sitting there at a computer screen--and I've been there--and 
you hit the blind canyon, you don't know where to go, you're 
stuck, you can't call 1-800-HOLD. You've got to have somebody 
immediately available to be able to access you to get you 
through that.
    And I would encourage you, if you don't do anything, that 
will stop a lot of the decreased productivity, is just having 
somebody get stuck and they don't know where to end up.
    I yield back.
    Mr. Dalton. Yes, sir.
    Mr. Banks. Thank you, Chairman Roe.
    The chair recognizes the gentleman from Colorado, Mr. 
Coffman.
    Mr. Coffman. Thank you.
    Mr. Windom, in part you've answered this, but I wanted to 
go into a little bit more detail. A $350 million cost estimate 
increase this early in the project is clearly bad news. I get 
that it's the 10 years.
    Cost increases tend to lead to more cost increases. If you 
have more cost increases down the road, is VA going to ask 
Congress to appropriate the additional amounts or do more 
internal reallocations to take it out of other accounts?
    Mr. Windom. Sir, I'm more than sensitive to cost schedule 
and performance. I couldn't have been more clear 19 months ago 
when we offered our estimate and then refined it that it did 
not include the cost of VA government employees. We are 
staffing 18 councils. We were also required to go back and pay 
our bills back to October of 2017 generated by the EHR program 
in reimbursing VHA activities as well as OI&T activities that 
supported us.
    So, again, this is a moving target. Extremely dynamic 
environment. What you can count on me to do, sir, is be 
transparent with you. We have given you projections over the 
next 10 years. We hope that efficiencies are gained as part of 
discoveries at IOC. And we will continue to refine.
    One of the reasons that our projected numbers of a 700-
person OEHRM have come down to 269 is because I value 
leveraging the existing resources that are present in the VA 
today. I have a great relationship with VHA. I have a great 
relationship with OI&T. They have tremendous expertise that 
they can bring and provide at our disposal. We will be 
leveraging that to the maximum extent. The more we can utilize 
that, the more that bill comes down, because those are 
resources that are already in place, sir.
    Mr. Coffman. Thank you, Mr. Windom. I've got confidence in 
you; I don't have confidence in the structure. I think the 
notion that we're still at the point where neither DoD or VA 
has taken the lead--and I think that one of them has to have 
ownership for it. One of them has to call the shots. The notion 
of having this intermediate organization between the two, these 
two behemoths, these two gigantic entities, I think at the end 
of the day is just unworkable.
    And I would like to you comment on that.
    Mr. Windom. Yes, sir. I mean, my military background has 
been revealed. I am an organizational-chain-of-command person. 
I understand a single person in charge. That single person in 
charge is the DepSec. Secretary Byrne is in charge of this 
activity.
    Between DoD and VA, one thing I can assure you is that 
Secretary Wilkie has challenged us daily to look at 
opportunities for efficiencies between the two agencies. And, 
also, the joint statement that he and Secretary Mattis released 
reaffirming their commitment to our jointness, our 
interoperable objectives, is evident throughout our processes. 
And I feel very good about the working relationship with DoD. 
And we're going to be looking to gain greater efficiencies as 
we work the various challenges that we will encounter, sir. I 
recognize and understand your concern.
    Mr. Coffman. But wouldn't you agree that the reason for--
that the fact is that the problems with the failures in the 
past were that you had these two entities with no one in charge 
and they simply couldn't come to an agreement?
    Mr. Windom. Sir, I spent 33 careers in the Navy, so my 
experience within VA and the history of VA is very limited. 
What I can tell you over the past 20 months is we've succeeded 
at every milestone that we've encountered or desired to 
achieve.
    And so I've seen nothing but unity in pursuit of this 
mission amongst the entities that are alleged to be fractured 
over the years. They have come together. I don't know if it's 
the stars aligning, but the stars have aligned. I feel the 
momentum. You folks have paved the way with regards to your 
support. The VSOs, everyone is on board that this is something 
that needs to be done.
    I think that it's important to have disagreements and 
healthy tension because that's what keeps us on our toes. 
That's what keeps us from entering into groupthink, and that 
keeps us in support of our veterans and moving in the right 
direction.
    Mr. Coffman. Well, I thank you for the service. As someone 
who--an Army-Marine Corps person here, I thank you for your 
service to the country.
    You mentioned that there was an allegation that these 
organizations were fractured. I think it's more than an 
allegation. I think they, in fact, were fractured, and I hope 
that's not the case today.
    I yield back.
    Mr. Banks. The chair recognizes the gentleman from 
Michigan, Mr. Bergman.
    Mr. Bergman. Thank you, Mr. Chairman.
    Probably there hasn't been a VA hearing that I haven't 
asked the question of the witnesses, do you, you know, feel a 
sense of urgency in your organization. I'm not going to ask 
that question today. I'm not going to ask it probably ever 
again. Because I'm just going to say: Show me where the sense 
of urgency, give me examples, give our Committee examples, if 
you will, of the sense of urgency for this.
    You hear about cost overruns. You hear about delays. You 
hear about entities not working together. There's always going 
to be some of that.
    I guess what I'm looking for, as a Committee Member here, 
Subcommittee Member, is to have you build our confidence that 
we're actually going to see results. Okay? Build our 
confidence. Because when we go back to the district and I go 
back to my district, I mean, if I had 10 interactions today in 
the district, probably 5 of them are VA-related, and usually 
it's involving health care.
    But the point is, for now and future, it's going to be: 
Show me, show us that sense of urgency.
    Is there any reward for those participating in the project 
to achieve results? Is there any reward, financial or 
otherwise, or promotion?
    Mr. Windom. Sir, the Booz Allen contract is a time and 
materials contract, so there's no incentive other than the 
profit associated with that contract. The Cerner contract is an 
IDIQ contract where there's no additional incentive outside of 
the profit that has been negotiated.
