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


                  IMPLEMENTATION OF ELECTRONIC HEALTH 
                   RECORD SYSTEMS AT THE DEPARTMENT OF 
                   VETERANS AFFAIRS (VA) AND THE DEPART-
                   MENT OF DEFENSE (DOD)

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

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                 OF THE

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JUNE 12, 2019

                               __________

                           Serial No. 116-17

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     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

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                     SUSIE LEE, Nevada, Chairwoman

JULIA BROWNLEY, California           JIM BANKS, Indiana, Ranking Member
CONOR LAMB, Pennsylvania             STEVE WATKINS, Kansas
JOE CUNNINGHAM, South Carolina       CHIP ROY, Texas

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

                              ----------                              

                        Wednesday, June 12, 2019

                                                                   Page

Implementation Of Electronic Health Record Systems At The 
  Department Of Veterans Affairs (VA) And The Department Of 
  Defense (DoD)..................................................     1

                           OPENING STATEMENTS

Honorable Susie Lee, Chairwoman..................................     1
Honorable Jim Banks, Ranking Member..............................     3

                               WITNESSES

Mr. John Windom, Executive Director, Office of Electronic Health 
  Record Modernization, Department of Veterans Affairs...........     4
    Prepared Statement...........................................    31

        Accompanied by:

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

    Mr. John Short, Chief Technical Officer, Office of Electronic 
        Health Record Modernization, Department of Veterans 
        Affairs

Mr. William J. Tinston, Program Executive Officer, Defense 
  Healthcare Management Systems, Department of Defense...........     6
    Prepared Statement...........................................    34

        Accompanied by:

    Maj. Gen. Lee E. Payne, M.D., Assistant Director for Combat 
        Support, Defense Health Agency, Department of Defense

Dr. Lauren Thompson, Director, Interagency Program Office, 
  Department of Defense, Department of Veterans Affairs..........     8
    Prepared Statement...........................................    37


 
IMPLEMENTATION OF ELECTRONIC HEALTH RECORD SYSTEMS AT THE DEPARTMENT OF 
       VETERANS AFFAIRS (VA) AND THE DEPARTMENT OF DEFENSE (DOD)

                              ----------                              


                        Wednesday, June 12, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:19 a.m., in 
Room 210, House Visitors Center, Hon. Susie Lee presiding.
    Present: Representatives Lee, Lamb, Cunningham, Banks, 
Watkins, and Roy.
    Also Present: Representative Roe

           OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN

    Ms. Lee. Good morning. This hearing will come to order. I 
would like to welcome everyone.
    And last week, the Subcommittee on Technology Modernization 
heard from the prime contractors on the programs to implement 
electronic health record systems at the Department of Defense 
and the Department of Veterans Affairs. Today, we continue 
oversight of these programs with testimony from the Departments 
accountable for their implementation.
    In providing oversight, it is important that we have the 
proper time to review documents and receiving the DoD testimony 
at 10:30 p.m. last night certainly does not optimize our 
ability to do our job. Accountability, obviously, is a big part 
of this effort, perhaps the most important.
    In the history of failed efforts to implement information 
technology throughout the Federal Government, more often than 
not, technology was not the problem; rather, it was a failure 
of leadership and management. The questions most often asked 
are after failed technology implementations were: Who is in 
charge? Who is accountable to the taxpayers and Congress? And 
the answers often are a confusion of finger pointing and a 
leadership vacuum. And after every failed project, there are 
lessons learned and promises to do before.
    Before us today, we have the leadership of the respective 
offices for VA's electronic health record modernization and the 
DoD's health care management system modernization. We also have 
the current director of the Interagency Program Office.
    We are at a moment in time when critical decisions must be 
made in order to advance the implementation of this program, 
but we are doing so without a fully functioning joint 
governance structure. For months, this Subcommittee has asked 
for a joint proposal to address the longstanding programs with 
the existing IPO, and as of March 1st, we now have the Federal 
electronic health record modernization program office, or 
FEHRM, and we will hear testimony about the initial 
organizational plans.
    We have a one-page slide right here about a three-phased 
plan, but it is hard to find where the governance and 
accountability is in this plan. We are also missing a plan 
about staffing and resources. Based on the timeline for 
implementation, it appears that it will come too late to 
address the critical decisions that must be made now.
    Further, I wonder whether the DoD and VA are invested in 
the idea of true joint governance and transparency since both 
declined to provide feedback on a potential legislative 
solution to finally create a single accountable joint-
governance office with a role to promote and facilitate 
interoperability between the Departments for health records and 
beyond.
    I hope I am wrong and that the VA and DoD do want a real 
solution in a functional governance structure. I would like to 
believe that after we made this investment, are prepared to 
spend at least $16 billion in taxpayer money on modernizing 
health records for our servicemembers, veterans, and their 
families, that we are prepared to do this right.
    Joint governance is not the only challenge DoD and the VA 
are facing now. The time for VA's first go-live is March 2020, 
and that is fast approaching. There are many key decisions and 
tasks that have yet to be completed. We are concerned that the 
VA has left itself with very little margin for error. There are 
many lessons to be learned from the Department of Defense, 
which now has its ongoing struggles, and I hope we will get 
some transparency about that today.
    But my questions really come down to these: Why not spend 
the time to get the governance right? Why not take the time to 
get the infrastructure in place? And why not leave yourselves 
room to do the necessary testing and training to ensure a 
successful rollout?
    This Subcommittee has been clear that we want to work with 
the VA, even if that means delay, as long as the VA is 
transparent and accountable. Why insist on leaving yourselves 
very little margin for error when history is not on your side 
for successful IT implementations. What is the VA doing to 
mitigate risk and ensure that the final product delivered to 
clinicians and veterans is the best it can possibly be, 
understanding that opportunities for improvement and innovation 
should be part of the management of the EHRM?
    I would like to get these answers to these and other 
questions, and we are asking for transparency and 
accountability now to pave the way for implementation ahead and 
what we owe to our servicemembers and veterans.
    I thank all the witnesses for being here and I look forward 
to their testimony. And I would like to now recognize my 
colleague, Ranking Member Jim Banks, for 5 minutes to deliver 
his opening remarks that he may have.
    Mr. Banks?

