[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]





 
  MISSION CRITICAL: ASSESSING THE TECHNOLOGY TO SUPPORT COMMUNITY CARE

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

                                HEARING

                               before the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, APRIL 2, 2019

                               __________

                            Serial No. 116-3

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]       
       
       


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


             U.S. GOVERNMENT PUBLISHING OFFICE 
38-953 PDF           WASHINGTON : 2021 
 
         
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                         Tuesday, April 2, 2019

                                                                   Page

Mission Critical: Assessing The Technology To Support Community 
  Care...........................................................     1

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member...........................     2

                               WITNESSES

Dr. Richard Stone, Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............     4
    Prepared Statement...........................................    31

        Accompanied by:

    Mr. James Gfrerer, Assistant Secretary for Office of 
        Information and Technology/Chief Information Officer, 
        U.S. Department of Veterans Affairs

    Dr. Melissa Glynn, Assistant Secretary for Enterprise 
        Integration, U.S. Department of Veterans Affairs

                        QUESTIONS FOR THE RECORD

House Committee Members To: Department of Veterans Affairs (VA)..    33


  MISSION CRITICAL: ASSESSING THE TECHNOLOGY TO SUPPORT COMMUNITY CARE

                              ----------                              


                         Tuesday, April 2, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 2:03 p.m., in 
Room 2360, Rayburn House Office Building, Hon. Mark Takano 
[Chairman of the Committee] presiding.
    Present: Representatives Brownley, Rice, Lamb, Levin, Rose, 
Brindisi, Cisneros, Lee, Underwood, Cunningham, Luria, Pappas, 
Allred, Peterson, Sablan, Roe, Bilirakis, Radewagen, Bost, 
Dunn, Bergman, Banks, Barr, Meuser, Watkins, Roy, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good afternoon. I call this hearing to order. 
Today, the House Committee on Veterans Affairs is gathered to 
assess the implementation status of the community care 
requirements under the MISSION Act, including the technology 
that will support the program.
    The impetus for this hearing is a report prepared by the 
U.S. Digital Service at the request of Dr. Melissa Glynn of the 
Office of Enterprise Integration. Before we discuss the report, 
I want to establish a few items for the record. First, I had 
hoped that the U.S. Digital Service would be here today to 
discuss both, the work that it is doing at VA in general, and, 
specifically, its work on this report.
    I want to be clear that I believe USDS is doing good work 
at VA and in other Federal agencies. USDS is filled with very 
talented individuals who have heard the call of public service 
and are tempting to help fix very challenging technology 
problems.
    Although the administrator of USDS was invited, it appears 
that the Office of Management and Budget, OMB, had a role in 
Mr. Cutts, or his staff, not being here today. I have to say 
that I am disappointed in this result, and I urge OMB to 
reconsider whether its bureaucratic internal processes are 
actually serving the government and the taxpayer well. If 
Congress is prevented from conducting legitimate oversight 
because of unnecessary bureaucratic hurdles, then it is a real 
problem. I hope we will have an opportunity to hear from USDS 
at a future hearing and to learn more about the work the 
digital services team is doing at VA.
    Second, I understand that there are sensitivities involved 
in USDS's role in advising agencies on technology. We want 
agency staff to speak freely to USDS and for USDS to be able to 
provide unvarnished advice because we want agencies to succeed 
at their technology projects. We want agencies to have the room 
to fix known problems before it endangers an entire program.
    The Committee understands that this report was not meant 
for the public, but it is now in the open. And as the Committee 
responsible for overseeing the implementation of one of the 
most significant pieces of veterans' legislation, we are 
compelled to ask questions about it. This is what brings us 
here today.
    Third, I want to be clear that this is a fact- finding 
hearing. We have invited VA leadership here in order to 
exchange information and to have a robust discussion about that 
state of implementation. I want you to understand, Dr. Stone, 
Dr. Glynn, and Mr. Gfrerer, that I want to have an open and 
honest conversation, and if there are things that the Committee 
needs to know about, such as resources, implementation 
timelines, or the real state of the technology, this is the 
time to share that information. We want transparency. Veterans 
expect and deserve transparency.
    And this is because when we talk about technology at VA, we 
are talking about more than technology. Information systems at 
VA support the very backbone of the mission of VA. These are 
systems that directly impact veterans' lives, their health, and 
their ability to access the benefits they have earned.
    The MISSION Act is a big mandate and we need to get it 
right. If the technology experts say that VA should cease 
development on the Decision Support Tool and for VA to rethink 
its approach to implementation, we want to understand those 
recommendations and what VA is doing about them. If a veteran-
centric vision is not guiding this implementation, then we need 
to figure out what needs to change. Our veterans deserve 
nothing less.
    So, I want to thank the witnesses for being here today and 
I look forward to their testimony. And with that, I now 
recognize Dr. Roe for his opening statement.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman. I welcome the opportunity 
to be here this afternoon to discuss the implementation of our 
new MISSION Act Community Care Program. That program is 
intended to take place of many disparate Community Care 
programs that the Department of Veterans Affairs uses today and 
create a streamlined process for veteran patients to be 
referred to community providers.
    The MISSION Act requires that the Community Care Program to 
begin on June 6th, just a little more than two short months 
from now. I know that Secretary Wilkie and his team are working 
hard to meet that deadline; however, United States Digital 
Service, USDS, issued a report last month that was highly 
critical of VA's implementation of the law to date and called 
into question, VA's ability to ensure timely access to care for 
veterans using authorities Congress provided under the MISSION 
Act.
    Some of the media reports, especially the headlines about 
the report, were down right alarming. Unfortunately, alarming 
reports about the readiness of major VA modernization efforts 
are nothing new. We have seen VA stumble too many times because 
of inadequate IT solutions, poor communication, failure to 
properly train clinical and sports staff, contract problems, 
and more. This Committee has done a deep-dive work into all of 
those areas in the past and I am sure that we will continue 
this moving forward.
    But in the meantime, veterans are counting on us to 
deliver. You heard me say before, and I will say it again, that 
I believe in taking the time to get things right, not just get 
them in a hurry. I said it in December when I chaired the first 
oversight hearing regarding MISSION Act implementation, and I 
will say it again now: I would rather postpone--VA postpone 
implementation of this program than to rush to implementation 
in name only and have veterans pay the price for it.
    I do not want to repeat the mistakes that were made with 
respect to the G.I. Bill last year. As such, I am taking the 
additional service findings seriously and I am focused on 
solutions. The way I see them, they fall into three general 
areas. First, there are concerns about Decision Support Tool, 
the eligibility-determination software underdeveloped to 
support the Community Care Program. Second, there are various 
critiques of this, strategic decisions VA made with regard to 
the Community Care network contracts. And, thirdly, there are 
continued alarms that VA needs to institute better 
interoperability capabilities with community providers right 
now.
    I think the Digital Service recommendations are right on 
target with respect to interoperability and the need to use 
data standards in what are called ``application program 
interfaces'' or APIs to jump-start interoperability with 
community providers' electronic health records. Certainly, it 
will undoubtedly improve interoperability, but the nationwide 
rollout is 9 long years away and we are 60 days from getting 
started. We are working on legislation that would create a 
competitive interoperability strategy to make sure we resolve 
this problem as soon as possible. I look forward to discussing 
that bill in a future hearing.
    As for other concerns detailed in the report, there is no 
doubt that the rollout of the new Community Care Program will 
bring with it, its own set of complications that VA will have 
to overcome. The same could be said of any new endeavor. 
Transformation is never easy, especially for an organization as 
large and complex as VA.
    I want to hear today how VA is preparing clinical and 
support staff on the front lines for the rollout of this new 
program, how they are training them on the new processes, 
procedures, and systems, that they will need to work with and 
how VA will mitigate any setbacks that may occur to prevent 
disruptions to veteran care.
    As to DST, my understanding is this new system is meant to 
create an automated system to replace a manual process that is 
been used for a number of years. If done well, the DST would 
make processing veterans' eligibility more efficient, but its 
failure or delay means continuation of the status quo, not the 
falling off of some sort of cliff. The Digital Service report 
raised the possibility of a worst-case scenario that the VA's 
daily appointment capacity nationwide could be reduced by 
75,000 if DST usability issues are as severe as the report 
suggests.
    I want to be sure that we leave this hearing today 
absolutely clear on what would have to happen for the worst- 
case scenario to come to pass. My understanding is it would 
entail rushing DST into use after inadequate testing, that only 
doctors are permitted to use the DST, rather than nurses or 
medical-support personnel, and that VA employees try to use DST 
with web browsers other than Google Chrome, and that a glitch 
between those other web browsers and VA's EHR cannot be fixed. 
I wanted you all to know this is not an infomercial for Google, 
but it sounds like it would be a good idea for everybody at the 
VA to download Chrome.
    Now that we have this report out in the open and we are 
discussing these issues, my sincere hope is that we can help VA 
work through them, rather than arguing about them later about 
what happened.
    With that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Roe.
    Before I recognize--not recognize myself yet--Dr. Stone, 
you are recognized for 5 minutes.

                   STATEMENT OF RICHARD STONE

    Dr. Stone. Good afternoon, Chairman Takano, Ranking Member 
Roe, and Members of the Committee. Thank you for the 
opportunity to discuss the implementation of information 
technology systems that will support the new Veterans Community 
Care Program under the MISSION Act.
    I am accompanied today by Dr. Melissa Glynn, assistant 
secretary for enterprise integration, and Mr. James Gfrerer, 
assistant secretary for information technology, and our chief 
information officer.
    The MISSION Act is an unprecedented opportunity to increase 
veterans' empowerment over their own health care and to drive 
the entire health care industry on behalf of those that we 
serve. Under the MISSION Act, veterans and their families will 
be able to choose the balance of VA-coordinated care that is 
right for them.
    Our job in VA is to ensure that the VA health care system 
is so exceptional that it earns the trust of America's veterans 
and they, therefore, choose VA. We know that veterans who are 
given the opportunity to choose their care from VA or from the 
community will typically choose to stay with the Veterans 
Health Administration. That is because research has shown that 
the VA provides care that is as good as or better than what 
veterans can receive in the community.
    While we increase veterans' empowerment and choice with 
Community Care, we are continuing to invest in our direct care 
delivery system and will use tools provided under the MISSION 
Act to ensure that high-quality, direct VA care is readily 
accessible for veterans who choose it. VA's recent achievements 
in expanding access to care are supported by new authorities 
under the MISSION Act that focus on underserved facilities, 
recruitment, and retention of health care providers. We are, in 
fact, the only health care system in this industry to make 
information about quality and access to VA health care fully 
transparent to our patients and we will continue to increase 
that transparency.
    While our vision is to ensure veterans choose VA for their 
care, we are committed to successfully implementing the 
expanded Community Care options under MISSION Act. VHA 
Community Care has partnered with information technology staff 
to design technology improvements that will streamline the 
process of identifying which veterans are eligible for 
Community Care.
    Because of the importance of the MISSION Act, VA has 
welcomed broad input on how best to implement these major 
programmatic changes. That is exactly why we asked U.S. Digital 
Services to review the development of the Decision Support 
Tool. Digital Services has offered VA in past initiatives. 
While I acknowledge the draft report, I reiterate that VA will 
be ready to offer veterans Community Care under the MISSION Act 
on June 6th.
    Once it goes live, the Decision Support Tool will improve 
efficiency for VA providers, making referrals by helping to 
simplify decisions about Community Care eligibility. But the 
tool is not essential for implementing any of the new 
provisions of the MISSION Act. VA is planning to develop tests 
and deploy the Decision Support Tool by June 6th. In the event 
that any technical challenge occur, VA will be able to make 
eligibility decisions, using existing and enhanced methods and 
tools. Veteran care will not be disrupted.
    VA's actions to modernize our systems and leverage the 
opportunities in the MISSION Act will place VA at the leading 
edge of health care evolution. We are committed to building 
both, the trust and health of our patients, and will continue 
to advance options that empower them to receive care when and 
where they need it.
    Your continued support is essential to providing this care 
for veterans and their families. Mr. Chairman, this concludes 
my oral testimony. My colleagues and I are prepared to answer 
your questions.