    What I can tell you is that the partnership--you know, sir, 
we talk all the times amongst ourselves about going into VA 
medical centers and the VA facilities. That's a heck of a 
reward in seeing what we can do in the way of improving patient 
care in that arena. So, really, I don't think you'll find 
anybody at this panel--or most people in the VA, they're not 
doing it for the financial windfall. They're doing it because 
the ability--
    Mr. Bergman. Well, let me--yeah, let me--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--cut to the point. Because it's 
okay if there's no reward. Is there any threat to anybody's 
jobs if it doesn't work?
    Mr. Windom. Sir, as we--
    Mr. Bergman. Yes or no?
    Mr. Windom. Sir, the threat would be to my job, because I 
feel I'm the accountable person to the DepSec. So--
    Mr. Bergman. Do you have milestones in your job, if you 
don't meet them, you're relieved?
    Mr. Windom. Sir, I have an evaluation that I am required to 
complete, and I am graded every year on my performance. So my 
performance is constantly being graded. I serve at the pleasure 
of Secretary Wilkie--
    Mr. Bergman. Okay.
    Mr. Windom [continued].--as I did of the President.
    Mr. Bergman. All right. Well, let's get in--
    Mr. Windom. So that's how I feel.
    Mr. Bergman. Okay. Well, I'm curious, because, you know, 
either if we don't incentivize good behavior, we're not going 
to get it, and if we don't hold people accountable for their 
actions--and you've chosen a responsible position. And people 
who lead, you know, lead. And if they--in the military terms, 
if you're not doing the job, you're relieved of command, I 
mean--
    Mr. Windom. Yes, sir.
    Mr. Bergman [continued].--in simple terms. And it gets gray 
when you get outside of the military when it comes to 
performance, resignation, you know, moving upward, whatever it 
happens to be.
    But in specific--and this is for either you, Mr. Windom, or 
Mr. Dalton - what have you found in your readiness assessments 
of the Spokane, Seattle, and American Lake medical centers? How 
much will it cost in money and time to resolve the findings and 
prepare the facilities for the EHR to be installed. Because 
that's our beta site, right?
    Mr. Windom. Yes, sir.
    Mr. Bergman. Okay. So what are the numbers?
    Mr. Windom. Sir, we've got full infrastructure plans that 
we just presented to the staff yesterday, as a matter of fact, 
that we can give you a full laydown of costs associated with 
the infrastructure.
    I will tell you, the term I use is: Our CSR have revealed 
no show-stoppers. And I'll let Mr. Dalton comment on that. What 
I mean is, when they went out to our respective sites, they saw 
the similar and same deficiencies that they've seen in their 
commercial implementation. So we feel very comfortable that we 
have a path to success.
    So I'll let Mr. Dalton comment on the remainder of that.
    Mr. Dalton. Yeah, I think we were pleasantly surprised by 
the impetus for change. So there are a lot of folks that were 
glad to see us and want this change.
    I think that VA is unique and it's different, so there were 
some areas we uncovered that we need to focus on now: 
telehealth, behavioral health, reporting. Those are big areas, 
big content areas, unique patient population. We wanted to know 
that now; that's why we went.
    Mr. Bergman. Okay. I see my time is up. Again, you can take 
the question for the record. How much time and how much money, 
the question I asked, in specific. How much will it cost in 
money and time to resolve the findings that you have?
    Mr. Windom. Sir--
    Mr. Bergman. For the record.
    Mr. Windom. We--
    Mr. Bergman. My time has expired.
    Mr. Windom. Oh, yes, sir.
    Mr. Bergman. Mr. Chairman.
    Mr. Banks. Thank you.
    The Committee now will begin a second round of questioning, 
and I will begin with this.
    Mr. Windom, on September 26th, Secretary Wilkie and 
Secretary Mattis issued a joint statement that promised a new 
and improved organizational structure to manage EHRM and MHS 
Genesis. When will this be announced? And what have you so far 
ruled in and ruled out as part of that structure?
    Mr. Windom. Sir, I would offer: Nothing has been ruled in 
or nothing has been ruled out. The undertaking that you 
described is a complex undertaking, and in such--
    Mr. Banks. Okay. Then will you at least commit to briefing 
the Subcommittee before you institute any organizational 
changes?
    Mr. Windom. Sir, I don't speak for the Secretary, but the 
Secretary will not take exception to that briefing whatsoever.
    Mr. Banks. Okay.
    Mr. Windom. So, after the appropriate assessments are done, 
I welcome the opportunity to come back and tell you what has 
transpired.
    Mr. Banks. Okay. I appreciate that.
    I'm sure that you're aware there was a media report 
recently that the DoD examined the possibility of taking over 
VA's EHRM program, but the lawyers determined DoD lacks the 
statutory authority to do so.
    VA must have been aware of that discussion. You came from 
DoD, so I'm sure that you have many relationships there. Do you 
confirm that DoD considered a takeover, or do you deny that?
    Mr. Windom. Sir, I know of no such attempt. The VA has been 
on a course that we have not wavered from since the signing of 
the D&F back in June of 2017. I have been either the lead or 
the deputy for that entire period of time, and no such 
proposals were broached with me whatsoever.
    Mr. Banks. So, Mr. Windom, in my opinion, a complete 
takeover by one department would be very risky. That being 
said, further integration is probably inevitable given the 
nature of the single Cerner instance. My concern is that VA and 
DoD align what makes practical sense, not what serves a 
bureaucratic interest. What functions do you think should be 
managed jointly?
    Mr. Windom. Sir, I think there are a myriad of things. I 
can give you a few, but there's differences that we still have 
to assess. So I think, from a VA perspective, we are very much 
in line with your thoughts. An assessment has to be done as to 
what inhibitors or challenges may exist.
    There are efficiencies we can gain immediately: 
cybersecurity; system engineering architecture that revolves 
around data hosting where we are putting our data in the single 
enclave; URLs, which we already have gained a success because 
we have a united commitment with DoD to use the same URL. We 
just got PKI certificates issued for that URL. So there are a 
number things. Joint patient identity management.
    Sir, what we'd like to do is come back to you in total and 
brief you on areas we think efficiencies can be gained sooner 
rather than later.