         OPENING STATEMENT OF JIM BANKS, RANKING MEMBER

    Mr. Banks. Thank you, Madam Chair.
    I would like to begin by thanking our witnesses, are 
especially our DoD witnesses for appearing today. You do so 
voluntarily, and I sincerely appreciate it.
    Anyone who watched our contractor hearing last week or any 
of our Subcommittee hearings know that we think that 
cooperation between DoD and VA on electronic health records is 
very important.
    Lack of cooperation has been the graveyard of all of the 
previous efforts. I have no doubt that it is a high priority 
for each of you. Case in point, you have spent much of the last 
9 months hammering out a joint-management structure. I want 
EHRM and MHS Genesis to succeed. I want to support your 
decisions.
    But it is not reasonable to expect this Subcommittee to 
endorse decisions that we have scant details about; decisions 
that are the product of a secretive process. By all accounts, 
DoD and VA are getting close to standing up the Federal 
Electronic Health Record Modernization Program Management 
Office, the FEHRM, to jointly manage EHRM and MHS Genesis.
    I understand the desire to make the agreement in private 
before disclosing anything. The problem is, though, there has 
been no agreement. Compromise has been elusive because the 
stakes were so high and both sides were apparently dug in so 
deeply.
    My hope was, and still is, for this Committee and the Armed 
Service Committee, which I am also proud to serve on, to help 
mediate the situation. No one wanted the FEHRM to be stood up 
this late, but this is the reality. We are now 4 months out 
from the go-live dates for MHS Genesis wave 1 and 10 months out 
from the go-live date for VA's initial operating capability 
sites. The opportunity for the FEHRM to have impact is right 
now. It is time for a candid discussion of the Department's 
vision to integrate EHRM and MHS Genesis.
    However, I am more interested in what the FEHRM will 
accomplish than how it will be structured, or which individuals 
will lead it. I expect it to solve real problems, or better 
yet, prevent them from happening in the first place.
    Since taking on this assignment 1 year ago, I have seen and 
heard enough to have some serious concerns. VA and DoD are 
different animals. VHA and the military health system have 
cultures, priorities, organizational structures, and even 
missions that are quite different. I happen to believe that 
they should be more closely integrated in the future.
    But if we force them into a one-size-fits-all solution now 
and ignore these realities, it may very well break them. 
Healthcare is a roughly ninety-billion-dollar enterprise in VA, 
and it is one of the 3 core missions of the Department. 
Military health care is a critical component of force 
readiness; both are personally important to me.
    But electronic health records are simply not central to the 
DoD mission in the same way that they are to the VA mission. 
DoD is in a unique position with the creation of the Defense 
Health Agency and the consolidation of the military services 
treatment facilities into one organization.
    I understand MHS Genesis is a critical element in 
accomplishing that, so preserving the schedule is paramount. I 
have also seen for myself that AHLTA and CHCS are incredibly 
difficult on popular EHR systems; on the other hand, while the 
structure of VA is not changing at all, the Department is 
implementing the MISSION Act and Community Care is growing in 
importance.
    VA is not replacing VistA because it works poorly--in fact, 
some clinicians like it very much--VA is replacing Vista 
because it has fallen too far behind to meet the needs of the 
future. A single longitudinal DoD-VA health record would be a 
major accomplishment.
    But as Dr. Roe can attest, any EHR implementation is 
disruptive, at best, and traumatic, at worst. In order for the 
cost and time and disruption to be worthwhile, VA also needs 
true interoperability with the community providers. Attaining 
that 9 years from now is simply not good enough.
    I believe Congress has a duty to spell out its expectations 
and a time to make impact is right now. That is why I will be 
offering two amendments in the National Defense Authorization 
Markup Act that is going to occur today. The first puts in 
place requirements to ensure the FEHRM has qualified 
leadership. The second calls for DoD and VA to develop a 
comprehensive interoperability strategy to accomplish strategic 
goals and defines interoperability for the first time.
    Unfortunately, the Armed Service Markup happens to be going 
on simultaneous with this hearing, and Madam Chair, with your 
forbearance, I have to be present there to advocate for these 
amendments. So, I will be heading back there, but I appreciate, 
once again, all of you being here today for this important 
discussion.
    And with that, Madam Chair, I yield back.
    Ms. Lee. Thank you, Mr. Banks.
    I would now like to introduce our witnesses we have before 
the Subcommittee. First, we have John Windom, who is the 
Executive Director of the Office of Electronic Health Record 
Modernization at the Department of Veterans Affairs. Mr. Windom 
is accompanied by Dr. Laura Kroupa, Chief Medical Officer for 
OEHRM, and John Short, Chief Technical Officer for OEHRM.
    William Tinston is the Program Executive Officer for the 
Defense Healthcare Management Systems at the Department of 
Defense. Mr. Tinston is accompanied by Major General Lee Payne, 
the Assistant Director For Combat Support at the Defense Health 
Agency.
    And we have Dr. Lauren Thompson, who is the Director for 
the DoD-VA Interagency Program Office.
    Welcome. We will now hear from the prepared statements from 
our panel Members. Your written statements, in full, will be 
included in the hearing record.
    Without objection, Mr. Windom, you are recognized for 5 
minutes.