    [The prepared statement of Richard Stone appears in the 
Appendix]

    The Chairman. Thank you, Dr. Stone.
    Dr. Stone's full written testimony will be included in the 
hearing record.
    Before I recognize myself for questions, without objection, 
I will enter the report from the U.S. Digital Services into the 
record.
    The Chairman. I now recognize myself for 5 minutes. So, I 
wanted to begin with Dr. Glynn. Dr. Glynn, why did you request 
that the U.S. Digital Service conduct a discovery sprint of the 
VA's preparations to implement Section 101 of the MISSION Act?
    Ms. Glynn. Thank you for the opportunity to be here today. 
Well, I joined the VA coming from the private sector and it's a 
common leading practice when you have a milestone, a priority 
to enlist all of the expertise that we have at our disposal and 
certainly believe that our veterans, you know, the best value 
that we can bring to them is bring forward that level of 
expertise. Digital Service represented that level of expertise, 
especially around digital technology and pushing the envelope 
on technology. So, we sought an independent perspective on our 
implementation efforts and that was the impetus for the 
request.
    The Chairman. Did you have any particular concerns about 
the implementation?
    Ms. Glynn. There were no particular concerns, just making 
sure that we were doing everything in our power to make sure 
that the implementation would go smoothly, that we had thought 
of every kind of pitfall, and we had thought of how to mitigate 
the situation from an implementation standpoint.
    The Chairman. Were there any other reviews or assessments 
conducted about preparations prior to the discovery spread?
    Ms. Glynn. No, there were not, sir.
    The Chairman. This is really just your general standard 
practice when you come onboard and are trying to--
    Ms. Glynn. Yes, my responsibility is to make sure that we 
deliver, and this was the path we took.
    The Chairman. Okay. Thank you for that.
    We understand that the U.S. Digital Service held a 
discussion with VA after it prepared its report. Who from the 
VA was present for that discussion; do you recall that?
    Ms. Glynn. I know I was present. I'm trying to think of--I 
would have to go back and look at the attendee list. There were 
members of our working team, but there not broad representation 
from some leadership. I would have to go back and check our 
attendance to give you names.
    The Chairman. Okay. If you would, I would appreciate that, 
if you could provide that to the staff.
    As you know, we have been concerned about access standards, 
as currently contemplated. The criteria needed to develop the 
tool adds further complexities and exposes the ambiguity in the 
standards. The United States Digital Service requires a 
simpler, technical approach to attempt to avoid inconsistent 
and unfair results from this tool.
    Do you agree with the USDS' recommendation?
    Ms. Glynn. I believe I understood the recommendation that 
in order to make sure that there was consistency that we would 
have to put policies in place to support the fielding of the 
tool and I believe that we can deliver that level of 
consistency with the policies that are drafted currently.
    The Chairman. All right. So, what is VA doing to establish 
clear standards--I mean, you just mentioned the policies in 
place--
    Ms. Glynn. Yes.
    The Chairman [continued].--and veteran-centric guidelines 
to address the discrepancies due to data variation?
    Ms. Glynn. So, we're working internally to make sure, I 
think as Dr. Roe and yourself had mentioned, it is critical 
that we are ready for June 6th, so we are working internally on 
implementation planning and the rollout process, which includes 
training, policies, all of those tools that will make sure that 
there is consistency for the veteran working on communications 
that are directed specifically for the veterans and their 
family and support teams to make sure that there is 
understanding of how we can implement these access standards.
    The Chairman. Yeah, you know, as I was reading through the 
U.S. Digital Service report, I am trying to remember some of 
the particular--I mean, some of the particulars of just how--
some of the examples that they gave for how the tool could be 
inconsistent. Of course, what we are concerned about is 
veterans thinking that they should qualify and veterans not 
qualifying, people comparing notes and finding out that they 
are not qualified to go into the community and that this tool 
was potentially a source of a lot of inconsistency.
    But do you feel that you can get these policies in place in 
time for--
    Ms. Glynn. I personally feel, and my colleagues will 
certainly join in and provide their perspective from technology 
and from the leadership from the Health Administration, but 
overall, I feel that the tool will actually help us drive 
consistency and certainly drive more consistency. It is the 
sort of front-facing dashboard, which will help everybody have 
the same kind of perspective and see the same kinds of 
information every time they have that opportunity to look at 
whether they are going to receive care in the community or not.
    The Chairman. That is great. My time is up.
    I want to now recognize Dr. Roe for 5 minutes.
    Mr. Roe. Thank you. I was sitting down for dinner last 
night about 8:30 and my phone rings and it is a veteran who had 
been in the hospital at our local hospital, which is about a 
quarter mile from the VA medical center. So, he calls me up to 
get his record transferred from--he can't get the record 
transferred between his 7 days he had spent in the hospital, so 
that when he sees his doctor over at the VA. We are having that 
problem now 2 months from--so, how are we going to make sure 
that there is a seamless flow of information--anybody can take 
this--between the outside providers?
    Because if this doesn't work, then the whole system won't 
work. It will defeat what we are trying to do if we can't do 
that one simple thing, is get that information from me on the 
outside, back to the VA and vice-versa. That happened last 
night.
    Dr. Stone. So, certainly this is exactly the problem that 
we have dealt with for decades across medicine and one of the 
things that we are doing--and one of--there are 11 separate 
information systems that we are implementing as part of the 
MISSION Act. Some are out there already. Some are in further 
development, but the ability to move medical records right now 
is dependent upon the participation of various community 
providers in our health information exchange.
    One support we could get from the Committee, we would hope, 
is that good discussion with the community providers about 
participating in our health information exchanges so we are not 
forced to either fax or hand-carry records back to the VA from 
community referrals.
    Mr. Roe. And this is for you, Dr. Stone, you said this, but 
I want to make sure that we get it on record. How confident are 
you that the VA is on track to enact the MISSION Act Community 
Care Program on June 6th, as required by law? And the second 
part of that question is: You mentioned something in your 
testimony, if it didn't work by the--if the digital system, new 
system didn't work, that existing and enhanced tools could be 
used. What does that mean?
    Dr. Stone. So, let me answer the second half of that first, 
sir. We fielded last October, a provider-listing software 
system. That provider-listing software system included 30- and 
60-minute drive time calculations. That is been in use since 
last October.
    Now, since at least 2013, under the PC3 Program and then 
under the Choice Program in 2014, our providers and our 
provider care teams have been working hard to adjudicate 40- 
mile distances for veterans, as well as wait times of 30 days.
    What you have asked us to do under the MISSION Act is to 
take some different access standards in order to adjudicate 
whether the patient is eligible to go out. That work is going 
on every day today.
    What the Decision Support Tool does is automate it. So, if 
I am seeing you as a patient and make a decision to send you 
out for orthopedic care, that when I make that decision in 
VistA or CPRS, our current electronic system, a pop-up comes up 
that I need to use the Decision Support Tool. When I click on 
that, the whole thing pops up and gives me all the information 
I need on a single screen.
    But if that fails or that system is just not at the point 
that it should be, all of the software systems that are 
necessary to support the referral of you to a patient--or to an 
outside provider are in place.
    Mr. Roe. Okay. And you feel comfortable that you will be 
ready to go?
    Dr. Stone. I do, sir.
    Mr. Roe. And how will the experience of a veteran patient 
who is seeking Community Care referral and VA employees, who 
will be authorized Community Care referrals differ on June the 
5th before the MISSION Act Community Care Program is 
implemented and on June 7th after the MISSION Act Community 
Care Program is--what difference will they notice, if any?
    Dr. Stone. The mainstay of VA health care is the patient-
aligned care team, and what I mean by that is the physician, 
the nurse, the assistance, the schedulers that all work with 
that provider and that veteran in order to provide care. On 
June 6th, just like on June 5th, the veteran will be 
interacting with their care team in order to make decisions 
ongoing forward.
    So, although, I would not underestimate the fact that there 
are multiple criteria that are included in the Act--and this is 
complex work--for the veteran, it is not going to look terribly 
different in their approach to getting care.
    Mr. Roe. So, that pop-up screen is going to be the same 
then? They won't notice a difference.
    Dr. Stone. I think--with your permission, sir?
    The Chairman. You may.
    Dr. Stone. For you and I, as clinicians, we have spent our 
whole career with people calling us up saying, what do I do? 
All of us, when we get symptoms, and especially lay personnel, 
when we have symptoms, you don't want people out just Googling 
those symptoms and figuring they have got some sort of awful 
thing and end up in the emergency room.
    What you really want is them interacting with their 
provider and making decisions together. We are not going to 
abandon the American veteran on June 6th; they are still going 
to be interacting with their care team, making decisions on 
what is best for them.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Pappas, you are recognized for 5 minutes.
    Mr. Pappas. Thank you, Mr. Chairman.
    I appreciate your comments. And, you know, my concern is 
with the end user here and the veteran and their teams. I am 
just wondering on Page 5 of the report, the quote is, ``Little 
research has been done in the field to understand how veterans' 
physicians and clinical staff are currently providing and 
receiving care in the community through the VA before a new 
process is established.''
    And I am just wondering if you could talk a little bit more 
about the field research that was done as part of the IT 
rollout.
    Dr. Stone. Yes, I can, and I appreciate that question. As 
you are well aware, sir, we have been buying care since 1945. 
We have been through 6 major transitions in care. I talked 
earlier about the 2013 change in PC3 and the 2014 Choice Act 
and now the MISSION Act. But, literally, since 1945, we have 
been buying care in the community.
    On any given day, we decide to buy care about 50,000 times 
and we will see about 323,000 patients today. About 50,000 
additional patients will go out to the community.
    The Decision Support Tool was designed by our clinicians in 
the field, and, literally, a field clinician designed this and 
said, you know, what do I need today and what would be nice if 
I had that all in a pop-up screen? And there are 6 major 
information systems that connect to the Decision Support Tool 
that provide a single screen.
    And I have had an opportunity to see the prototype of it; 
it is pretty impressive. I sat with other clinicians from the 
field looking at it, and so the research, although, I would 
guess I would refer to it as anecdotal because we drew in 
people, it was all from actively practicing clinicians.
    Mr. Pappas. And, you know, if there are delays in further 
development or deployment of the new IT systems, I guess, do 
you have contingency plans of how to stay on track and do you 
potentially anticipate any further funds-transfer requests to 
make sure things hit their mark and they are on schedule?
    Dr. Stone. I think that the contingency plan is the 
fielding of the other 10 software systems with the Decision 
Support Tool as sort of being the icing on top that brings 
everything together. Should the Decision Support Tool not be 
effective or hit a technology glitch, then we will be working 
just about the same way we are working today as we go through.
    We do not anticipate large movement of patients into the 
system. I don't think the MISSION Act is going to force 
somebody that trusts their doctor to leave their doctor and 
come to the VA. By the same token, I don't see patients that 
trust their doctor in the VA leaving in large numbers to go out 
someplace else. Now, there may be transactions of care, and we 
monitor this, as I have said, on a daily basis.
    The second question you asked is about funds transfer. As 
you all are well aware, the MISSION Act was passed without 
appropriation as we looked at the one-year implementation, as 
we have moved our way through the requirements, as well as then 
getting the feedback from the comment period on those 
requirements for access, and as we then began to design these 
systems and move forward. That is a lot of work to do in 12 
months.
    When we found ourselves without appropriation, IT 
leadership came to me and said, Gee, we need some help. Now, IT 
has committed funds to this, but we are able, because of the 
generosity of all of you and how you funded us over the last 
few years, that we do have the funds in order to support this 
until appropriate appropriation occurs.
    And, Jim, I don't know if you have additional comments?
    Mr. Gfrerer. I guess from a technical perspective, the only 
thing I would offer additionally is I think there is a lack of 
understanding broadly around what the tool does. It is actually 
pretty simple. It goes out. It looks at the master veteran 
index. It then establishes some level of eligibility. It looks 
at the provider database and it makes a determination around 
drive and wait-time eligibility.
    The other, I think, misconception is the tool does have the 
opportunity to what is called in software ``fail elegantly''; 
in other words, if any one of those steps, if there is an 
interruption in the data query from the system, it can come 
back with a null and continue on with the process. So, it is 
not an all-or-nothing proposition.
    Mr. Pappas. Okay. Thank you. I yield back, Mr. Chairman.
    The Chairman. I now recognize Mr. Banks for 5 minutes.
    Mr. Banks. Thank you, Mr. Chairman.