    I can tell you that the VA's mission set is different. 
We've got 30 percent more capabilities to deliver as part of 
our clinical requirements. And those are things that we have to 
apply effort to as well. So we understand the differences but 
the sameness, if you will, but we are solidifying what the 
strategies could be or should be to capitalize on those 
prospective efficiencies.
    Mr. Banks. Okay. I appreciate that.
    Let me shift gears a little bit. Mr. Windom, I still don't 
understand why Seattle and Spokane were chosen as the initial 
implementation sites--as you know, I've visited them--other 
than that because DoD had already chosen nearby sites.
    Early on, the Committee advocated for the James A. Lovell 
joint VA-DoD health care center to be one of the early sites. 
The VA rejected that out of hand, essentially because it would 
be too hard. That does not say much, by the way, for 
integration.
    Subsequently, there has been some discussion of an east 
coast site in one of the first several implementation waves, 
ideally another joint VA-DoD facility. Has any decision been 
made about that? And if not, when might a decision be made?
    Mr. Windom. Sir, there has been no additional discussions 
under Secretary Wilkie and Secretary Byrne, DepSec Byrne, on an 
additional east coast site. So we have done no further analysis 
on for the past 3 months.
    As far as the north Chicago facility, sir, what we sought 
to do was align our schedule to the deployment schedule of DoD 
at those joint facilities. We did not want to cause the people 
who populate those to incur an additional burden of DoD coming 
to deploy and then us coming to deploy. That would be an 
unreasonable and unnecessary change management burden. So we 
aligned our schedule to when the DoD was appointed at site.
    Now, as far as why we went to the Pacific Northwest, as 
part of our negotiations process--and we've got Mr. Dalton 
sitting here--certain economies of scale, labor efficiencies 
associated with them being in that region at this point in 
time, led to a lower cost to our taxpayers in that negotiation 
process.
    Mr. Banks. Well, let me stop you right there. And, briefly, 
can you explain, why wouldn't DoD and VA deploy at the same 
time? Why couldn't they?
    Mr. Windom. Well, they could, sir. What we chose to do in 
our negotiation process is align to what the DoD already had on 
their schedule. And so their schedule was awarded, obviously, 
before ours, so we simply aligned those joint facilities to 
their schedule. We brought all 13 of those facilities forward 
in our schedule and are prepared to deploy those out of the 
normal sequence that that region would offer.
    Mr. Banks. Okay.
    My time has expired. The chair recognizes the Ranking 
Member for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    Mr. Dalton, just kind of a couple things before we pick up 
where we left off. The 2,760 decisions I think someone 
mentioned, so is Cerner generating those and then presenting 
them to the workflow council? Is that how that works?
    Mr. Dalton. Yes. We have a process and a tool that we use 
where we generate those decisions.
    Now, to be clear, our goal is to be proactive in that 
decision-making. We're not welcoming the councils in and 
saying, ``Hey, what do you think?'' We're trying to be 
proactive based on our best practice and our experience across 
the industry and the globe.
    Mr. Lamb. Okay. So those decisions, is that kind of what 
sets the agenda of these workflow council meetings? Is that 
basically what--
    Mr. Dalton. It is.
    Mr. Lamb [continued].--time is spent talking about?
    Mr. Dalton. Yes, sir. We're doing multiple things. So one 
is training and education up front, so they have a better 
understanding of the workflow and the system. Secondly is 
validation of decisions that have already been made. So we've 
done a lot of hard work with the DoD. We'd like to leverage 
that work. I think that makes sense for the taxpayer, it makes 
sense for the program going forward. So they're validating 
those decisions. And then they're doing work around the 
creation of some of the new capabilities that the VA has that 
the DoD did not obtain. So they're doing multiple things.
    And, furthermore, they're also participating in content 
development. So in areas where we know--we don't claim 
perfection. There are areas where we need to work closely with 
the VA. I've mentioned a few of those. We expect to work with 
those councils on developing content to help us best meet the 
needs of the veteran.
    Mr. Lamb. Can you give me some examples of how clinicians' 
feedback in some of those areas shapes the way that Cerner acts 
going forward?
    Mr. Dalton. Sure. I think a couple of the big ones we've 
talked about. Specifically, the VA has a unique population. I 
don't think that's a secret to anyone here. You've got an 
older, sicker population. They have unique needs in terms of 
behavioral health and some of those areas.
    We expect that the work we do with the VA will help lead us 
into the future in that area. We expect that we're going to 
have to work closely together in that area in order to meet the 
needs of the agency, but we also think that helps make us 
better, commercially and otherwise, as well.
    Mr. Lamb. I guess what I'm asking you is, how does the 
information from the clinicians on these councils inform the 
work you're doing in those areas on the electronic health 
record?
    Mr. Dalton. Sure. So we capture those decisions. We have a 
tool that we use. So we capture all those decisions. We utilize 
those decisions to configure our systems. We also utilize those 
decisions as part of our broader process we use as a company. 
So our best practices are generated by our clients. So we have 
a structure where we utilize client feedback from across the 
globe in order to inform our best practices. The work we're 
doing with the VA and with the DoD also informs that process--
    Mr. Lamb. Okay.
    Mr. Dalton [continued].--as well.
    Mr. Lamb. Is there a mechanism for kind of open-ended 
feedback from the clinicians on these councils to Cerner? Or is 
it all kind of confined within this structure of the decisions 
you're presenting them?
    Mr. Dalton. There's a mechanism for open-ended feedback. 
From our perspective, we'll consider all of their feedback. In 
the interest of efficiency and getting done, you have to try 
your best to maintain some level of standard in decision-
making--
    Mr. Lamb. Sure.
    Mr. Dalton [continued].--but we're always open to new ideas 
and innovation. So, absolutely.
    Mr. Lamb. So, like, if a clinician is sitting on one of 
these councils, you're saying that they do have the opportunity 