                    STATEMENT OF JOHN WINDOM

    Mr. Windom. Good morning, Madam Chair Lee, Ranking Member 
Banks, who just departed, Dr. Roe, Congressman Lamb, your 
respective support staffs, good morning. Thank you for the 
opportunity.
    I am accompanied by Dr. Kroupa, ma'am, as you mentioned, 
who is my chief medical officer; Mr. John Short, who is my 
chief technology and integration officer.
    First, I want to take this opportunity to personally thank 
you and the Members of the Subcommittee for your unwavering 
support of the EHR modernization effort. Without your steadfast 
support, VA would not be able to deliver this critical 
capability in support of our veterans.
    On June 5th, 2017, VA announced the decision to replace 
VistA, its existing legacy system, which is costly to sustain, 
and cannot deliver commercially available critical capabilities 
to meet the evolving needs of the health care market. Though 
the decision, VA is working to adopt the same EHR solution as 
the Department of Defense, allowing patient data to reside in a 
single hosting site, using a single common system.
    This initiative will ultimately enable the seamless sharing 
of health information, deliver enhanced analytics, improve care 
delivery and coordination, and provide clinicians with the 
requisite data and tools to support patients safely.
    On May 17th, 2018, VA awarded a contract to Cerner 
Corporation, leveraging an existing commercial off-the-shelf 
solution in pursuit of interoperability objectives within the 
VA, between VA and DoD, and with community providers. This 
contract contains the necessary conditions to foster innovation 
and keep pace with the evolving commercial technology.
    To the end, OEHRM hosted an industry day on May 29th, 2019, 
with over 750 registered industry executives and leaders and 
over 450 companies in attendance. VA and OEHRM leadership 
presented a status update on EHRM modernization efforts, 
consistent--what are--and your demand for transparency.
    In coordination with OEHRM, Cerner Corporation and Booz 
Allen Hamilton, our support contractor, informed attendees on 
the way to provide value-added programmatic support to the EHR 
modernization initiative.
    Now, I want to highlight three important aspects of the EHR 
modernization effort which will contribute to the overall 
success of the program. First, given the size, scope, and 
complexity of the EHR modernization effort, VA plans to deploy 
its new EHR solution in slightly under 10 years. The plan will 
evolve as technology advances and efficiencies are further 
identified. VA's approach involves deploying a solution at 
initial operating capability sites in the Pacific Northwest to 
mitigate risk and to solidify processes, procedures, and 
allowing enterprise initiatives before deploying to additional 
sites. Additionally, the IOC sites will further hone 
governance, configuration management, and a myriad of other 
implementation and change management strategies we intend to 
employ.
    VA targeted the Pacific Northwest Region based on DoD's 
deployment of the EHR solution. By deploying in the same 
region, VA will be able to immediately demonstrate 
interoperability and reduce potential risk at the VA sites.
    Second, VA has involved and is instituting a changed 
management strategy that involves engaging users in the field 
early in the process to determine their specific needs and 
quickly alleviate their concerns; furthermore, OEHRM 
established clinical councils that include nurses, doctors, and 
other end-users from the field to support assessments and 
configurations of workflows. These clinical councils meet 
during the 8 scheduled national workshops which educate this 
diverse frontline, clinical end-user community, enabling them 
to validate workflows, ensuring the new EHRM solution meets the 
VA's needs. To date, VA has completed 5 national workshops, 
with the remaining scheduled to occur throughout the remainder 
of the fiscal year.
    Finally, VA and DoD currently work with the Interagency 
Program Office to facilitate governance, collaboration, and 
decision-making. To further promote a comprehensive, rapid, and 
agile decision-making authority in support of interoperability 
objectives, DoD and VA are co-developing a joint 
organizational/management structure.
    To execute this strategy, DoD and VA proposed establishing 
a FEHRM, Federal Electronic Health Record Modernization Office, 
responsible for effectively adjudicating functional, technical, 
and programmatic decisions in support of DoD's and VA's 
integrated EHR solutions. This strategy will optimize the use 
of DoD and VA resources, while minimizing risks, promoting 
interoperability without compromising patients' safety.
    As demonstrated by our efforts, it is clear that VA is 
committed to providing the best care to our Nation's veterans, 
including access to a single longitudinal electronic health 
record. The effort to support one of VA's top priorities to 
modernize the VA health care system and ensure VA remains a 
source of pride for our veterans, beneficiaries, employees, and 
the taxpayers.
    Madam Chair, this concludes my opening remarks. I am happy 
to answer any questions that you or the Subcommittee may have. 
Thank you, again.

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

    Ms. Lee. Thank you, Mr. Windom.
    Mr. Tinston, you are now recognized for 5 minutes.