    Once again, as I have said before, we really may be 
whistling be past the graveyard with the access standards 
debate. I understand that there is a lot of pent-up political 
energy anticipating the release of the standards, but they 
don't appear to be radically different than the existing 
standards.
    My concern is that the MISSION Act actually fixes Community 
Care, that the situation actually improves. That we don't just 
wind up with different programs with different names with the 
same old problems. Claims processing has been far and away, the 
worst problem.
    Dr. Stone, the Digital Service recommends scrapping the new 
Community Care network contracts. VA has a new claims system 
called eCAMS used to pay the network administrators, but it is 
my understanding that VA is expecting these contractors to 
provide the new claims system that is actually used to pay the 
providers' claims.
    Is getting rid of the contracts realistic and what would it 
mean to claims processing?
    Dr. Stone. I don't find, sir, that getting rid of contracts 
is realistic. I think we are going to need a third-party 
administrator.
    Let me talk a little bit about the standup of the Choice 
system and, certainly, across the Nation we ran into very 
substantial problems paying our bills, as well as the fact that 
we needed to change out one of our third-party administrators 
partway through that. We have done two things. Number one, we 
have gone to a nationwide safety net under a third-party 
administrator while we get our additional contracts out for 
Community Care. Secondly, we have moved from processing from 
about 140,000 claims a month to 1.7 million claims in the month 
of March in paid claims. So, we have dramatically increased the 
amount of claims that we are paying.
    We will still need a third-party payor. We have two systems 
coming online. One is eCAMS, which you talked about, which our 
non-network providers will be paid from. The second something 
called the Community Care Reimbursement System, CCRS, which 
will literally pay our third-party administrators and monitor 
their work. Those two systems are--the first, eCAMS is in 
production in VISN 19 and will expand in the next few weeks 
over the entire system. It is operating very well. The second, 
the Community Care Reimbursement System is a new system that 
will be completed in the month of May.
    Mr. Banks. Okay. Let me move on.
    Dr. Stone and Mr. Gfrerer, it is very important to me that 
the claims-processing system improves. I never want to hear 
from another veteran being hounded by a bill collector because 
the VA or its contractors failed to pay a provider. VA is 
asking the new network contractor to walk in the door with a 
claims system that meets all of VA's requirements, meaning it 
can handle all the EDI transactions that VA uses.
    First of all, can anyone tell me what claims system the 
company, I believe it is call Optum, uses? Dr. Stone? Mr. 
Gfrerer?
    Dr. Stone. I certainly cannot tell you, except that I have 
had--I do a monthly meeting with Optum talking about problems 
and this is--
    Mr. Banks. If you don't know, maybe you can take that for 
the record and get back with us?
    Dr. Stone. I would be happy to do that for you.
    Mr. Banks. Okay. So, Dr. Stone and Mr. Gfrerer, VA also set 
out 14 requirements for how the contractor system will 
adjudicate claims. Does the system already do those things, or 
would the company need to modify it to meet VA's requirements?
    Dr. Stone. We will take that for the record, also.
    Mr. Banks. Okay. Mr. Chairman, Dr. Roe, I think that we 
should keep an eye on both of these issues--they are very 
important--I know it is a big lift.
    And Dr. Stone, just as a follow-up to that, the VA also has 
to provide a company with the correct fee schedules for every 
type of claim. As you know, VA personnel have had a hard time 
picking the right fee schedules to pay their own claims. Has 
this problem finally been solved, and if so, how did you solve 
it?
    Dr. Stone. I believe it has been solved because it was part 
of the contractual bid of the winning bidder that proposed a 
fee schedule as part of it.
    Mr. Banks. As simple as that?
    Dr. Stone. Yes, sir.
    Mr. Banks. Okay. With that, I yield back.
    The Chairman. I now call on Ms. Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    Thank you all for being here and, you know, we, obviously--
this piece of it for implementation of the MISSION Act is 
critically important and it was certainly concerning to all of 
us here on the dais to read this USDS report. And just, you 
know, in the executive summary it says really right up front, 
it says, ``To stop the development on DST as it is currently 
implemented.'' And it goes on to talk about the 
interoperability with the 6 legacy systems and then goes on to 
say, you know, ``adding this eligibility work to the already 
time-constrained physician in a worst case could increase each 
appointment by an estimated 5 to 10 minutes forcing physicians 
to see approximately 3 fewer veterans each day and ultimately 
decreasing the VA's nationwide capacity by approximately 75,000 
appointments daily.''
    That is a concern for me. When I read that I think--and, 
particularly, we have an oversight responsibility to say we 
should stop right here and now until we can get some assurances 
and not just trust, but real honest-to-God assurances that we 
are moving ahead, understanding some of these recommendations 
that are coming out from this report and moving down a path of 
success.
    And so, I guess my question, Dr. Stone, you had said that 
this was all designed, but with the input of practicing 
physicians, but then the report gives some quotes from various 
physicians and one of them says, These people are out of their 
minds; they aren't housekeepers, door keepers, or garage men, 
saying, you know, really, you are going to ask me to do all of 
this, you know, sort of enforcement, who is eligible, who is 
not eligible.
    So, it raises my concerns. We don't have a great reputation 
when it comes to IT within the VA, and so I guess my question 
is, you know, how are you going to give us assurances that you 
are traveling down the right road and at the same time, able to 
meet these deadlines? It seems to me that if you have a way of 
interacting, if you don't meet the June 6th deadline, you have 
said that you have a way of addressing that, that you will do 
it the way that you are doing it now and interacting with a 
physician team and making, you know, good, solid clinical 
decisions down the road. But if we don't meet that deadline, we 
can do that, so I understand that there is a backup here, but 
should we just be doing that now and taking a deep breath, 
doing it as we are doing it and taking a deep breath and making 
sure that we are doing this properly to ensure that we are 
going down a road to success? It is a long-winded question, I 
understand, but--
    Dr. Stone. Congresswoman, it is exactly the question. This 
is complex work that you have asked us to do and I wouldn't 
underestimate it in any way. There is a lot of new 
requirements. There are a lot of new pieces to it, and in 
essence, every single veteran that we are seeing needs to have 
adjudicated, are they eligible to go out.
    And so, I would say, are we concerned? Yes. Do I think that 
the Decision Support Tool will make life easier when it comes 
into fruition? Yes.
    That said, the Choice Act expires on the 6th. I have no 
ability to buy care if we don't go forward. We must go forward 
with the MISSION Act on June 6th. And that said, I think your 
expectation of me is to be transparent, especially when I am 
concerned.
    What I have to say to you is that I am very, very pleased 
that the team has been working closely with IT. That we have 
gotten a third party to take a look at us, that has given us a 
really hard look, hence we are sitting here, but--
    Ms. Brownley. And I applaud you for doing that, too.
    Dr. Stone [continued].--most importantly, it was a chance 
to take a good hard look at ourselves. And so, are we concerned 
about the complexity of work? Absolutely, but I am optimistic 
that we are going to get this done.
    Now, that optimism is not a blind optimism. It is an 
optimism by the fact that we have gotten our provider- 
automated system out into the field last October and our 
providers and our care teams that I referred to earlier are 
using it today and they could call up the 30- and 60-minute 
drive time today.
    Ms. Brownley. Well, I thank you for that, and I appreciate 
your confidence, and, you know, I hope that we can interact 
more frequently as we move forward in the next couple of 
months. I apologize that I am over my time, but I hope that we 
can, you know, communicate closely over the next few months to 
keep us informed of the progress.
    So, sorry, Mr. Chairman. I yield back.
    The Chairman. Thank you, Ms. Brownley.
    Who is next? Ms. Radewagen, you are recognized for 5 
minutes.
    Ms. Radewagen. Thank you, Chairman Takano and Ranking 
Member Dr. Roe for holding this hearing.
    I want to thank the panel for being here. I also want to 
welcome my constituent, Ms. Lisa Tuato'o, who is all the way in 
from American Samoa on Homeland Security business.
    I appreciate everyone's work here to ensure that the 
MISSION Act implementation is going smoothly. And as I have 
mentioned in previous hearings, I also appreciate that the VA 
is really making an effort to meet the unique needs of those in 
rural areas, as well as the U.S. territories through the 
Community Care contracts.
    So, my question is for anyone on the panel who can answer: 
What is the status of the Community Care network contracts and 
what are you doing to ensure that the transition from the PC3 
Choice contracts to the CCM contracts will be as seamless as 
possible for veterans, community providers, and VA staff? And, 
also, what do you any are the major differences between the 
current PC3 Choice contract and the CCM contract that members 
should be aware of?
    Dr. Stone. So, the status of the contracts are as follows: 
Region 1 in the northeast part of the United States is in the 
process of implementation with Optum, as you heard previously. 
The major difference in that contract is a stable payment 
levels tied to Medicare, and so I think that is the major 
change, as well as probably about 140 other data points that we 
have locked through with the vendor as we have gone forward in 
improvements and how we interact with each other, and we would 
be happy to lay those out for you in separate session.
    Region 2 and 3 are under protest. They were awarded and 
then protested. We anticipate in the month of May, they will 
come out of protest, and, certainly, I would not suppose what 
the effect is of the protests, but we are hopeful.
    Region 4 will award in the next few months. Those bids are 
back in. That is the western half of the United States. Those 
bids are all in and being evaluated, and I probably should say 
nothing more about that at this point.
    Region 5, Alaska, we just finished tribal consultations and 
will implement the further either RFIs or RFP over the next 
year.
    And then Region 6 will also--we have consultations, an 
industry day actually tomorrow in Region 6 that we will begin 
to look at what the questions of the provider community are in 
providing care in the Pacific.
    Ms. Radewagen. Thank you. USDS alleges that the additional 
administrative burden of continuing to pursue the new contract 
arrangements outweigh their benefit. Do you agree? Why or why 
not?
    Dr. Stone. So, I do not agree, and as a matter of fact, 
they refer in their report to maybe we should use Medicare. 
Please remember that Medicare uses third-party administrators. 
Medicare does not deliver care directly.
    I spent most of my career in the upper Midwest. I dealt 
with Blue Cross of Illinois as the Medicare adjudicator of 
payment of claims. So, I think that criticism reflect a failure 
to understand Medicare and how it reports. And I am not being 
pejorative in any way towards U.S. Digital Services, but that 
concept just didn't bear fruit.
    I think the second thing they suggested is maybe we have to 
use TRICARE. And please remember that I spent 25 years in 
uniform, so I know a little bit about TRICARE and certainly 
have been a consumer of TRICARE services over my family's time 
and service and even today.
    The problem with the regional delivery systems with TRICARE 
is they are centered in areas of the country that just are not 
broad enough in order for us to take care of the dispersed 
veterans as we look in the Pacific, as we look in Alaska, and 
in the rural areas of this country. Forty-five percent of our 
veterans are out in rural areas, well away from TRICARE 
delivery networks.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back the 
balance of my time.
    The Chairman. Thank you, Ms. Radewagen.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    Dr. Stone, if we could just step back for a second, the 
MISSION Act and Choice before that were all done before I 
arrived in Congress, but my understanding of them is that the 
expansion of Community Care was motivated by what is good for 
our veterans, right?
    Dr. Stone. Absolutely. I think all of the work going back 
to 1945, has been what is good for veterans.
    Mr. Lamb. And we have kind of reached a shared 
understanding at this point that one thing that might be good 
for them would be to give them more choice in where they could 
get providers; again, for their own sake, not for anybody 
else's sake, but so that they could feel like they had some 
choices for things that were closer to home, for simple 
conditions, they wouldn't have to go all the way to the VA; 
that was the idea, right, to do something nice for veterans?
    Dr. Stone. Sir, I would not suppose to think or to suppose 
what Congress thought as they passed it, but as I read it, I 
think this is law that is good for veterans.
    Mr. Lamb. I agree. I guess my point is just we didn't do 
this to make things easier on the VA or to give Congress 
something good to talk about. We did it because veterans wanted 
it and we thought it might be a better way to get them health 
care; would you agree with that?
    Dr. Stone. Yes.
    Mr. Lamb. Now, does this Decision Support Tool that we are 
talking about here, does it allow veterans, themselves, to use 
it?
    Dr. Stone. It does not.
    Mr. Lamb. Okay.
    Dr. Stone. It is a provider-facing, patient-aligned care 
team facing tool.
    Mr. Lamb. So, it does not provide a tool for the veterans, 
themselves, before they go in to the VA to determine if they 
are eligible for Community Care?
    Dr. Stone. It does not, although, that is something that 
Digital Services suggested, and we are respectful of that.
    Now, the complexity of delivering care to America's 
veterans has to reflect how complex their disease processes 
are. This is not about giving them a Google site to go to and 
then make decisions. Those decisions are best made in 
conjunction with their provider care team.
    Mr. Lamb. And I appreciate that, and that is a mission that 