to raise issues to Cerner that are in front of them right now?
    Mr. Dalton. Absolutely.
    Mr. Lamb. If they're dissatisfied with the way the current 
system works and they want to tell you about it so that you can 
fix it in the new EHR system.
    Mr. Dalton. Absolutely. And we capture that, and we 
adjudicate each of those.
    Mr. Lamb. Okay.
    Mr. Short, the site assessments that were conducted over 
the summer, it sounds like there were a lot of deficiencies in 
technological readiness, particularly with computers, printers, 
that kind of thing. Do you agree that it appears that most of 
the computers are not up to the standard that they need to be?
    Mr. Short. Yes, sir. Most of them are 5 years old--
    Mr. Lamb. Okay.
    Mr. Short [continued].--and need to be replaced.
    Mr. Lamb. So what is the plan for that moving forward? Or 
what do you need from us? What do we need to do in the next 
year or two to address that?
    Mr. Short. We have an integrated infrastructure readiness 
plan with OI&T where we're both working together to maximize 
the use of their current contracts so we don't have additional 
administrative overhead for those.
    And OI&T is also taking our specification for other 
replacements that they will do in that area in the future. So 
when they do a replacement for other facilities before we get 
there, rather than buying a brand-new computer that we would 
roll to a year later and replace, they'll be using that as 
specification for monitors and that sort of thing.
    Mr. Lamb. Okay. Would you agree that that has to be fixed 
before the go-live time at the three test sites?
    Mr. Short. Yes, sir. Our goal is to be done 6 months ahead 
of time. The IOC sites may go a little bit shorter than that, 
but after that, they'll be 6 months before. That way, the 
technology readiness is completed for change management before 
the functional matters.
    Mr. Lamb. Thank you.
    Thank you, Mr. Chairman.
    Mr. Banks. The chair recognizes Dr. Roe for 5 minutes.
    Mr. Roe. Thank you.
    And the reason this Technology Subcommittee was stood up, 
we're looking at a--and when I went out to Fairchild and DoD, I 
realized that that was not going as well as it should and we 
should really pay close attention to it.
    The other reason that I think all of us have some angst--
we're going to have a hearing later today on the disability 
exams by contract physicians that the VA can't account for. 
Every one of us has heard from student veterans around the 
country now, this fiasco about being able to get the schools 
paid, the per diems paid. There's a technology failure at VA 
that really is creating real problems when the taxpayer dollars 
are there. The money's been appropriated, and yet we can't get 
it disbursed right.
    So that's why we're doing this. And I think this 
Subcommittee and the Full Committee are trying to work to make 
you successful. We want to make you successful.
    When Mr. Lamb was mentioning about the council, 35 percent 
of the VA health care is not provided inside the VA--at least 
35 percent. It's provided outside. What are we doing for 
outside practitioners, like myself, who, when I went home this 
past weekend, or this past month, I mean, before the election 
and talked to a dialysis center that can't get any information 
shared--I'm pairing the VA and that particular dialysis center 
together so they can work those problems out. They have no way 
to share data. That's a third of all VA health care.
    Are we doing anything? I noticed you mentioned Yale and 
others in the private sector out there working with you. But 
how are you going to integrate an individual practitioner like 
me so when I'm seeing a VA patient I can get that information 
back to the VA for that patient?
    And, Dr. Kroupa, you can probably take that.
    Dr. Kroupa. Thank you. That is a challenge, definitely.
    So, by going on the Cerner platform, that will allow us to 
utilize the national systems that are in place for 
interoperability.
    We also have included--we have a whole community care 
council that is looking at all the different workflows for how 
patients get referred into and out of the VA and all the 
mechanisms that go into that to make sure that information is 
exchanged and put into the system not just as a piece of paper 
or as an image but actually the data itself is--
    Mr. Roe. But how will I, out in my practice out in Johnson 
City, Tennessee, how will I be able to access the record? How 
am I being brought in to access that--because there are 
thousands of doctors out across the country that are doing 
this--the record at Mountain Home? We're getting right down to 
the specifics of how is that going to work.
    Dr. Kroupa. We're working--
    Mr. Roe. Because if that doesn't work, the system doesn't 
work.
    Dr. Kroupa. We're working on that in terms of we will be 
using the interoperability mechanisms that Cerner has in place, 
the health information exchanges--
    Mr. Roe. Okay.
    Dr. Kroupa [continued].--that are already in place, and the 
care well system that's in place. So we'll be able to utilize 
that.
    We'll also--again, Community Care also has different 
mechanisms. They're currently using the VistA system. Some of 
those may be brought over into our referral process so that 
there will be more information coming to you when you get our 
patients and then a mechanism for you to put that information--
send that information back to us.
    Mr. Roe. Well, it isn't happening right now. And I wonder--
again, I hear that, but will that health information exchange--
will I be able to, when I see a patient out in--like, in 
Spokane, Washington, that's going to go--you're beginning to 
get that live. There are physicians out there that are going to 
be seeing patients outside the VA in remote areas. Will they be 
able to access the information through the health--because if 
you can't make that step work, this won't work; it's a failure.
    So I guess--
    Mr. Windom. Yes, Congressman Roe, if I may touch on that as 
well, is that there's two issues. There's one that's 
technology-based, which is solved. The HIEs, the CommonWell 
platform, the Carequality platform will allow that seamless 
exchange of information that you speak to.
    But there also is another piece, which is: The information 
has to be put in. And so that information has to be made 
accessible by the people on those networks. But we've got the 
technology piece solved.
    So let me let Mr. Dalton touch on that as well, about some 
of their HIE enterprise.
    Mr. Dalton. Yeah. So the answer is: Yes, it's going to 
happen. It's technically possible and feasible. We're going to 
use open APIs, fire-based integration. We're committed to that 
contractually.