                STATEMENT OF WILLIAM J. TINSTON

    Mr. Tinston. Madam Chair and distinguished Members of the 
Subcommittee, it is an honor to testify before you today. I 
represent the Department of Defense, as the program executive 
officer, Defense Healthcare Management Systems. Our mission is 
to transform the delivery of health care, advance data sharing 
through modernized electronic health records for 
servicemembers, veterans, and their families.
    In July 2015, the DoD awarded a contract to the Leidos 
Partnership for Defense Health, to deliver a modern, 
interoperable EHR, designed to share data with our Federal and 
private sector partners. This modern, secure, connected EHR, 
known as MHS Genesis, provides a state-of-the-market, 
commercial, off-the-shelf solution, consisting of Cerner 
Millennium, and industry-leading EHR, and Henry Schein's 
Dentrix Enterprise, a best-of-breed dental module.
    Deploying a capability of this magnitude requires extensive 
coordination and communication with our stakeholders and 
industry partners. It is a complex business. This is not simply 
an IT solution; it is a complex business transformation and 
leadership is key to its success. The right people must be in 
the right place to make decisions and deliver solutions.
    MHS Genesis concluded its pilot deployment in January 2018. 
Our deployment to 4 sites, ranging in both size and capability, 
allowed us to observe the system, assess performance, and 
capture user feedback. We used this information to enhance 
system capabilities as we developed our strategy to deploy our 
next sites, starting in September of this year.
    The VA's decision to implement the same EHR as the DoD and 
the United States Coast Guard will result in a single, common 
record, eliminating the need for interoperability with VA. The 
DoD understands this decision demands extensive collaboration 
and joint decision-making between the Departments, and is 
working daily to ensure efficient workflows and standardized 
processes.
    Cybersecurity is one area of extensive collaboration and 
joint decision-making. The DoD sets the standard for 
cybersecurity and PEO DHMS invests time and resources to ensure 
the common system meets that second degree. Our cyber team is 
co-located with the commercial data center, which strengthens 
our Federal and commercial relationships and allows for 
continuous cyber monitoring. As a result of our efforts, the VA 
will leverage this cyber posture and actively participate in 
critical decisions required to protect the environment.
    We also work closely with our VA partners to ensure we 
maintain system integrity. Recommendations for system 
enhancements are carefully evaluated by our joint workgroups to 
minimize program risks and impacts. For example, we recently 
agreed to accept a Cerner software upgrade, only a few weeks 
following our next site implementation. The timing of the 
upgrade address complexity and a risk to DoD's implementation, 
but it will ensure that VA meets its scheduled initial 
operational capability in March of 2020. Understanding this, we 
knew it was the right decision for the successful 
implementation for both Departments.
    Another example of our collaborative efforts is continuity 
of operations. The Departments have agreed to a joint approach, 
which provides both, technical and programmatic efficiencies, 
and will focus on clinical continuity of operations and IT 
disaster recovery.
    As a prior beneficiary and the son of a veteran, I am 
passionate about the mission and firmly believe we are on the 
right track to improve health care delivery for our 
servicemembers, veterans, and their families. Working with the 
VA, the Coast Guard, and our industry partners, I am confident 
this team is committed to the successful deployment of a modern 
EHR. We are making daily strides in the implementation of an 
enterprise solution that will not only advance care for our 
beneficiary and veteran communities, but will ultimately lead 
to a longitudinal record focused on the patient, not where care 
is delivered.
    Thank you, again, for the opportunity to share our progress 
as we deliver a single, common record for servicemembers, 
veterans, and their families. I look forward to your questions.

    [The prepared statement of William J. Tinston appears in 
the Appendix]

    Ms. Lee. Thank you, Mr. Tinston.
    Dr. Thompson, you are now recognized for 5 minutes.

                STATEMENT OF DR. LAUREN THOMPSON

    Dr. Thompson. Chairwoman Lee, Ranking Member Banks, and 
distinguished Members of the Subcommittee, thank you for the 
opportunity to testify before you today. As the director of the 
Department of Defense-Department of Veterans Affairs 
Interagency Program Office, I am honored to be here.
    The mission of the DoD-VA IPO is to advance data 
interoperability across DoD, VA, and with private-partner 
systems. Providing high-quality health care to servicemembers, 
veterans, and their families is the IPO's highest priority and 
health data interoperability is essential to improving the care 
delivered.
    A key component of meeting the unique needs of our 
beneficiaries and ensuring they receive the best care possible 
is making certain that no matter their status, location, or 
provider, their health data is readily available and accurate, 
or in other words, ensuring health data interoperability.