we have given you and that you are trying to execute, so I 
totally understand that.
    But as a result of the way that this Decision Support Tool 
was developed, the discussion and decision is going to have to 
take place during the appointments, right?
    Dr. Stone. No, not at all. Certainly, the patient can call 
for their care team as they do today. They can call for an 
appointment and say, Gee, am I eligible to go out? And all of 
this can be done with the patient-aligned care team scheduler 
or the nurse. Usually, we do involve either the nurse or the 
physician in that discussion just because of the complexity.
    I referred earlier to, gee, if I want to refer you to out 
for an orthopedic visit, well, if you are on a blood thinner, 
just me referring you out to an orthopedic surgeon will create 
a disconnect in care and potential risk if you are not talking 
to your care team.
    Mr. Lamb. Right. Absolutely.
    So, do you accept the finding or suggestion of this report 
that this will probably result in fewer appointments a day 
systemwide because of the additional time that it is going to 
take from the care teams?
    Dr. Stone. I do not.
    Mr. Lamb. Okay. And that is a fair disagreement.
    I am trying to think of how I want to ask this. Given what 
we have happening right now is the risks presented in this 
report, one of which, for example, is that--I guess I want to 
back up. The report suggested that several primary care 
providers told the authors of this report that veterans often 
are not presented directly with a choice for a veteran's care 
if they don't ask about it from their care team or don't ask 
about it with the providers. Have you heard that before, as 
well?
    Dr. Stone. Just in the report.
    Mr. Lamb. Okay. Do you accept that as a possibility? I 
mean, that has, obviously, been said to these authors.
    Dr. Stone. Certainly, I would expect all of our providers 
to act in an ethical and honest manner with their patients. I 
think that is how you earn future trust.
    Mr. Lamb. Sure.
    Dr. Stone. And I would expect everyone to discuss exactly 
what is in the best interests of the veteran.
    Mr. Lamb. Okay.
    Dr. Stone. And that is actually in the law as part of the 
statute, that if it is in the best interests of the veteran, 
even if they don't qualify to be referred out because of wait 
times or drive times, that if it is it in their best interests, 
they should be referred out.
    Mr. Lamb. Sure. And that part I understand. I guess it is 
just coming back to my point that what we are supposed to be 
doing here is presenting our veterans with an actual choice 
that they get to make, obviously, in conjunction with their 
care team. But we have created a tool that they are not able to 
use. They have to know to ask about it in some cases from their 
care team. They may have to call. They may have to do it in an 
appointment, which slows it down. They may reduce the number of 
appointments systemwide, and that seems, to me, to not 
accomplish the mission of giving them more actual choices.
    Given all of that I just--and I am out of time--I just urge 
you to consider slowing down on this and doing a less- complex 
version of it on June 7th. I understand that you are under the 
gun timewise, but this seems rushed in a way that does not 
reinforce the actual choices that our veterans get to make.
    And, Mr. Chairman, I yield back. I apologize for going 
over.
    The Chairman. All right. I thank the gentleman.
    I would like to move on to asking Mr. Barr, you are 
recognized for 5 minutes.
    Mr. Barr. Thank you, Mr. Chairman.
    Dr. Stone, good afternoon. How are you? That is okay. Dr. 
Stone, last year my office assisted a veteran from our district 
who, after receiving two hip replacements from the same Choice-
approved doctor through TriWest, was told at the desk of the 
doctor's office when he showed up for an appointment that he 
was no longer eligible to see that doctor under the Choice 
Program. After looking into my constituent's case, it was found 
that due to a VA system glitch, my constituent's distance 
eligibility was erroneously terminated under no fault of his 
own.
    How is the VA going to ensure that veterans are not going 
to be arbitrarily kicked off of the eligibility rolls for the 
Community Care Program, particularly, with the issues being 
highlighted by the rollout of the Decision Support Tool?
    Dr. Stone. So, I think this is exactly what I was talking 
about in the Provider Profile Management System that we rolled 
out 6 months ago, and have begun to look at that getting ready 
for June 6th. That is a generally used tool across at least 13 
states and 20 health care systems in that 30- and 60-minute 
time.
    We have got really good data that we currently have on our 
wait times on the 20- and 28-day wait time that the secretary 
has ordered as part of the access standards and the eligibility 
to go out. What we don't good data yet is the wait time in the 
community; it is just not as transparent as we are in VA.
    Now, in the Decision Support Tool, when we looked at the 
prototype, it pops up our wait time, as well as any information 
on the distance from the home address for the veteran in the 
30- and 60-minute software system, as well as any information 
eventually when we accumulate it on wait times in the 
community. So, in essence, that provider team scheduler will 
need to make a phone call with you, the veteran, in front of 
them, to find out what--how long it is going to be before we 
can get you in before you leave the office.
    Mr. Barr. And this DST is an automated system, and I think 
my veterans would want to know the role of human beings in 
checking the system. And so the next question I have is, you 
know, what role will VA personnel play in reviewing the 
accuracy of these determinations and then also when there is a 
change in a veteran's Community Care eligibility?
    Dr. Stone. So, I think we are comfortable with the work and 
transparency that we have been doing for a number of years on 
wait time--how many days' wait there is inside of our system 
and the accuracy of that data. It appears that the 30- and 60-
minute tool is going to be solid just because it has been used 
for many years in the commercial space.
    But your question really relates to how are we going to 
manually override that and check it?
    Mr. Barr. Well, so, in other words, if the veteran is 
pretty confident that he or she would meet the criteria and for 
whatever reason the digital tool, the Decision Support Tool, 
rather, makes an alternative, a different determination, you 
know, how can there be an appeal? How quickly can the veteran 
question that automated determination?
    Dr. Stone. So, that automated determination is also going 
to be overseen by your provider care team, and your provider 
care team then will decide if it is in your best interests. And 
if you are convinced that because of some other health problem 
or transportation problem, you ought to be someplace else for 
your care, then the beauty of this law is it says, if in the 
best interests of the veteran, that can all be overridden right 
at the point of care, at the point of scheduling.
    Mr. Barr. As you know, one of the flaws, with respect to 
the implementation of the Choice Program was a failure to 
properly communicate with trained VA staff regarding 
expectations, processes, procedures, et cetera. What is the 
status of that work for the MISSION Act Community Care Program, 
and can you ensure that the VA staff on the front lines will be 
ready, willing, and able to effectively administer care under 
this new program on June 6th, again, speaking to the issue of, 
you know, human beings ultimately being accountable, Dr. Stone?
    Dr. Stone. So, we have automated all of this training and 
both, web-based training and e-training. We have got at least 
two dozen training modules out even for our community providers 
and Web sites and I would be happy to go through that training 
with you. But this has all been done through automated training 
that does not require the provider to go to anyplace.
    Mr. Barr. Thank you. I yield back.
    The Chairman. I knew call on Ms. Lee for 5 minutes.
    Ms. Lee. And I am down here. Thank you all for coming out. 
And, clearly, this is an incredibly complicated task with, you 
know, very far-reaching and potentially grave consequences if 
we don't get it right.
    And, Dr. Stone, I wanted to ask you, you made a comment 
earlier, you know, this, obviously, is dictated by the MISSION 
Act. There is a June 6th deadline. And I wanted to ask you, 
like, waving a magic wand, if we did not have this June 6th 
deadline, what would you be doing differently?
    Dr. Stone. I think the ability to move--first of all, the 
ability for me to buy care in the community expires on June 
6th. What I would be doing differently is trying to figure out 
how to go back to a system that preceded 2013 that didn't work 
very effectively.
    I think all three pieces of legislation could have been 
implemented slightly differently, but it is good legislation, 
and I think it brings us from 6 or 7 different ways of buying 
care to 1. That is good for the veteran. The veteran will now 
be able to understand from a single methodology how decisions 
are made, instead trying to figure out which program they are 
eligible for.
    I wanted to ask, you know, the MISSION--and I am sorry if 
this was asked earlier, but the MISSION Act emphasizes the need 
for efficiency, potential consolidation for the provider 
network. The USDS recommended that the VA discontinue its 
efforts to create its own payer network and explore--perhaps 
explore partnering with another existing network. What is the 
response to this--the VA's response to that recommendation?
    Dr. Stone. Congresswoman, we did go over that previously. 
Let me say to you that the two recommended systems that they 
suggested were Medicare, one. Medicare does not run its own 
delivery system. That is done through fiscal intermediaries out 
in the commercial space. The second is TRICARE. And the problem 
with TRICARE is it is just not broad enough because of the 
rural nature of many veterans. Forty-five percent of veterans 
are in rural space.
    Ms. Lee. Are you exploring any other opportunities?
    Dr. Stone. Certainly. We are exploring a number of other 
opportunities. Number one, we have given priority to our third-
party administrators to the federally disadvantaged clinic 
system. We have over 900 providers that are in the federally 
disadvantaged clinic system that participate with us. In fact, 
we will buy this year almost three quarters of a billion 
dollars' worth of care through those Federal clinics.
    Secondly, we continue to work in innovative methods with 
the Department of Defense, as well as Indian Health Service, in 
order to buy services through them as preferential partners.
    Ms. Lee. And finally, the USDS also recommended using 
resources to have like a concierge approach to managing care, 
essentially closing the loop with the veteran-centric approach. 
What is your response to that recommendation?
    Dr. Stone. I think that is exactly what we are trying to 
move to. I think by--if you were seeing me as your provider, 
you would get me involved in a concierge approach of what is 
best for you, what are the nuances and difficulties of care.
    Because of the extraordinary amount of pain we deal with 
across the veteran population in chronic pain, degenerative 
diseases of the spine, hips, and knee, it requires a concierge 
approach to every one of our veterans. And I think this goes 
back to Congressman Lamb's question of what you want is a 
veteran-centric approach to this care.
    Ms. Lee. Thank you. I yield.
    The Chairman. Dr. Dunn, I recognize you for five minutes.
    Mr. Dunn. Thank you very much, Chairman Takano. Dr. Stone, 
it is good to see you again. I want to describe my district 
briefly to you, so you understand my situation. I have 19 
largely rural counties, a couple of CBOCs, one VA hospital. The 
vast majority of my veterans--there are 70,000 veterans living 
in my district--the vast majority of them per force meet all of 
the choice requirements. I mean, you just know they aren't 
within an hour's drive of specialty care. So and it is the 
specialty care, specifically, I would like to address.
    We saw--we never turned away a veteran in my offices, but I 
will say that our accounts receivable with the VA habitually 
were in the 180 day plus range. There are a lot of physicians 
who will not tolerate, that can't tolerate that really in their 
offices. And so the reimbursements become the problem. And the 
choice of provider goes away if there is no reimbursing the 
other specialty providers there in the district.
    And so what I would like to know is what are we going to do 
to make sure that this problem ends, so that we don't have the 
problems with the veterans going out, seeking care, and there 
is no reimbursement?
    Dr. Stone. Congressman, first of all, your district is one 
of the most rapidly growing areas we have in the country when 
it comes to veterans. Veterans are seeking that area of the 
country and--
    Mr. Dunn. We are nice to our veterans. We like them down 
there.
    Dr. Stone. Thank you, sir. Secondly, the primary corporate 
structure of the physicians providing care to veterans in your 
district and many areas of the country is small businesses. 
They cannot carry 180-day accounts receivable. So for that 
reason, community care has been working hard to increase the 
number of claims that they are processing on a monthly basis. 
And I monitor that on a weekly basis of where they are at.
    And I am pleased that we have moved, and I have said 
earlier from 140,000 claims a month to over 1.7 million. We 
will approach 2 million claims processing a month and begin to 
exhaust this backlog.
    As this system grows, we will need to continue that growth, 
and therefore I have authorized the expansion into a third-
party claims payer that will move us towards the goal of at 
least 90 percent of claims paid within 30 days.
    Mr. Dunn. We would be very grateful for that. That would 
certainly be a change that we would experience. And I would 
like to know that we have some recourse offline. We will talk 
to your office. Some recourse to talk to when I do get 
complaints from my district from the care providers on the 
civilian side. And we can talk about that offline.
    Dr. Stone. I know that wasn't presented as a question, but 
please understand that we recognize the fact that unless we 
have credibility as a payor, we cannot maintain a delivery 
network. And our providers in the community deserve better than 
that.
    Mr. Dunn. We understand each other. Let me ask you also if 
you will nail something down for me. I am a little fuzzy on 
this. Is it only the physicians who are using the DST, or is it 
your mid-levels, nurses, administrative personnel, contracts, 
who gets to use the DST?
    Dr. Stone. You are exactly correct, sir. It is entire 
patient aligned care team. So it could be the--
    Mr. Dunn. Okay, so not the veteran, but anybody else in the 