    I think the thing that will be powerful for the industry 
and our commercial partners will be if the DoD and the VA 
choose a common standard that actually will move the industry 
forward. Because this isn't always a technical issue; it's a 
standards-based issue. The power of the DoD and the VA making 
that choice to move it forward will actually influence the 
commercial marketplaces.
    Now, you're talking about a little different issue, because 
this is a VA community provider. But, nonetheless, the tools 
exist--through HIEs, through direct exchange. It's a standards 
issue, generally speaking, in the industry. It really is.
    Mr. Roe. My time's expired. I yield back.
    And, Mr. Chairman, I want to applaud you and the Ranking 
Member for having this. And I would encourage us to do this 
every 90 days or whatever so we can keep everyone informed.
    I yield back.
    Mr. Banks. Thank you, Mr. Chairman. We applaud you for the 
foresight in creating this Subcommittee and leading this 
conversation forward.
    The chair recognizes the gentleman from Colorado for 5 
minutes, Mr. Coffman.
    Mr. Coffman. Thank you.
    Mr. Windom, you started out--this organization started out 
in excess of 700 employees--am I correct in that?--in terms of 
your planning--for planning purposes?
    Mr. Windom. Sir, the original projections were 250, 
augmented by the Booz Allen contractor workforce. They 
ballooned to about 700 as there was a thought process that we 
needed to bring more expertise into our portfolio, vice 
leverage the expertise in the existing OI&T VHA portfolios.
    That is the path we're now choosing. So our numbers look 
like about 269 and leveraging the expertise in those portfolios 
I just identified.
    Mr. Coffman. And tell me again, what are the practical 
effects on the project with a much smaller staff?
    Mr. Windom. Well, at the stage we're at now, sir, where our 
primary focus is IOC, I think a flatter, leaner organization 
lends for responsiveness, lends for the facilitation of change 
management, especially when you're given the access that VHA 
and OI&T have given us to their expertise where there is no--
it's a seamless interaction. We need this subject-matter 
expertise on one of our councils, and it's there to support Dr. 
Kroupa. We need this technological data migration expertise, 
and it's there to support John Short.
    So having the ability to move people in and out of our 
portfolio is equally as advantageous as having to bring someone 
in off the street to orient them on the as-is environment of 
the VA, wonder whether they understand the Cerner solution. So 
we believe we've gained a tremendous efficiency by taking that 
approach.
    Mr. Coffman. So part of this is that you have access to the 
respective agencies, the respective departments that you're 
serving. Has that mitigated the numbers then?
    Mr. Windom. Absolutely, sir. That makes us seamless. You 
know, we're a direct report to the DepSec. There is an 
understanding of that.
    And so the--and then the commitment by VHA and OI&T have 
been such that we cannot succeed without having a team concept. 
And that team concept involves, if you will, to use a Navy 
term, all hands on deck. All hands are on deck for this in 
support of this. This is a top priority of the Secretary, and 
people are treating it as such.
    Mr. Coffman. So what do you think the--how is the culture 
different, organizationally, between the failures of the past 
and what we have today, from your perspective?
    Mr. Windom. Sir, again, I can speak for the past 20 months, 
is that--
    Mr. Coffman. Before that.
    Mr. Windom. Well--
    Mr. Coffman. Obviously, you studied what was there prior, 
because if you didn't do it, you didn't do your homework. So 
tell me--
    Mr. Windom. Well--
    Mr. Coffman. Let's go before those 20 months.
    Mr. Windom. Sir, so I could say it in one word: team. A 
teaming spirit. That's what I know from DoD. That was what I 
believed to be part of the missing element, is a teaming 
spirit.
    I feel that teaming spirit now. I feel people from all over 
the VA wanting to be part of OEHRM and wanting to be involved 
in this mission set. I get calls daily of people who want to 
join this team.
    Mr. Coffman. Mr. Chairman, I yield back.
    Mr. Banks. We'll now enter a third round of questioning, 
and I'll begin with that. And we'll pick up right where Mr. 
Coffman left off.
    Mr. Windom, in August, the VA submitted a legislative 
proposal to give the Office of EHR Modernization streamlined 
hiring and special pay authority. A few weeks later, though, 
the Department retracted that proposal without explanation.
    Did you decide that you don't need those authorities at 
all, or did you find another means to accomplish them?
    Mr. Windom. Sir, I think we have another means to 
accomplish it, which is: Title 38 authority rests with VHA. In 
sitting down with Dr. Stone, who presently leads VHA, he agreed 
to set up a cost pool, a cost center for us, where he would 
effectively take the administrative burdens off of our lap. 
That means we can focus more energy on the implementation, more 
time on implementation, vice the hiring process.
    Dr. Kroupa is part of any hiring panel associated with any 
personnel brought through that vehicle. And, therefore, we felt 
we were able to get the benefits of an efficient hiring process 
that was already in place, influence who was hired, but not 
take on the administrative burden of setting up our own from 
scratch, if you will.
    So I think that's an important efficiency. And, again, it's 
a byproduct of teamwork. He's taking on that burden 
administratively for us, but we get to reap the benefits of it 
from an efficiency standpoint.
    Mr. Banks. All right.
    My next question is for Mr. Short and Mr. Dalton.
    The contract says VA will have access to Cerner's data 
architecture, not just the data in the system, which VA should 
already own. This came out of the MITRE interoperability 
assessment, and VA hailed it as a big victory.
    What is Cerner doing differently to give VA this access, 
and how is VA using it?
    We can start with you, Mr. Dalton.
    Mr. Dalton. Yeah. So, I mean, all I can say is we've 
committed to that. So we're opening that book to our 
architecture, what we do and how we do it, not just necessarily 
the data. That was something we don't normally do with our 
commercial clients, but we agreed to do it in the best 
interests of the program with the VA. So that was--I'd say 
that's a foot that we put forward in the interest of the 
program.
    I'd let Mr. Short comment.
    Mr. Banks. Mr. Short, what are we doing with it?
    Mr. Short. Our architects, engineers, and data scientists 