    DoD and VA represent two of the Nation's largest health 
care systems; together, the Departments serve over--million 
eligible beneficiaries, including servicemembers, veterans, and 
their families. Over 60 percent of the DoD and 30 percent of VA 
beneficiaries receive care from the private sector.
    Currently, the Departments share more than 1.5 million data 
elements daily and more than 430,000 DoD and VA clinicians are 
able to view the real time records of more than 16 million 
patients who receive care from both Departments.
    The fiscal year 2008 National Defense Authorization Act 
directed DoD and VA to develop and implement electronic health 
records systems or capabilities that allow for full 
interoperability of health care data between the DoD and VA, 
instructing the establishment of the IPO to guide both 
Departments in their efforts.
    In January 2009, the IPO completed its first charter, 
aiding the Departments in attaining interoperable electronic 
health data.
    In March 2011, the Secretary of Defense and Secretary of VA 
instructed the Departments to develop a single, integrated EHR.
    In 2013, the Departments decided to pursue modernization of 
their respective EHR systems. In December 2013, the IPO was 
rechartered to lead the efforts of DoD and VA to implement 
national health data standards for interoperability and to 
establish, monitor, and approve clinical and technical 
standards for the integration of health data between the 
Departments and the private sector, in accordance with the 2014 
NDAA and in compliance with the THHS, Office of the National 
Coordinator for Health IT's guidance on standards, 
interoperability for clinical records.
    The IPO acts as the point of accountability for 
identifying, monitoring, and approving the clinical and 
technical data standards and profiles to ensure seamless 
integration of clinically relevant health data between the 
Departments and private-sector providers who treat DoD and VA 
beneficiaries.
    In April 2016, the Departments, with the IPO's assistance, 
met a requirement of the fiscal year 2014 NDAA, certifying to 
Congress that their systems are interoperable with an 
integrated display of data through the Joint Legacy Viewer or 
JLV.
    JLV integrates data from the clinical data repositories of 
both Departments, as well as data on beneficiary encounters 
with private providers who participate in national health 
information exchange. The IPO monitors the usage of JLV and 
other interoperability metrics across the Departments to track 
progress on data exchange and interoperability.
    The IPO collaborates extensively with ONC, other government 
agencies, and industry-standards development organizations to 
advance the state of interoperability across the health 
industry.
    In 2018, Secretaries Wilkie and Mattis issued a joint-
commitment statement pledging to align strategies to implement 
an integrated EHR system. DoD and VA leaders chartered the 
Joint Electronic Health Record Modernization working group, 
referred to as the JEHRM, to develop recommendations for an 
optimal organization construct that would enable an agile, 
single-decision-making authority to efficiently adjudicate 
functional, technical, and programmatic interoperability issues 
while advancing unity, synergy, and efficiencies.
    On March 1st, 2019, the joint VA-DoD executive leadership 
group approved a course of action, plan of action, and 
milestones, and implementation plan to establish the Federal 
Electronic Health Record Modernization program office, or the 
FEHRM, in a phased manner in order to minimize risk.
    The FEHRM will provide a comprehensive, agile, and 
coordinated management authority to execute requirements 
necessary for a single, seamless, integrated EHR, and will 
serve as a single point of authority for the Departments' EHR 
modernization program decisions.
    FEHRM leaders will have the authority to direct each 
Department to execute joint decisions for technical, 
programmatic, and functional functions under its purview and 
will provide oversight regarding required funding and policy, 
as necessary. This management model creates a centralized 
structure for interagency decisions related to EHR 
modernization, accountable to both, the VA and DoD deputy 
secretaries.
    And interim FEHRM director and deputy director will be 
appointed to work with the implementation team in transitioning 
joint functions into the FEHRM once the FEHRM has an approved 
charter. The interim leaders will manage and execute joint, 
technical, programmatic, and functional requirements and 
synchronize strategies between the two Department EHR program 
offices to ensure single, seamlessly integrated EHR is 
implemented with minimal risk to cost, performance, and 
schedule. The interim leaders will remain in these roles until 
permanent FEHRM director and FEHRM deputy director are 
appointed.
    The permanent director and deputy director will report 
equally to the Deputy Secretary of Defense and Deputy Secretary 
of Veterans Affairs.
    The IPO will continue to support the Departments as it 
transitions to the FEHRM in implementing a single EHR system to 
ensure a seamless, patient-centric experience that will 
ultimately lead to improved care for our servicemembers and 
their families.
    Thank you for the opportunity to speak with you today. I 
look forward to your questions.