VA, basically, who does patient care?
    Dr. Stone. Exactly. This is not unique. It could be the 
telephone scheduler. It is not just the physician. So if I, as 
a physician, make a decision to refer you out for some sort of 
episode of care, it may be that the nurse that is working with 
me that day, the physician extender that is working with me 
that day will pick that up and finish that work. This is not 
simply the physician who needs to do that.
    Now, we have talked to a number of physicians that enjoy 
doing all of that work, right up to the point of picking up the 
phone and calling the referring office for an appointment.
    Mr. Dunn. We don't have a lot of those. Thank you very 
much. I appreciate your reassurances, Dr. Stone. I look forward 
to working with you. Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn. I now recognize Mr. 
Bilirakis for 5 minutes. He is not here. I now recognize Mr. 
Watkins for 5 minutes.
    Mr. Watkins. Thank you Mr. Chairman. I have the honor of 
representing eastern Kansas, rural communities. I think 
communities 3,000 people and less. So the MISSION Act is very 
important to us. Thousands of rural veterans in eastern Kansas 
live outside the VA medical facility areas. They need community 
care options and the MISSION Act is imperative.
    So Dr. Stone and Mr. Gfrerer, which IT systems do you 
consider critical to implementing the MISSION Act by June 6th 
and which IT systems are not?
    Dr. Stone. So all of them help. All of them help, right 
down to those systems and program integrity for us to detect 
fraud. So all of them help and together, they make our life a 
lot easier. In order to do this, none of them can we operate 
without. Now, it just makes it a more inefficient system.
    And this is where we acknowledge digital services concerns. 
I think you bring it all together, and you lay DST over the top 
of it, it all works pretty well. But every one of them, we are 
still going to be delivering care on June 6th if every one of 
them failed.
    Mr. Watkins. Thank you very much, Mr. Chairman. I yield my 
time.
    The Chairman. Thank you. Mr. Meuser, you are recognized for 
5 minutes.
    Mr. Meuser. Thank you, Mr. Chairman. Thank you all very 
much for presenting here today and discussing this complicated 
and difficult initiative. I have had experiences in 
implementing IT systems in the private sector, as well as for 
the Commonwealth of Pennsylvania, when I served as Secretary of 
Revenue. Something we called a tax integration system and 
modernization act.
    The moment I reviewed when I entered as secretary, after 
the--it went online or began to be implemented a few months 
earlier and contracted, after about 3 months, I realized that 
everything was going to be about 6 or 7 months delayed from the 
initial--from the get-go.
    So I certainly can understand a system like this and 
running into some shortcomings and some--particularly from 
contractors, then perhaps overstating what can be done in a 
perfect scenario. I also recognize very clearly the backgrounds 
of all of you, just incredibly impressive. Thank you for your 
service and thank you for what you are doing now, Dr. Stone, 
Assistant Secretary Gfrerer.
    Mr. Gfrerer. Gfrerer.
    Mr. Meuser. Gfrerer. All right, and Dr. Melissa Glynn. I 
won't go through your resumes. You probably did that before, 
but incredibly impressive and clearly you are the right people 
to be handling this very challenging task, which is very 
important to all of us.
    I, as well in my district, Pennsylvania Ninth, I have 
80,000 plus veterans. We really--we have two Vas: one in 
Lebanon VA, which does a terrific job for our veterans, as well 
as the Wilkes-Barre VA. So again, very appreciative and 
understanding.
    Now, the USDS assessment did point out three areas. Number 
one, it says your IT systems to automate veterans' eligibility 
determinations for community care. That is clearly important. I 
will leave it open to whoever would like to respond to that. 
And maybe you did earlier. My apologies. But where do you think 
you are versus their assessment or just honest--your honest 
look at where things are right now? And when do you think you 
will get to where you would be satisfied?
    Mr. Gfrerer. Congressman, as I came on in January, the 
decision had been made that, you know--as you know probably 
from your experience, you have to manage a program according to 
a certain set of risk parameters, cost schedule, and 
performance. This one was clearly falling into the schedule 
bucket. As you said, too, with the delays that you have seen in 
IT systems, you know that information technology serves to 
automate and support a business process.
    And so when you look at one year to accomplish everything 
that is in a very complex statute, and then all of the 
activities that have to occur from the regulations, to 
eliciting user requirements, to--from there on forward. That is 
quite a lengthy flow if you are going to get it right.
    And so I would tell you that I am confident we will have 
the functionality by 6/6 for the decision support tool. I think 
when you look in the report, you are sometimes left with 
choosing--making a binary choice. We talked about the ability 
of the system to fail elegantly across the different criteria 
that it is going to look at, so it doesn't just blow up and 
cease.
    Alternatively, I would say as well that we certainly looked 
at and within VA, we are going to an application program 
interface architecture, right? Applications are the wave of the 
future. We are going to the cloud, again, managing that program 
to risk. We just couldn't get there fact enough from January to 
June 6th.
    Now, that said, there is a parallel development team that 
is taking those requirements around that Legacy architecture 
and developing it on an API basis. So it is really not an 
either/or, it is an and. It is just, again, managing the 
program to a schedule risk.
    Mr. Meuser. All right. Very good. I'm going to jump to the 
third that they mentioned here regarding health record exchange 
with the community providers. That certainly sounds like a bit 
of a challenge. Maybe you could just address that in the 
remaining seconds.
    Mr. Gfrerer. I know at the HIMSS Conference in Orlando in 
January; the entire medical and health care community really 
looks to the VA to be a leader in this area. So we are, again, 
via our API approach, we are rapidly, and we are a leading 
adopter of the fire standard, you know, the fast health care 
interoperability resource standard. Again, the entire market is 
looking to the VA to develop that and kind of put its weight 
behind it, because I think, again, as someone that has served 
in uniform for 28 years and then migrated to VA with putting my 
paper records over, and you know, no one thinks that that is a 
vision of a future that we all want to be a part of.
    And so whether it is--those health information exchange 
opportunities and those standards are things that we are 
rapidly adopting. And as Dr. Stone sort of alluded to, bringing 
our community care partners into that. And part of the reason 
for that, too, is around the proliferation of electronic health 
record systems.
    Someone corrected me a couple of weeks ago. I thought I was 
on over about 80 systems and I said--they said, ``No. It is 
about 400 different electronic health record systems.''
    Mr. Meuser. Well, thank you. You have many veterans 
counting on you. Let us know how we can help. And I yield back, 
Mr. Chairman.
    The Chairman. Mr. Bergman, you are recognized for five 
minutes.
    Mr. Bergman. Thank you, Mr. Chairman. And thanks to all of 
you for being here. Now that Mr. Gfrerer, right? Colonel 
Gfrerer, retired.
    Mr. Gfrerer. Recovering.
    Mr. Bergman. Recovering. Well, that is--there is no such 
thing as a recovering Marine. Maybe retired. We know that one 
of the challenges that we have in any system, but especially, 
let's say as related to United States military, the challenge 
of balancing, maintaining Legacy systems while we overlap and 
implement Next Gen systems. So now that you are in the VA 
system, I am hopeful that you will bring that tenacity that you 
had as a Marine to the urgency to truly seek a balanced 
blending of the Legacy with the Next Gen, whatever it is we are 
trying to do, and not look at life just linearly: we are going 
to do A, then B, then C. We are probably doing all three of 
them at the same time. We are just running at different speeds.
    So let's take, for example, here as to the two community 
care network contracts that are under protest currently. Why 
has the secretary not exercised his authority to allow the 
contractors to proceed with their work while the protests are 
being resolved? To me, that sounds linear. How can we keep the 
ball moving forward while we deal with protests?
    Dr. Stone. I would need to defer that to counsel. Counsel 
made the decisions on how to proceed with this, and advised the 
secretary, and I would ask to take this one for the record.
    Mr. Bergman. Well, please do, because the--again, the--we 
all have our roles to play and while we need to make sure we do 
everything legally, we can't let the battlefield just lay, if 
you will. In this case, the battlefield is the implementation 
so that we can move it forward. So I appreciate you taking that 
for the record. And because if there is a way possible, let's 
keep the inertia going.
    Next question. What abilities will the VA have to improve 
these IT systems over time, again. Okay. We are going to go 
from Legacy to Next Gen. But that Next Gen is going to be 
Legacy at some point. And how do we keep a--because I think in 
somebody's resume here, I saw Lean Six Sigma certifications. 
How do we keep that system updated over time, future updates, 
what is the plan?
    Mr. Gfrerer. Congressman, I would start by saying that part 
of the job of the Chief Information Office is to constantly 
partner with the business and find ways to increase 
effectiveness, contain cost, but also drive innovation, right? 
And so sometimes that innovation responsibility of the CIO is 
really kind of top of mind. I know it is something that I have 
prioritized. While I have all of the, you know, kind of keeping 
the lights on activity, I can't just be maintaining, as you 
would say, the Legacy systems. I have to be looking to the 
future.
    I would point to a few things that specifically--certainly, 
our migration to an electronic health record. I am spending a 
lot of cycles on that with our partner, Mr. John Windom in that 
office, and Dr. Stone. Certainly our movement to the cloud. We 
have an entire enterprise cloud strategy where we are moving 
applications and there is a lot of really good use cases around 
that, about increased functionality.
    You know, one of our team told me about recently was right 
before Hurricane Harvey, the decision was made to move some 
benefits applications into the cloud, along with that 
associated data. And as soon as Harvey rolled in and the on-
premise data centers were shut down, because it had been 
migrated to a cloud, the rating officials were able to continue 
their business.
    Mr. Bergman. Okay. Well, and I know my time is running 
short and I appreciate that because there are sometimes you 
cannot predict, stuff happens. Life happens around you. But it 
would, I think it would be helpful for all concerned, 
especially as Congress, as we continue to give money to the VA 
for projects, that if there is a way on some kind of a scale 
for all of you to say, ``Well, we think at this point, 2 years 
from now, or based on whatever it is, it could be a guess, but 
let's see how close we get.'' Because without any kind of 
predictive nature, we are going to have surprises. Let's face 
it. That is just the nature of the world. If we could predict 
and see how close we get to some of these surprises, then it 
would help us long term to have better planning, and I yield 
back, Mr. Chairman.
    The Chairman. Thank you, General Bergman. Mr. Cisneros, you 
are recognized for 5 minutes.
    Mr. Cisneros. Good evening. Thank you all for being here. 
Or I should say good afternoon. Thank you all for being here 
today. You know, in my--I'm from California, 39th Congressional 
District, and unfortunately, we don't have a VA health center. 
My veteran constituents need to travel at least 30, 40 plus 
miles in about two hours of traffic to get to the VA care, 
which depending on the time of day, like I said, could be 
anywhere from an hour to two hours.
    This is something I am very mindful of when thinking of VA 
services for the veterans in my district, as traffic congestion 
is a way of life for many constituents in Los Angeles and 
Orange County area. And although the MISSION Act has expanded 
the community care access standards to include drive time, 
there are major concerns that neither the law nor the draft 
regulations specify to an adequate level of detail how the VA 
should calculate drive time and wait times to make eligibility 
determinations leading to unreliable and inconsistent 
calculations.
    Additionally, the USDS report finds that much of the data 
necessary to determine eligibility is currently housed across 
several VA systems that don't interoperate. However, the VA 
only gave itself 12 weeks to develop the decision support tools 
meant to address this. It is a big concern of mine.
    So where is the VA in the development of tools veterans 
makes access on the development Web site to determine the drive 
time associated with their local facility? And is the VA open 
to adopting a people-centered approach in this field, providing 
that most liberal interpretations possible for eligibility 
criteria as recommended by the USDS report?
    Dr. Stone. Congressman, we appreciate the nature of the 
drive times in that area of the country. There are many areas 
of the country that we have struggled with drive times and 
various different drive times at different times of the day or 
different times of the year.
    We struggled mightily with the 40-mile limit, just because 
of geography that 40 miles in an area like the Pacific 
Northwest may be just completely untenable. Whereas, in 
Montana, it may be fairly acceptable in an area that is-- that 
you are able to get through.
    So as we adjudicate this, and as we work these, the actual 
30- and 60-minute drive time is a commercially available system 
that has been linked to one of our programs and is in current 
use today. So we are comfortable at its accuracy because it has 
been used for many, many years, including in the State of 
California to assess the adequacy of the Medicaid system. And 
so the California Medicaid system uses the same software 
system.
    So we are comfortable with its accuracy, but remain 
respectful of the fact that different times of the day are 
pretty tough to get around the area that you represent.
    Mr. Gfrerer. Congressman, I just wanted to address your 
technical concerns and I think this was before you stepped in, 
potentially. There are certainly three systems that are at the 
core of what the decision support tool has to reference in 