have had unfettered access to anything they've requested in 
this regard with Cerner. We're using that for data migration 
planning as well as future planning for all data interaction. 
We will have the Community Care partners, DoD, as well as DHS, 
Coast Guard.
    Mr. Banks. Okay. Thank you.
    Mr. Windom, do you have--would you say that you have 
operational control of the VHA and OIT employees who support 
EHRM?
    Mr. Windom. Yes, sir.
    Mr. Banks. Okay.
    Mr. Windom, it can be difficult to direct employees who do 
not actually work for you. Do you consider that to be a risk?
    Mr. Windom. It's 1 of 200-plus risks we manage, sir, as 
part of our program oversight efforts. So yes. But I can tell 
you, when you have the support of the DepSec and then the CIO 
and VHA, it makes it easier. And people, sir--there's a genuine 
commitment to do this. And people wanting to be involved and 
lending their expertise is something we have not had to 
struggle with. So we feel we've got multiple forces working in 
our favor.
    Mr. Banks. Okay.
    Mr. Windom, where are these employees physically located? 
Are they in D.C.? Are they in Washington State? Or are they 
elsewhere?
    Mr. Windom. Sir, we've got employees--you know, as a 
byproduct of the VA's strategies in hiring and supporting us, 
we've got them dispersed from Austin, Texas, to Seattle, to San 
Francisco, to here in the D.C. metropolitan area, to Florida. 
You know, technology has evolved to where we're able to 
leverage the technological advancements to really close the 
distance. I believe in having critical and key members here 
nearby to respond to queries that you may have and other 
concerns from leadership. But we've been working, you know, 
with the challenges of distance.
    We've got a hiring strategy. We've got 131 billets to fill 
over the next year, and so I can tell you we are looking hard 
at the locations of those billets, because we know where those 
people are located may enhance their performance. We know we 
need to have a presence in the Pacific Northwest. That's where 
IOC is. So we've started that track as well. So I promise you, 
we're looking at the locations of total workforce to ensure we 
optimize the placement.
    Mr. Banks. All right.
    Mr. Windom, the scheduling system has been a persistent 
question. VA is piloting the Epic scheduling system in 
Columbus, Ohio. But Cerner provides its own scheduling system 
as part of the EHR. At one point, VA was considering 
implementing both systems in different parts of the country.
    Can you comment on that a little bit further?
    Mr. Windom. Sir, I will tell you that number one is we know 
we owe the legislators a response to your queries in December 
and that the OI&T, OEHRM, and VHA teams, you know, with the 
oversight of VA leadership, are working through the various 
course of actions that are being considered in deploying a 
scheduling system out of sequence of our contract.
    And so I can tell you we'll be ready to brief you, as 
required, as to what our position is at the appropriate time. 
But I can assure you--
    Mr. Banks. In December?
    Mr. Windom. Pardon me, sir?
    Mr. Banks. In December?
    Mr. Windom. Oh, yes, sir.
    Mr. Banks. So that briefing will come in December.
    Mr. Windom. Yes, sir. I think that decision will have been 
made by then and we will be prepared to brief you as 
appropriate.
    Mr. Banks. So, if it doesn't happen in December--which I 
hope that it will--at what point does this indecision either 
become a de facto decision or cause major problems for the EHR 
modernization program?
    Mr. Windom. Sir, we've got a negotiated contract and a 
negotiated schedule. I will tell you that you have directed us 
to be ready to brief you in December, so we'll be ready in 
December to brief you.
    Mr. Banks. Okay. Very good.
    My last question. I'm the last man standing. My time--
    Mr. Windom. Yes, sir.
    Mr. Banks [continued].--has expired, but I'm going to ask 
one more question, if you don't mind.
    To go back to the initial questioning with you, Mr. Windom, 
I'm still struggling with the budget explanation a little bit. 
The tangible parts of the project, like your spending to date 
and the infrastructure, are running below estimate, but, 
nonetheless, we have the bottom line going up. It seems to be 
driven by intangibles and costs that come into play years from 
now.
    We already have the cost estimate going in the wrong 
direction and fuzzy explanations as to why. My colleagues and I 
need and demand better answers, so please expect a document 
request for the financial records and basis of these estimates.
    Can you comment any further on maybe some of those--?
    Mr. Windom. Sir--
    Mr. Banks [continued].--as you reflected on those--
    Mr. Windom. Sir, I will go--and I will be prepared to sit 
down with your staff, as appropriate, to give them a full 
laydown. I'll bring my chief financial officer and give you a 
full laydown.
    We've only obligated $28 million to date in fiscal year 
2019. And so I look forward to providing additional clarity to 
your staff for, hopefully, conveyance to you. And if you want 
me to come in, I gladly will. So I'll take that as a lookup, 
sir, and come in and brief you in great detail.
    Mr. Banks. Thank you very much.
    And in closing, thank you to the witnesses for your 
testimony.
    If there are no further questions, then the panel is now 
excused.
    And as final closing comments, this morning we have 
examined many of the major questions that will determine the 
course of the EHRM program. The next big development should be 
VA and DoD determining how best to organize their joint 
management. They have to be close enough to act in concert 
while flexible enough to address their unique requirements. The 
Subcommittee has urged both leadership teams to communicate 
their thinking as early as possible.
    It is my sincere hope and expectation that this 
Subcommittee will continue in the next Congress. And I want to 
thank Ranking Member Lamb for his willingness to volunteer for 
this unconventional assignment. We hit the ground running, and 
we are going to run through the tape. In my opinion, on this 
issue, one way to measure our success in our oversight 
responsibilities is if the party composition changes and no one 
can tell the difference.
    That is not to say things won't get more difficult. On the 
contrary, there is every indication that they probably will. 
But I am committed to tackling the challenges transparently and 
firmly grounded in reality.
    So thank you all again for your participation in today's 
hearing.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Without objection, so ordered.
    Mr. Banks. This hearing is adjourned.