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

    Ms. Lee. Thank you. I will now recognize myself for 5 
minutes for questions.
    Perhaps my first question is, why the name change? Why do 
we just not--I guess this is for Mr. Tinston and Mr. Windom--
why do we just not continue with the IPO?
    Mr. Tinston. Well, I wasn't--ma'am, I wasn't here when the 
decision was made and the JEHRM working group was put in place. 
I understand why they changed it from JEHRM to FEHRM. It just 
seemed an odd name.
    Ms. Lee. It is really confusing.
    Mr. Tinston. So, internally we talk about it sometimes as 
IPO 2.0 or joint program office, but I can't really explain why 
we went with FEHRM.
    Ms. Lee. Okay.
    Mr. Windom. Ma'am, I can tell you, as we migrated from the 
JEHRM to the FEHRM, only that the JEHRM has a connotation that 
did not reflect the clinical desires, and so in the Federal 
element reflected, I think, an overarching responsibility 
within the Federal space that encompassed DoD and VA. I think 
we are not hard and fast on any name, ma'am; we are just trying 
to be distinguished that we are doing something different than 
is perceived to be occurring now, hence, the name.
    But I can tell you--Bill, I think I can speak for both of 
us--I don't think we have any--
    Ms. Lee. No, I was just curious.
    Mr. Windom [continued]. --issues.
    Ms. Lee. Yes.
    Mr. Windom. Yes, ma'am.
    Ms. Lee. All right. Thank you.
    Dr. Thompson, in your testimony you stated that FEHRM 
leaders will have the authority to direct the Department to 
execute decisions for technical, programmatic, and functional 
functions under its purview. And it sounds--based on that, it 
sounds like the FEHRM has the authority to direct the 
Departments to execute the decisions that have already been 
agreed to.
    And I would like to know what is the FEHRM's role, related 
to the issues that the Departments fail to reach consensus on?
    Dr. Thompson. The intention of the FEHRM is to be the 
deciding authority on issues.
    Ms. Lee. Okay. Thank you.
    What does that mean? Like, who all--can you explain that 
further.
    Dr. Thompson. So, the director and deputy director of the 
FEHRM, who will be hired to report equally to the deputy 
secretaries of the DoD and the VA, will have the authority to 
make decisions, that will then be executed by the respective 
Departments.
    Ms. Lee. Okay. Mr. Windom and Mr. Tinston based on the DoD 
and IPO testimony; it seems like this FEHRM is just getting 
operational. Have your respective agencies signed off on a 
charter, and is that charter operational, functional, and are 
there any establishing documents that you are able to share 
with us?
    Mr. Windom. Ma'am, I would start by saying that the 
documents are in staffing, including the charter, as are the 
persons that will serve as the director and the deputy 
director.
    The concept that Bill and I primarily worked out, this 
three-phase concept, is a concept that was imperative to 
establish because it balances where we feel the greatest risks 
are. And so, the three-phase concept is not to delay, but it is 
to support the proper, efficient, and timely movement of 
resources into the FEHRM to support the decision-making process 
without compromising the risks in our present portfolios. So, 
hence, the three-phase--the second phase would be in support of 
Dr. Kroupa's team solidifying workflows in alignment with DoD 
in that arena. And then the third phase would revolve around a 
critical milestone called IOC, Initial Operating Capabilities.
    As you know, until we demonstrate that it works in an 
operational environment, it really does not make sense to move 
a resource until we solidify our strategies. So, we are being 
consistent with what I heard you say and others regarding 
accountability and regarding understanding that it is the end-
users that will solidify our success. And so, taking into 
consideration those same end-users is what has driven our 
three-phase strategy.
    Bill?
    Mr. Tinston. Well, I think Mr. Windom addressed very 
clearly that the charters and staffing and the Departments are 
considering their options for who the interim directors and 
intend to pursue permanent hires for the deputy and the 
director of the organization.
    Ms. Lee. Is there a plan that can be shared with us on 
timing on all of this? On timing for the hiring and the 
resources that are being put behind this?
    Mr. Windom. Ma'am, my understanding is that events are 
being coordinated, literally, as we speak, to come over and 
brief your respective staffs on the details, where Bill and I 
will be co-leading an organization that comes over and 
literally gives you those details. We will be prepared to do so 
and offer those details and also discussion points on whatever 
detail you would like, and your staff would like.
    Ms. Lee. Can I expect that in the next week or two weeks?
    Mr. Windom. Ma'am, I would like to kind of get with the DoD 
counterparts to really solidify that date, and we will gladly 
reach out to your staff, through our legislative affairs, to 
solidify that. I really wouldn't want to give you a date in the 
hearing and then--I haven't agreed to mutually with Bill.
    Ms. Lee. Okay. I am over my time, so I yield and will 
recognize Dr. Roe.
    Mr. Roe. Thank you, Madam Chair.
    And just to start with grumbling a little bit, I don't like 
this room. We ought to have the next hearing in the Verizon 
Center. I feel like that is where I am.
    And, two, I actually read this stuff, so I would appreciate 
you all getting this to me a little sooner so I can sit down 
and read it. And I was able to read a few pages before the 
hearing, so I have got the grumbling over.
    There are huge challenges with this. Obviously, your 
organizational structure is one; you are dealing with two 
separate Departments. One of the reasons we are concerned here, 
I know Mr. Lamb and the Chairwoman was not here when DoD and VA 
spent a billion dollars to try to make AHLTA and VistA 
interoperative, and could not.
    So, I think this is a step in the right direction. And I 
guess about 18 months ago, whenever it was, I went to Spokane 
and was able to be there at Fairchild and began to see the 
rollout, and it was a bumpy rollout. And it was not because 
effort was not there.
    Look, I have saluted many generals. I didn't have near as 
much on my sleeve as, General Payne, as you do. So, I know what 
they did, was they saluted and said, Yes, sir, we will try to 
get this job done.
    The problem is that was a--when I saw that, I had 
implemented an electronic health record in own office with 
70,000 charts in our practice. This was 10,000, basically, 
healthy people in a system that really didn't seem like it 
worked all that well. And I know that you had to use the legacy 
reader to get back and get any information.
    And I guess my first question is, I know you, Dr. Payne, 
you are the champion for the providers. I do know that. Isn't 
that correct, you are the person that is looking after them, 
that is sitting down every day at the computer terminal?
    General Payne. Yes, sir. That is correct.
    Mr. Roe. And do you think that the MHS Genesis, as it 
exists at Madigan, Riverton, Oak Harbor, and Fairchild, are 
meeting the needs of the clinicians there now?
    General Payne. Yes, sir. I do. I think we have made 
significant progress since you saw the record in 2017. We have 
made some significant advancements. We learned that network 
stability was really, really important and we requiring that 
well in advance of go-live now.