order to help the clinician and the veteran reach this best 
medical interest decision. One is the master veteran index; one 
is the enrollment system; and the other is the provider 
database. So there is just kind of no getting around. Those are 
three very discreet and differential databases.
    And I know in the report, one of the things it talked about 
was the brittleness of the architecture, really referring to 
could the data calls on these three systems handle the 
additional load that would potentially occur, even with say a 
50,000 to 75,000 patient a day referral. And I can tell you 
that we have done the sufficient stress test to show that it is 
orders of magnitude more capable of handling that increased 
load.
    Mr. Cisneros. On another--just kind of changing the subject 
a little bit. The overachieving findings of the report also 
said the need for a veteran-centric vision for implementation. 
For technology implementation, this translates to user-based 
approach. In this case, the user is both the care team that has 
to manage the eligibility determination and the veteran whose 
care is at issue. Do you agree or disagree with the assertion 
that the VA leadership has to define what community care should 
be from a veteran's perspective?
    Dr. Stone. Congressman, I think that is exactly what we 
have done. The VA's foundational service is to be veteran-
centric and to recognize the nuances of service and the 
injuries that it causes, even injuries that can't be seen. And 
the reason this system was designed in this manner is because 
of that belief in the integration of care between the provider 
team and the veteran.
    This is not simply a system that you can go out and say to 
a veteran, ``Well, get on the Web site and decide if you are 
eligible to go out or not.'' That doesn't at all recognize how 
many of our patients suffer from mental health diseases, as 
well as the amount of even--I could just focus on military 
sexual trauma. The real importance of this as a health care 
system is about our ability to integrate care and not just 
simply send people out to a Web site in order to make a 
decision on care.
    Now, that is the same as people have in the commercial 
space, and the frustration of trying to figure out what doctor 
to go to. What we do is partner with the veteran and make this 
a veteran-centric system.
    Mr. Cisneros. I yield back my time.
    The Chairman. We have an option for a second round of 
questions. I will recognize myself for the first 5 minutes. Dr. 
Stone, you mentioned the participation of community care 
providers in the VA's health system as a concern of yours. Can 
you tell me what --
    Dr. Stone. Sir, I--
    The Chairman [continued].--that they may or may not 
participate. Is that the--
    Dr. Stone. There are areas of the country where Medicare 
participation is very low: Alaska. As we begin to work our way 
through and effectively recover from a period of years in which 
we were slow to pay bills, as you heard from your colleagues, 
we need to regain the trust of the providers in America. And so 
I do worry about the willingness to participate in our system 
as we regain that trust.
    The Chairman. Okay. So that wasn't about the Health 
Information Systems? The--
    Dr. Stone. That was not.
    The Chairman [continued].--ELH, so that was, okay.
    Dr. Stone. No, that strictly related to the fact of are we 
paying the right rates to earn your trust, and are we paying in 
a timely manner, and are we giving you a bundle of care that 
is--
    The Chairman. I understand now the issue. Okay. I want to 
ask you about the Patient Aligned Care Team initiative within 
the VA and the workflow that that entails. And there was--on 
page five, there was some pull quotes from actual VA 
physicians. One said--one of the pull quotes says, ``There was 
a misconception that the primary care provider,'' i.e., the 
provider within the VA, ``will co-manage community care.''
    And there is a sense of, like, resentment about that. And 
it says, ``I will instruct every one of my primary care 
providers not to do this.'' And I believe that is coming from a 
place of the concern within VA among the primary care providers 
that the way MISSION is going to be implemented is not really 
taking into consideration about the workflow and the potential 
disruption of the workflow. Can you respond to that?
    Dr. Stone. I can. And it certainly is a concern. And what 
it reflects the fact is we need to do more training. We need to 
do more communication. And as we have come out of the period of 
comment on the regulations on access standards, we have begun 
communicating more effectively, I think, with our providers.
    Our providers are nervous. Our providers are concerned 
about the change. And our providers are concerned about 
privatization. They read about privatization all the time and 
they are concerned of, ``Are we going to do that?'' I would 
hope that from my comments today, and my previous testimony, 
and the secretary's testimony, you would recognize that the 
fact that we are not privatizing, the future of the VA's health 
care system is in the hands of the American veteran. And just 
like you and I get to choose sort of where we are going for our 
health care, the American veteran will choose, and they will 
determine our future.
    The Chairman. Well, I will remind you that it is a pretty 
limited choice. I mean, depending on which health care plan we 
belong to. We stay in network, or out of network, and we pay 
our price if we go out--I mean, this idea that choice is being 
extended willy-nilly to all veterans, I think no American seems 
to have that unless you are super wealthy and can--it is no--
price is no consideration, right?
    Dr. Stone. Yes, sir.
    The Chairman. So it is--I mean, I want to be careful about 
the language we are using because I think people in the 
leadership of the administration often throws it out there and 
I think it is misleading, because we are not looking at 
unfettered choice here. And to create a sense of--like the 
charter school movement. I mean, that is also--I also have 
problems the way we talk about choice in that context as well.
    So I hope that we are retaining the coordinating role of 
the VA and it is not sort of being outsourced to some sort of 
technological formula that we are looking all--I mean, I am 
concerned about how much--we don't even know how much all of 
this is going to cost in terms of what these access standards 
will do to the cost of care.
    And that is, I think, the concern is that will it raise 
cost so much in private sector care that it is going to hollow 
out existing internal capacity?
    Dr. Stone. Sir, I appreciate your comments and that is 
exactly right. I think all of our intention is to have the VA 
remain as the centerpiece of the decision process for America's 
veteran. And as America's veterans go through these decisions, 
it is our intention to remain the integrator of that care.
    The Chairman. Thank you. I recognize Dr. Roe for five 
minutes.
    Mr. Roe. Thank you, Mr. Chairman. Obviously, and briefly, 
so look, I am a veteran and I have been a patient. And like any 
other veteran or patient, civilian or not, I am going to seek 
out the best care that I feel for me and my family. That is 
what I am going to do, and I think that is what veterans will 
do. And you started out, Dr. Stone, VA care in most places is 
as good or better than the community. And I think that sale 
itself will keep people in the VA.
    Where I live, the veterans are very happy with it. We are 
very fortunate where we live. But that is not the case in other 
places. And so we tried to create a MISSION Act that was good 
from east coast to west coast. And I think we have succeeded if 
it is implemented properly and doing just that to meet most--
you can't meet every need, but most veteran needs.
    And we know that VA can't be everything to everybody, just 
like the private sector sometimes has to--we have a very 
sophisticated center at home, but we have to occasionally send 
some out for a super specialist somewhere that we can't handle 
at home. So having said that, just a couple three real quick 
questions.
    One is still making sure that our doctors out there in 
network can access VA data. That is extremely important for me 
when I see a patient to have all necessary information, and 
will that be live come June 6th? Can we get to it? Number two, 
it is amazing you processed 1.7 million claims, but did the 
payment go out on time? Did we process those claims that were 
clean claims and got the check out the door for those folks?
    Because I talk to people all the time. They have hundreds 
of thousands of dollars of back claims to VA.
    Dr. Stone. First of all, the community care referral and 
authorization system allows us to move data to the community 
providers.
    Mr. Roe. Okay.
    Dr. Stone. So to your first question, yes. I think one of 
those software systems of the 11 I talked about moves data out 
in an effective manner to--
    Mr. Roe. That's great.
    Dr. Stone [continued].--you as a provider if I am sending 
somebody to you.
    Secondly, it is my understanding that the 1.7 million last 
month was not only authorization but also payment of claims.
    Mr. Roe. And thirdly, we need to know the status of the 
clinical networks because--and we asked VA in 2014 to do 
something no organization can do, which is to put up a 
nationwide network together in 90 days. We also asked MISSION 
in 365 days to put this network out. And the contracts are just 
now going out. Are your partners that have gotten these 
contracts now, and I know there are two that are being held up 
right now, is that network going to be ready to go? Because 
once again, if that network is not ready to go, it won't work.
    Dr. Stone. So this is exactly why when I came last summer 
to this position, we stood up the Triwest nationwide system as 
a safety net, to begin building across the Nation a delivery 
system as our other vender went away. And then to hopefully use 
that provider network as our next generation of community care 
comes on board to actually facilitate a rapid and smooth 
transition.
    The other thing that digital services did in their report 
is they actually questioned continuity of care. Please 
understand that we have been through this a number of times, 
including as Health Net stepped away. And we will not disrupt 
the care if we have authorized a bundle of care for somebody 
that has got ongoing chemotherapy or ongoing dialysis. We are 
not going to disrupt that care.
    Mr. Roe. Because really all the patient--all the veteran 
patient cares about June 7, I come down to the VA and I need an 
appointment, can I get an appointment? That is all they really 
care about.
    Dr. Stone. That is right. And the goal, sir, in community 
care and in all of VA is to take on the administrative burden 
of this ourselves and to make sure it is invisible to the 
veteran and we are just meeting the veteran's needs.
    Mr. Roe. I appreciate it. I will yield back.
    The Chairman. Thank you. Ms. Brownley, you are recognized 
for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chair. I wanted to ask, again 
on the USDS report, do you agree with what they suggest that if 
the criteria model for the MISSION Act fully implemented, you 
know, the regulations of 30 minutes for primary care, 60 
minutes for specialty care, that the--that they expect a 
significant increase from 685,000 veterans under the Veterans' 
Choice Program to 3.7 million veterans under the MISSION Act. 
Do you believe in that premise or--
    Dr. Stone. It is my belief that they got that from our 
actuaries. I am not really sure the source of the 3.7 million, 
Congresswoman. But I would bet it is from our actuaries. Now, 
there is something else--
    Ms. Brownley. Does that mean that is good data or--
    Dr. Stone. I think it is good data. I think it is good 
data. I think that already today, every single veteran we are 
seeing, we are looking at these criteria based on 40 miles and 
30 days. We are just changing this to 20, 28 days; and 30- and 
60-minute drive times.
    I don't believe that if you came to me as a doctor, and I 
incurred trust from you in the way I handled myself and my 
professionalism, that if I looked at you and said, ``Well, you 
know, I can find you another doctor 10 minutes closer, or 30 
minutes closer, or even an hour closer, you are going to leave 
me.'' I think very few people will leave a provider based on 
that kind of convenience.
    And we have actually surveyed five million veterans that 
don't use us. And that is exactly what they have told us. It is 
not just about convenience. So I don't see that somebody that 
is seeing us, and trusts us, and our trust scores are 
approaching 90 percent, about 87 percent, are going to leave us 
based on the fact that we have told them that we have got 
something that might be more convenient.
    Now, if they have never interacted with us, I think that is 
different. And I think that is a different discussion. By the 
same token, I don't see people that are out in the community 
already looking at the MISSION Act and saying in great numbers 
that they are going to come in to see us because of something 
that is in the MISSION Act. I don't think people leave your 
doctor for that reason.
    Now that I have said that, let me say to you that it 
appears in the first 6 months of this year that we have grown 
by a million visits. Not only that, 100,000 veterans have 
joined us that weren't with us 6 months ago. So I think we have 
got to watch it, we have got to communicate with you. I think 
we owe you, as part of oversight, really predicting what the 
future looks like. But I don't think there is--that 3.7 million 
number we should be concerned that droves of patients are going 
to leave us.
    Ms. Brownley. Thank you. Thank you for that. And just one 
last question in terms of the PPMS, these acronyms always just 
drive me absolutely crazy. Reading all this stuff, I have to go 
back and figure out, you know, what that acronym means again. 
But with regards to that, so the wait time in the community can 
vary day to day, week to week. So the question is how will the 
VA ensure that the PPMS data is current so that eligible 
veterans are able to make informed decisions about where they 
obtain their health care and how frequently will the system be 
updated to ensure it is providing the most accurate and up to 
date data?
    Mr. Gfrerer. Congresswoman, I am not--I would have to take 
that one for the record. I am not in a position to tell you 
exactly how those updates occur around that database and that 
data element. But I can take that for the record.
    Ms. Brownley. Very good. Thank you. I yield back.
    The Chairman. Thank you, Ms. Brownley. All--well, I want to 
thank all of the witnesses today and we look forward to working 
with you, your staff, and the USDS in the future. All Members 
will have five legislative days to revise and extend their 
remarks and include extraneous material.
    Again, I thank you all for appearing before us today and 
this hearing is now adjourned.