    [Whereupon, at 11:09 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

                  Prepared Statement of John H. Windom
    Good morning Chairman Banks, Ranking Member Lamb, and distinguished 
Members of the Subcommittee. Thank you for the opportunity to testify 
today in support of the Department of Veterans Affairs (VA) initiative 
to modernize its electronic health record (EHR) through the acquisition 
and deployment of the Cerner Millennium EHR solution. I am accompanied 
today by Dr. Laura Kroupa, Acting Chief Medical Officer of the Office 
of Electronic Health Record Modernization (OEHRM) and Mr. John Short, 
Technology and Integration Officer of OEHRM.
    I want to begin by thanking Congress, and specifically this 
Subcommittee, for your continued support and shared commitment for the 
program's success. Because of your continued support, VA has been able 
to stay on track for implementation, enabling us to continue our 
mission of improving care delivery for our Nation's Veterans and those 
who care for them while being a good steward of taxpayer dollars.

Program Milestones

    VA awarded Cerner Corporation with an Indefinite Delivery/
Indefinite Quantity (ID/IQ) contract to leverage maximum flexibility 
and the necessary structure to control cost. Through this acquisition, 
VA will implement the same EHR solution as the Department of Defense 
(DoD) to improve care coordination for Veterans and patient safety.
    Since VA provided testimony on the status of the Electronic Health 
Record Modernization (EHRM) effort before the House Committee on 
Veterans' Affairs on June 26, 2018, VA has accomplished several 
milestones, including the award of additional Task Orders (TOs) and key 
events outlined below.

Task Orders

    On May 17, 2018, VA awarded the first three TOs, consisting of 
project management, Initial Operating Capabilities (IOC) site 
assessments, and data hosting. By leveraging the ID/IQ contract 
structure, VA can award TOs as needs arise and negotiate firm-fixed-
prices on an individual TO basis, allowing VA to moderate work and 
modify deployment strategies more efficiently. Since June, VA awarded 
three additional TOs outlined below:

      Task Order 4- Data Migration and Enterprise Interface 
Development

    Cerner will provide data migration planning refinement, analysis, 
development, testing and execution. Cerner will support enterprise 
interface planning refinement, design, development, testing, and 
deployment. Cerner will provide commercially available registry 
selected by VA for IOC as well as details and updates on the progress 
of IOC data migration and enterprise interface development.

      Task Order 5- Functional Baseline Design and Development

    Cerner will provide project management, workflow, training, change 
management, and EHRM stakeholder communication.

      Task Order 6- IOC Deployment

    Cerner will provide project management, IOC planning and 
deployment, test and evaluation, pre-deployment training, go-live 
readiness assessment and deployment/release, go-live event, post-
production health check and deployment completion, post-deployment 
support, and continued deployment decision support.

Current State Review

    In July 2018, VA and Cerner conducted a Current State Review at 
VA's IOC sites to gain an understanding of the site's specific ``as-
is'' state, and how it aligns with the Cerner commercial standards to 
implement the proposed ``to-be'' state. The team conducted 
organizational reviews around people, process, and technology. They 
observed and captured current state workflows; identified areas that 
will affect value achievement and present risk to the project; 
identified quick wins from software being deployed; and identified any 
scope items that need to be addressed.
    VA reviewed final reports analyzing the Current State Review in 
October 2018 and discovered there are infrastructure readiness areas 
that are in better state than initially forecasted and areas that 
require slightly more investment due to the age of the infrastructure. 
However, there were no unexpected major needs or significant deviations 
from the current projected spend plan.

Model Validation Event

    On September 25-27, 2018, VA held its Model Validation Event, where 
VA's EHR Councils met with Cerner to begin the National and local 
workflow development process for VA's new EHR solution. There was a 
series of working sessions designed to examine Cerner's commercial 
recommended workflows and evaluate the current workflows used at VA 
medical centers. This allows VA to configure the workflows to best meet 
the needs of our Veterans, while also implementing commercial best 
practices.

Cerner Baseline Review

    VA is committed to closely align its workflows with commercial best 
practices; therefore, the Department commissioned Cerner to complete a 
baseline assessment of how closely DoD's MHS GENESIS aligns with these 
practices. In September 2018, Cerner presented the results of the 
assessment, which focused on the 70 percent of the capabilities that VA 
and DoD have in common. The remaining 30 percent are capabilities VA 
requires to meet the unique needs of Veterans. The assessment revealed 
MHS GENESIS has an 84 percent alignment to commercial best practices. 
This indicates DoD has high adoption of recommendations and system 
configuration, which are generally in alignment with commercial best 
practices.