    We also learned that connecting all of our medical devices 
was critical, and making sure those were all working and well-
established. All the cybersecurity standards were met before we 
went live.
    Mr. Roe. Well, I know that slowed--I know that the security 
issue was one of the things that held it up, and I think that 
is, hopefully, one of the lessons learned that DoD can pass to 
VA so they don't have to have the same problem that you had.
    Are you rolling out--is what is in Spokane now the same as 
what you are going to roll out, I think it is in California and 
Idaho is the next rollout that DoD is doing; is that correct?
    General Payne. Yes, sir. We start at Travis Air Force Base, 
Mountain Home, Monterey, and Lamar Naval Air Station.
    Mr. Roe. When does that--when do you start standing that 
up?
    General Payne. September.
    Mr. Roe. Of this year?
    General Payne. Yes, sir. It is right around the corner.
    Mr. Roe. And will it be different than what you rolled out, 
or the same thing, that they have now in Riverton and Spokane?
    General Payne. I would like to say that the record has been 
advanced markedly over the past 2 years. Number one, and one of 
the great things about having a commercial off-the-shelf 
product, is that we get regular updates, and we have taken 
those updates, we have integrated those across the system.
    We have also configured the system in a significant amount 
over the past two years. During the stabilization and adoption 
period, we added, to correct a lot of the problems that we were 
seeing initially in the sites.
    We have also, in the past year, conducted 14 sprint 
sessions that were led and directed by the clinicians at the 
IOC sites telling us where they thought they needed the most 
help. So, that has been really well received by the community.
    Mr. Roe. Well, my concern when I looked at it was, as a 
clinician seeing patients. And I was reading, just, again, the 
guide in here, which I find hard to believe, but it says, for 
instance, we can monitor the time a provider spends documenting 
care outside of duty hours, and it was less than 3 percent.
    General Payne. That is correct.
    Mr. Roe. Unless they are not seeing many patients, it 
certainly has been our experience in the private world, I mean, 
you are spending--I just saw a doctor when I got on the 
airplane to fly up here at home, and he was lamenting how many 
hours that he had to spend in entering data, because he had a 
very busy primary care practice.
    The other thing before my time expires is, I was reading 
that, are we going to run the VistA and AHLTA systems with the 
legacy reader throughout the full 10 years of this until it is 
fully implemented or do you turn the switch off in Spokane now, 
so that you can rely on--I have got the information that I need 
in front of me right now?
    General Payne. We do turn off.
    Bill, I don't know if you want to answer that, about the 
legacy system turn-offs? You are probably better than me to 
answer.
    Mr. Tinston. So, we run the JLV, the legacy viewer, while 
we are implementing the 23 sprints and getting to all the 
sites--and that is not 10 years; that is to 2023, when we get 
to all the military treatment facilities. JLV is actually 
embedded as a capability in the electronic health record that 
we are delivering so that we can get to have continued 
interoperability with the VA records, as the VA is bringing 
their records over to the Cerner solution. So, it will continue 
to be used and available, but it is what we are using for 
interoperability while we are in both environments.
    Mr. Roe. Madam Chair, I hope we have a second round. I know 
I am over my time.
    But, I mean, the idea is that we have the Cerner system off 
the shelf and you are running a parallel system with it. Are we 
going to continue doing that, because that is really a 
bureaucratic mess to keep up two systems?
    I yield back.
    Ms. Lee. Thank you, Dr. Roe.
    I now recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Thank you. And I want to thank Mr. Banks' thanks 
to the witnesses for appearing; we really do appreciate it.
    Mr. Windom, if I could just start with you and make sure I 
understand kind of where we are today in the timeline of 
everything. You noted in your testimony the contract that we 
are dealing with between Cerner and VA is what is known as an 
indefinite delivery, indefinite quantity contract--do I have 
that right--and that was not competitively bid out in the 
market because Cerner was already involved with DoD and the 
Government wanted to continue with Cerner, right?
    Mr. Windom. Sir, VA leadership endorsed what is called a 
determination and findings that allowed us to sole-source 
directly to Cerner Corporation, in support of interoperability 
objectives, which involved being on the same Cerner Millennium 
platform. So, that is what drove--so, a DNF drove the award of 
a sole-source contract.
    Mr. Lamb. Right. Got it. Okay. So, that was never--it 
wasn't put out for bid; it was sort of falling in line with 
what DoD had already done?
    Mr. Windom. Yes, sir. Correct.
    Mr. Lamb. That makes sense.
    Okay. So, under this type of contract, if the go-live at 
the initial sites does not happen in March 2020, is there any 
penalty in the contract for that? Like, will money that has 
been paid to them be recouped if it doesn't happen in March of 
2020?
    Mr. Windom. Sir, the question that you pose spawns a number 
of ``it depends.'' We are committed to the milestone identified 
in March of 2020.
    The IDIQ contract approach allows for flexibility, 
flexibility that may be needed due to variability that is 
introduced that we flat-out didn't know. As you know, we are 
doing current state reviews. Discoveries may be made, such that 
you need to build the rectification of those discoveries or 
problems into your schedule.
    We maintain an integrated master schedule, and in 
understanding of our critical path, we would know clearly when 
something was introduced to our critical path. Right now, our 
critical path revolves around clinical workflows, as controlled 
by Dr. Kroupa, in making sure that end-users embrace the 
solution and are educated on the solution. But the bottom line 
is--
    Mr. Lamb. Yeah, but that is not really my question, 
though--if I could just interrupt you--my question is more 
from--I understand that you are doing everything to stay on 
schedule.
    Mr. Windom. Right.
    Mr. Lamb. My question is, if something happens on Cerner's 
end and they just don't perform and March 1st of 2020 comes and 
they just don't go live--they are not ready--does the 
flexibility that you are referring to include the flexibility 
to impose any sort of penalty or sanction on them for not 
fulfilling that goal in the contract?
    Mr. Windom. So, the simple answer, sir, is yes. This is a 
performance-based contract. If Cerner fails to deliver in 
accordance with the performance and terms and conditions of the 
contract, we can withhold money. That would be the simple 
answer.
    Mr. Lamb. You can withhold future money?
    Mr. Windom. We could withhold money. We wouldn't obligate 
additional money if we had yet to rectify the issue that may be 
at hand. So, that would not be good oversight on my part. So, 
sir, we could withhold money. We could withhold work, in 
support of rectifying whatever concerns that have been 
identified that may have caused our milestone to slip.
    But, again, it depends. I don't want to say, because there 
are going to be discoveries that may spawn, potentially, a 
movement. But right now, we are tracking to our March 2020 go-