    [Whereupon, at 3:43 p.m., the Committee was adjourned.]




                            A P P E N D I X

                              ----------                              

              Prepared Statement of Richard A. Stone, M.D.
Introduction

    Good afternoon Chairman Takano, Ranking Member Roe, and Members of 
the Committee. Thank you for the opportunity to discuss the Information 
and Technology (IT) systems that will support the new Veterans 
Community Care Program required by the VA Maintaining Internal Systems 
and Strengthening Integrated Outside Networks Act of 2018 (the MISSION 
Act). I am accompanied today by Dr. Melissa Glynn, Assistant Secretary 
for Enterprise Integration, and James P. Gfrerer, Assistant Secretary 
for Information and Technology and Chief Information Officer.
    The MISSION Act, in combination with the transformative 
modernization efforts underway in VA, represent a unique opportunity 
for VA to lead the evolution of health care. VA is a leader in patient 
empowerment: we were among the first in the industry to make health 
care information and documents fully transparent to our customers; we 
are building technology and programs that are inclusive of the most 
important people in Veterans' lives, their families, and caregivers; we 
are driving innovation and research that informs better care and 
services; and we are emphasizing the whole health of Veterans well 
beyond the institution. For example, the MISSION Act has strengthened 
VA's ability to furnish telehealth across State lines and into 
Veteran's homes, allowing VA to enhance the accessibility, capacity, 
and quality of VA health care. VA has integrated telehealth technology 
with the Whole Health initiative, which is an approach to health care 
that empowers and equips Veterans to take charge of their health and 
well-being by focusing not only on treatment but also on self-
empowerment, self-healing, and self-care. To accomplish that, VA is 
combining innovative complementary treatments like yoga and tai chi 
with the latest technology to allow Veterans to receive world class 
treatments in their homes or local VA clinics. VA will also launch a 
Whole Health app this year that will guide Veterans through the 
Personal Health Inventory and resources available at VA.
    Alongside the MISSION Act, VA is expanding access to care in our 
direct care delivery system. VA is implementing the Improving Capacity, 
Efficiency, and Productivity initiative, a collaboration among VA 
offices focused on creating efficient practice solutions, including 
offering extended hours (evenings and Saturdays), using telehealth and 
video appointments, providing facilities with appropriate guidance for 
overbooking, and adopting point-of-care scheduling.
    These are only a few examples of the way VA is using its authority, 
including the MISSION Act, to strengthen both the in-house and 
community aspects of our integrated system, giving VA the ability to 
build on its innovative legacy and drive the industry forward. 
Veterans, their families, and their caregivers will now be more able to 
choose the balance of VA-coordinated care-whether direct care or 
community care-that is right for them, with an optimized network of 
excellent choices.

MISSION Act Community Care IT Collaboration

    The Veterans Health Administration (VHA) Office of Community Care 
(OCC) has been developing and deploying improvements to the community 
care program to improve the experiences of Veterans, community 
providers, and VA staff. Work began in 2016 to develop a standardized 
operating model for the community care staff working in VA medical 
centers (VAMC) and in recent years tools and technologies have been 
developed to support the upcoming implementation of the Community Care 
Network contracts. The operating model provides a standardized way to 
manage consults, referrals and authorizations, and perform care 
coordination to ensure good customer service.
    Even before the MISSION Act passed, OCC was working closely with 
VA's Office of Information and Technology (OIT) to discuss expected IT 
requirements and systems that would either be impacted by the new law 
or created entirely as a result of the law. Since passage of the 
MISSION Act, OCC has worked closely with OIT to develop new tools, such 
as a Decision Support Tool, to aid in community care eligibility 
determinations, as well to support enhancements to existing tools that 
will ensure that the capabilities necessary to implement the MISSION 
Act will be in place.
    Deployment of many tools that will support implementation of the 
MISSION Act already started and, for example, a tool known as the 
Provider Profile Management System (PPMS) was deployed nationally in 
Fiscal Year 2018 that provides VA staff and Veterans with a directory 
of VA providers, Department of Defense (DoD) providers, and community 
providers who are part of VA's network. In the coming months, VA will 
be deploying a new referral and authorization system that will 
streamline information sharing between VA and community providers and 
expand its deployment of Electronic Claims Adjudication Management 
System (eCAMS), which is a tool that will modernize our claims 
processing systems and improve both timeliness and accuracy of payments 
to community providers.

    Enhanced community care eligibility determination capability:

      Decision Support Tool (DST): This tool will help VA 
identify Veterans eligible for community care, as well as the basis for 
their eligibility, and will document the Veteran and provider decision. 
The tool interfaces with the PPMS, enrollment system, scheduling, and 
the access standard table on the use of community care. This will be 
available June 6, 2019.

    Enhanced referral and authorization/care coordination capabilities:

      Provider Profile Management System (PPMS): This is a 
directory of providers, including those in the DoD military treatment 
facilities, VAMCs, and in VA's community provider network. This is 
active with 1,500 VA users accessing the system 10,000 times in the 
past month since it went live in October 2018. PPMS will allow Veterans 
to find community providers via the VA.gov site. It also supports VA 
staff in identifying community providers when scheduling appointments 
for Veterans.
      Health Share Referral Manager (HSRM): This is a referral 
and authorization tool that includes a portal and will standardize how 
VAMC staff create and share referrals with VA's network contractors, 
other community providers, and with the claims payment systems (for 
validation that a claim was authorized by VA). It allows for electronic 
exchange of information between community providers and VA. Deployment 
is scheduled to begin in April and complete in June 2019.
      REFDOC: This is a Web-based tool that allows VA users to 
quickly extract a Veteran's health information and compile it into a 
PDF to send to community providers. This was deployed in May 2017.
      Community Viewer: This allows community providers to 
securely view Veteran health information via a Web browser. This was 
deployed in May 2017.
      Virtru Pro: This is a secure method for VA to exchange 
health information with community providers using encrypted e-mail. 
This was deployed in May 2017.

    Enhanced timeliness of payment of claims:

      Electronic Claims Adjudication Management System (eCAMS): 
This is a modern, efficient, and automated commercial-off-the-shelf 
product to process health care claims submitted by community providers. 
eCAMS will replace the legacy system and increase our capabilities to 
improve the accuracy and timeliness of payments.

VA OIT IT Development Process is Modernizing

    VA recognizes that we have faced technology challenges at times. 
Thus, we have made a strategic pivot in our approach to technology 
implementing the MISSION Act requirements. The business and technical 
elements of the organization have formed a tight partnership and 
focused on improving the Veteran experience. For example, OIT and VHA 
worked together on Community Care projects such as the PPMS release in 
September 2018. Prior to the deployment of this system, VA staff were 
required to locate provider information on spreadsheets and SharePoint 
sites. This system gives VA staff the ability to do location searches 
to identify nearby providers while scheduling care for Veterans outside 
of the VA. The Community Care teams also released the Veterans Choice 
Locator on VA.gov on December 26, 2018. This release allows Veterans 
and Staff to search for approved VA providers within a search radius by 
provider specialty. Prior to this functionality being available on 
VA.gov, Veterans had to call their local facility to identify 
providers. Our aim is for technology to be an enabler of streamlined 
business functions-all of which become invisible to our customers as 
they enjoy a smooth, coordinated, personalized experience of care.