OEHRM Organizational Structure/Strategic Alignment with DoD

    On June 25, 2018, VA established OEHRM to ensure VA successfully 
prepares for, deploys, and maintains the new EHR solution and the 
health IT tools dependent upon it. OEHRM reports directly to VA Deputy 
Secretary and works in close coordination with VA Veterans Health 
Administration and Office of Information Technology. I currently serve 
as the program's executive director and have been supporting the effort 
at a leadership-level since its inception, including pioneering the 
acquisition of the new VA EHR solution. Prior to joining VA, I was a 
Program Manager for the Program Executive Office of the Defense 
Healthcare Management Systems (DHMS).
    To ensure the appropriate VA and DoD coordination, there is an 
emphasis on transparency through integrated governance both within and 
across VA and from a decision-making perspective. The OEHRM governance 
structure has been established and is operational, consisting of the 
following five boards that will work to mitigate any potential risks to 
the EHRM program: (1) OEHRM Steering Committee; (2) OEHRM Governance 
Integration Board; (3) Functional Governance Board; (4) Technical 
Governance Board; and (5) Legacy OEHRM Pivot Work Group. The structure 
and process of the boards are designed to facilitate efficient and 
effective decision-making and the adjudication of risks to facilitate 
rapid implementation of recommended changes.
    At an inter-agency level, the Departments are committed to 
effectively working to institute an optimal organizational design that 
prioritizes accountability and effectiveness, while continuing to 
advance unity, synergy, and efficiencies between VA and DoD. The 
Departments have instituted an inter-agency working group to review 
use-cases and collaborate on best practices for business, functional, 
and IT workflows, with an emphasis on ensuring interoperability 
objectives are achieved between the two agencies. VA and DoD's 
leadership meet regularly to verify the working group's strategy, and 
course correct, when necessary. By learning from DoD, VA will be able 
to proactively address challenges and further reduce potential risks at 
VA's IOC sites. As challenges arise throughout the deployment, VA will 
work urgently to mitigate the impact to Veterans' health care.

Implementation Planning/Strategy

    The EHRM effort is anticipated to take several years to be fully 
complete and will continue to be an evolving process as technology 
advances are made. The new EHR solution will be designed to accommodate 
various aspects of health care delivery that are unique to Veterans and 
VA, while bringing industry best practices to improve VA care for 
Veterans and their families. Most medical centers should not expect 
immediate major changes to their EHR systems.
    VA's approach involves deploying the EHR solution at IOC sites to 
identify challenges and correct them. With this IOC site approach, VA 
will hone governance, identify efficient strategies, and reduce risk to 
the portfolio by solidifying workflows and detecting course correction 
opportunities prior to the deployment at additional sites. As 
mentioned, VA and Cerner have conducted Current State Reviews for VA's 
IOC sites. These site assessments include a current state technical and 
clinical operations review and the validation of the facility 
capabilities list. VA has started the go-live clock for the IOC sites, 
as planned, on October 1, 2018, with an estimated completion date set 
for March 2020.
    Further, VA is continuing to proactively work with DoD and experts 
from the private sector to reduce potential risks during the deployment 
of VA's new EHR by leveraging DoD's lessons learned from their IOC 
sites. Several examples of efficiencies VA is leveraging include: 
revised contract language to improve trouble ticket resolution based on 
DoD challenges; optimal VA EHRM governance structure; fully resourced 
PMO with highly qualified clinical and technical oversight expertise; 
effective change management strategy; and, utilizing Cerner Corporation 
as a developer and integrator consistent with commercial best 
practices.
    During the multi-year transition effort, VA will continue to use 
VistA and related clinical systems until all legacy VA EHR modules are 
replaced by the Cerner solution. For the purposes of ensuring 
uninterrupted health care delivery, existing systems will run 
concurrently with the deployment of Cerner's platform while we 
transition each facility. During the transition, VA will work 
tirelessly to ensure a seamless transition of care. A continued 
investment in legacy VA EHR systems will ensure patient safety, 
security, and a working functional system for all VA health care 
professionals.

Change Management/Workflow Councils

    Understanding a significant factor of the program's success relies 
on effective user adoption, VA is deploying a change management 
strategy to support this transformation effort. The strategy includes 
working with end-users, beginning with VA medical center leadership; 
managers/supervisors; and clinicians, to provide the necessary 
training. In addition, there will be on-going communications regarding 
deployment schedule and changes to their day-to-day. VA will also work 
with affected stakeholders to identify and resolve any outstanding 
employee resistance and/or additional reinforcement that is needed.
    VA has established 18 EHR Councils (EHRC) to support the 
development of national standardized clinical and business workflows 
for VA's new EHR solution. The councils represent each of the 
functional areas of the EHR solution, including behavioral health, 
pharmacy, ambulatory, dentistry, and business operations. VA 
understands a fundamental aspect in ensuring we meet the program's 
goals is engaging frontline staff and clinicians. Therefore, the design 
of the EHRCs will continue to be roughly 60 percent of clinicians in 
the field, who provide care for Veterans, and the remaining 40 percent 
consisting of those at the VA Central Office. As VA implements its new 
EHR solution across the enterprise, certain council members will 
continue to evolve depending on the current implementation location. 
While deploying in a particular VISN, the needs of Veterans and 
clinicians in that particular VISN will effectively be captured in the 
National workflows.

Closing

    Again, this effort will enable VA to provide the high-quality care 
and benefits our Nation's Veterans deserve. VA will continue to keep 
Congress informed of milestones as they occur. Mr. Chairman, Ranking 
Member, and Members of the Subcommittee, this concludes my statement. 
Thank you for the opportunity to testify before the Committee today to 
discuss the EHRM effort. I would be happy to respond to any questions 
you may have.

                                 [all]