U.S. Digital Services Report

    VA recognizes that we needed all available talent at the table for 
this shift in approach. U.S. Digital Service has been helpful in 
driving differential approaches to some VA business processes. 
Therefore, we recently invited them to review the development of key 
systems, including the Decision Support Tool (DST). Under the MISSION 
Act, DST will streamline the eligibility determination process to 
improve Veterans' experiences and support our local clinicians and 
field staff by improving the efficiency and effectiveness of 
eligibility determinations for Veterans seeking community care.
    U.S. Digital Service agreed to review the IT system and related 
policies over a 2-week period. They reviewed whether VA's technical 
solutions would meet the legal requirements for implementing the 
MISSION Act. While we fully anticipate that the DST will be operational 
on June 6, VA will still have the ability to perform the necessary 
functions to support MISSION Act implementation if it is not 
operational on-time. We look forward to continued engagement with U.S. 
Digital Service.

Funding Transfer Request

    To ensure the technology to support the MISSION Act is successful, 
VHA recently responded to a request from our OIT partners for 
additional funding. Despite proposing to use funding from the Medical 
Community Care and Medical Services accounts, the repurposing will not 
adversely affect Veterans' health care. Medical Services funds are 
available for repurposing as a result of efficiencies in the hiring 
process and improved ability to fill critical positions with the 
correct staff, reducing the need to over-hire to meet retention 
targets. VHA maintains staffing levels sufficient to provide 
exceptional care to Veterans, as evidenced by improving access and 
outcome measures. Medical Community Care funds are available for 
transfer as a result of higher than expected medical care collections 
from other health insurance for care provided in the community.
    On top of the $33.56 million committed from OIT, VA intends to 
transfer $95.94 million of Fiscal Year 2019 funds ($68.78 million from 
the Medical Community Care account and $27.16 million from the Medical 
Services account) to the IT Systems account to fund IT projects for 
various MISSION Act programs, including the projects listed above. VHA 
and OIT are collectively tracking the planned use and allocation of 
that funding through to fruition. Currently, VA OIT is tracking all 
MISSION Act investments at the program and project level where they are 
being executed. All MISSION Act spend plans are tagged with a unique 
identifier to allow transparency and accurate reporting of expenditures 
linked to existing program performance and goals. Additionally, VA's 
OIT Chief Financial Officer currently hosts weekly meetings with 
program officials to discuss planned acquisitions to meet the mandate 
and any foreseen risks that need to be mitigated.

Conclusion

    VA's transformation under the MISSION Act, is one of the largest 
such efforts the Department has ever seen. Veterans' care is our 
mission. We are committed to rebuilding the trust of Veterans and will 
continue the improvements we have made to Veterans' access to timely, 
high-quality care from VA facilities, while providing Veterans with 
more choice to receive community care where and when they want it. Your 
continued support is essential to providing this care for Veterans and 
their families. This concludes my testimony. My colleagues and I are 
prepared to answer any question.

                                 
                        Questions For The Record

    House Committee Members to: Department of Veterans Affairs (VA)
Questions for the Record from Congressman Mike Levin

    Question 1: The USDS report quotes a Marine veteran from my 
district saying, ``I don't know how they hand off records for a 
consult. I'd like them to have my history, so they could understand my 
condition.'' I understand the VA plans to use its new HealthShare 
Referral Manager to exchange records. However, the USDS found it 
unlikely that community providers will adopt a VA-specific platform, 
instead opting for manual, one-off methods such as fax or secure mail. 
Dr. Stone, have you considered this concern, and how do you plan to 
address it?

    VA Response: HealthShare Referral Manager (HSRM) allows VA and 
community providers to easily upload and download medical documents 
such as medical records and images. Prior to providing care to a 
Veteran, community providers can download and review documents that VA 
shares regarding the Veteran/patient. Following care, community 
providers upload relevant patient care documentation for VA's review. 
The use of HSRM eliminates faxing and emailing documentation and 
greatly enhances the accuracy of patient documentation. In the 
instances where a community provider does not utilize HSRM, a packet of 
information that contains referral details, additional referral 
information, billing and precertification information, patient details 
to include relevant medical history, and standardized episode of care 
(SEOC) information will be sent by the provider's preferred method to 
include secure email or electronic fax. VA medical center staff will 
document that medical packet was sent to a community care provider 
within the VA Consult Toolbox. The use of HSRM is highly encouraged in 
the Community Care Network by our contracting partners.

    Question 2: Dr. Stone, in your written testimony, you state, 
``While we fully anticipate that the DST will be operational on June 6, 
VA will still have the ability to perform the necessary functions to 
support MISSION Act implementation if it is not operational on-time.'' 
While I hope that the Decisional Support Tool is rolled out on time and 
smoothly, I also want to be sure we're prepared if that doesn't happen, 
as the USDS report anticipates. Can you explain in more detail how VA 
would conduct the new eligibility determinations without a functional 
DST?

    VA Response: The Decisional Support Tool (DST) went live and has 
been operational since June 6, 2019; however, VA has developed and 
tested a community care eligibility contingency plan which requires VA 
staff to access the Veteran's static community care eligibility (e.g., 
No Full-Service VA Medical Center in the State, Service Unavailable, 
Grandfathered Choice, certain categories of best medical interest, 
specifically Hardship) through both the Enrollment System and 
Computerized Patient Record System (CPRS). These static eligibility 
determinations generally will not change, as opposed to dynamic 
eligibility criteria (e.g., designated access standards, remaining 
categories of best medical interest, and VA medical service line), 
which could result in different eligibility determinations based on the 
care that is needed. VA staff will access the Veteran's dynamic 
Maintaining Internal Systems and Strengthening Integrated Outside 
Networks (MISSION) eligibility through Veterans Information Systems and 
Technology Architecture (VistA) clinic data and the Provider Profile 
Management System (PPMS).

    Question 2a: Who would be responsible for making those 
determinations, and how would that affect the existing workflow?

    VA Response: DST went live and has been operational since June 6, 
2019. In the unlikely event that DST is not available, VA's system will 
allow VA clinic staff, including the provider and clinic scheduler, to 
access the Veteran's static community care eligibility through both the 
Enrollment System and CPRS. Clinic staff can review the Health Benefits 
Plans section in the CPRS Patient Inquiry screen to determine the 
Veteran's static eligibility for community care. These will be actions 
that will need to be taken by the clinic staff within the appointment 
workflow or when speaking to the Veteran over the phone.
    The codes in CPRS will appear as follows:

                                      CPRS Eligibility Health Benefit Plans
 
 
 
                    Veteran Plan - CCP Grandfather                                            Grandfathered
----------------------------------------------------------------------------------------------------------------
Veteran Plan - CCP State with No Full-Service Medical    No Full-Service VA Medical Facility in Veteran's State
                                           Facility                                            of Residence
----------------------------------------------------------------------------------------------------------------
         Veteran Plan - CCP Hardship Determination                                                 Hardship
 

    VA has also separately established a code, ``Veteran Plan - Urgent 
Care,'' to reflect a Veteran's eligibility for the walk-in care benefit 
under 38 United States Code Sec.  1725A.
    For dynamic eligibility criteria, VA clinic and administrative 
staff can access wait time for the specific clinic in which the Veteran 
is to be scheduled by reviewing the appointment availability through 
the approved VA appointment software, which links to VistA clinic data. 
The average drive time eligibility determination can be made by using 
PPMS to calculate the average driving time from the Veteran's residence 
to the VA facility that can provide the requested care within the wait 
time standard.
    The VA provider will determine clinical need for community care 
purposes by reviewing if the care is nationally available at any VA 
facility; if VA does not offer this care at any location, the provider 
will enter a community care consult following normal consult entry 
processes as outlined in Veterans Health Administration Directive 
1232(1), Consult Processes and Procedures, and the Office of Community 
Care Field Guidebook. The VA provider will also need to determine if it 
is appropriate to request community care for the specific episode of 
care based on such a referral being in the best medical interest of the 
Veteran. If the referring clinician and the Veteran agree it is in the 
best medical interest of the Veteran to receive care in the community, 
the provider will either utilize DST to document the best medical 
interest eligibility or add the justification to the appropriate 
community care consult.

    Question 3: I appreciate VA launching the Veterans Choice Locator 
so that veterans can identify approved community providers. I believe, 
as the USDS recommends, that user-driven transparency should extend to 
eligibility determinations. Dr. Stone, has VA considered developing a 
veteran-facing eligibility tool?

    VA Response: VA is developing several tools to help Veterans 
understand and directly query their eligibility to receive community 
care. The VA Online Scheduling (VAOS) tool will incorporate the new 
MISSION eligibility criteria that are static, such as residing in a 
state without a full-service VA medical facility; VAOS has been 
available since June 6, 2019. The display of dynamic eligibility 
criteria such as average drive time will be available in VAOS by 
September. VA is also analyzing self-service capabilities that can be 
incorporated in MyHeatheVet to provide Veterans more information about 
their eligibility; there is currently no timeline for when this will be 
completed. Additionally, VA has established an Interactive Voice 
Response option to allow Veterans the ability to directly obtain 
eligibility information about the walk-in care benefit under 38 U.S.C. 
Sec.  1725A by working with the third-party administrator.

    Question 3a: If such a tool isn't provided, how will VA ensure 
every veteran knows and understands their eligibility status?

    VA Response: Veteran empowerment is at the core of VA's approach to 
the VA MISSION Act of 2018, and VA personnel are being trained to 
provide the best information available to each Veteran. As outlined 
above, eligibility under the VA MISSION Act of 2018 can be determined 
with or without a tool. VA is also working to educate Veterans and 
train Veterans Service Organization representatives on the eligibility 
process.

Questions for the Record from Congressman Chip Roy

    Question 1: During the hearing, the VA witnesses mentioned some new 
systems, RefDoc, VirtuPro, and Community Viewer, that VA is using to 
share health records with community care providers. Are these one-way 
transfers of records from VA to the provider? Or is there a capability 
for VA to transfer data from its electronic health record to the 
provider, that provider treat the veteran, and then that provider 
transfer the information back into VA's electronic health record? If 
not, what is the plan to achieve that capability?

    VA Response: RefDOC generates an electronically consolidated .pdf 
file that contains administrative and clinical information needed to 
facilitate a referral in a standardized format. Community Viewer is a 
``read only'' secure Web-based application that allows community 
providers to view a Veteran's entire Electronic Health Record once 
permission is granted by facility community care staff. In addition, 
the new portal, HSRM, has bidirectional communication functionality 
that can be used by VA and the community provider to upload medical 
records. Currently VA also utilizes Health Information Exchanges, which 
are secure networks of trusted partners that allow VA and participating 
community providers to electronically request and receive medical 
information about a specific Veteran for whom they are providing care. 
Direct messaging is also available, which allows the exchange of 
medical information via secure email-like messaging under a trusted 
network. With the implementation of Cerner, interoperability will 
continue to mature with the improved seamless flow of health data 
between VA and community providers.

Questions for the Record from Congressman Jim Banks

    Question 1: What is the claims processing system used by Optum and 
any other new CCN contractors? Please provide as much information about 
these systems' capabilities as possible.

    VA Response: First, Community Care Network contracts do not dictate 
utilization of any specific claims processing system. Second, to the 
extent that Optum has identified the claims processing system(s) that 
it has elected to use to meet contract requirements, such details would 
be confidential commercial information which is not typically disclosed 
without going through the predisclosure notification process (Executive 
Order 12600, 38 Code of Federal Regulations (CFR) 1.558).

    Question 2: In the CCN contracts, VA also set out 14 requirements 
for how the contractor's system will adjudicate claims. Does the system 
already do those things, or will the contractor need to modify the 
system to meet VA's requirements?

    VA Response: The 14 requirements for how the contractor's system 
will adjudicate claims include VA-specific requirements such as 
incorporating VA's fee schedule and adjudicating claims for emergency 
services under 38 CFR 17.4020(c). Therefore, the contractor is 
modifying its systems to meet VA's claims adjudication requirements. VA 
has been working closely with Optum to ensure Optum's claims systems 
are configured to meet VA's requirements for claims adjudication.