live, so I don't really spend a lot of time, sir, speculating 
what may happen. I simply say if performance is breached--
    Mr. Lamb. Again, I hate to cut you off, but you know that 
my time is limited.
    Mr. Windom. Yes, sir.
    Mr. Lamb. I am not asking you to speculate about what may 
happen. I am just asking basic questions about the terms of the 
contract.
    And tell me if I am correct here, it sounds like what you 
are saying is that in your understanding of the contract, if 
Cerner does not perform on schedule, VA has the ability to 
withhold funding from them going forward, yes or no?
    Mr. Windom. That is correct. Yes, sir.
    Mr. Lamb. Okay. Now, Mr. Tinston or General Payne, whoever 
wants to answer this, when DoD went live at the initial sites 
and there were all the problems that people had, you know, 
people were getting the wrong prescription drugs filled and, 
you know, everything that was widely reported at that time, was 
there any taken by DoD against the makers of MHS Genesis for 
those failings?
    Mr. Tinston. Congressman, I wasn't a part of the program at 
that point. I know that the DoD took those issues very 
seriously. We paused the implementation. We went through, as 
General Payne described, the stabilization and adoption period, 
and then set to correcting those, improving the capability of 
the system, and then building a different strategy and a 
different approach to--
    Mr. Lamb. Of course. I mean, you have to fix the actual 
product, and I can tell that is what you all are doing.
    My question, though, is, we have contracted with someone to 
do this work, and was there any sanction or penalty imposed for 
that initial--
    Mr. Tinston. Congressman, I will have to get back to you on 
that. I am not positive.
    Mr. Lamb. That's fine. Now, I take it from everyone--and I 
am basically out of time here--but Mr. Windom, you kind of 
referred to this, do you believe that as of today, Cerner is on 
schedule to do the initial rollout in March of 2020?
    Mr. Windom. Yes, sir.
    Mr. Lamb. Okay. And I just want you all to know that you 
use the terms--Mr. Windom said that we are looking to build an 
interagency program decision-making that was comprehensive, 
rapid, and agile. Mr. Tinston talked about being technically 
and programmatically efficient.
    You should know that that is not how the contractors 
described the current situation, as it stands right now. They 
were with us last week. They said that decisions are slow.
    When I asked them open-endedly, what is the number one 
thing you need to succeed? It is faster decision-making by the 
two Departments, which are two large Departments--I can 
understand how they would be slow--but that is what is driving 
our interest in a more efficient process that is implemented 
quickly.
    So, with that, Madam Chairwoman, I yield back.
    Ms. Lee. Thank you. I now recognize Mr. Watkins for 5 
minutes.
    Ms. Lee. Thank you.
    I now recognize Mr. Watkins for 5 minutes.
    Mr. Watkins. Thank you, Madam Chair.
    I represent Kansas' 2nd Congressional District, think small 
towns, rural communities, and that makes expanded community 
care programs so very important.
    And so, Mr. Short, what systems and mechanisms do you have 
in place to assure that the exchange records with community 
providers runs smoothly?
    Mr. Short. Sir, with our contract with the Cerner 
Corporation, we have their Health Information Exchange that 
they have used in many other partnerships that they have 
through community providers. The process we are working through 
right now is before we Go-Live in March for those processes and 
connections to be in place, so it will grow the connectivity 
and ability for VA to have community partner access data 
exchange at a greater level than we have ever had before.
    Mr. Watkins. That is good to hear. Thanks.
    And, General Payne and Mr. Short, would it be fair to say 
that the considerations for that interoperability are different 
for the DoD as compared to the VA, and so the DoD is 
implementing systems for the first time while the VA is 
replacing systems. Would either of you care to comment on that 
difference?
    General Payne. Just a clarifying question, sir. We are 
implementing systems for the first time. We have had, you know, 
AHLTA, CHCS for 30-plus years for our in-patient systems. I 
think what we are doing is taking multiple separate systems and 
bringing them together in an integrated system, which is a huge 
advantage for us.
    Mr. Short. And, sir, I will add to that. Currently, today, 
DoD and VA both have an HIE, Health Information Exchange, that 
are much smaller than what Cerner is going to provide for us 
later in this year where DoD and VA will both be able to share 
the same Health Information Exchange.
    As you know, VA has a lot of care on the outside with 
MISSION Act, community care, that has potential to grow. 
Obviously, DoD has been on record many times, they have a large 
portion of their care on the outside. So when Cerner launches 
that next year, both DoD and VA will have the ability to get a 
lot more records from the outside than we ever have.
    Mr. Watkins. And just as a clarification, General, what 
major systems or mechanisms do you have in place to exchange 
medical records with TRICARE providers?
    General Payne. I will start and then I think Mr. Tinston 
might be able to add. We use joint legacy viewer today, I want 
to say the number is over 50 health care information exchanges 
we have established with the civilian community, and that is 
going to expand, as Mr. Short pointed out. As we move into a 
Common Well into the future, there will be thousands of health 
information exchange. And we are exchanging information with 
both our civilian counterparts, as well as the VA, on a daily 
and hourly basis.
    Mr. Tinston?
    Mr. Tinston. Well, the number is 59 HIEs that we are 
connected to right now. When we move to Common Well and when we 
are joining VA in the Cerner environment, we get the added 
advantage that any HIEs or networks that we are connected to 
that the VA connects to, we also get to share the advantage of 
that same connection, and vice versa.
    Mr. Watkins. Thank you, Madam Chair. I yield my time.
    Ms. Lee. Thank you. I now recognize myself for 5 minutes.
    I would like to focus a little bit about patient 
identification. As I understand it, the VA and the DoD have 
different patient identification standards, understandably, in 
their medical record number formats; we heard that there has 
been more than some conversations about standardizing them.
    Mr. Short, what is the status of those conversations and 
have you been able to reach a consensus?
    Mr. Short. Ma'am, DoD and VA work together to create what 
is called a Joint Patient Identity Management Service. We have 
taken the back-end systems that we have had connected for many 
years, we have enhanced and created some new business rules. 
The current connections that DoD has feeding MHS GENESIS, as 
they call it, the EHRM platform, we have taken that connection 
and made modifications to it.
    As part of that, we have also had to make sure that every 
veteran had a unique identifier. DoD issues out an EDIPI 
identifier to all soldiers, sailors, airmen, Marines, but many 
veterans in the past didn't have those. So, as part of this, we 
also had those identifiers issued to all veterans that ever 
existed that we have a record of. They could have been a World 
War II veteran that passed away 30 years ago. If we have a 
record of them, they now have been issued this identifier.
    We have completed that in the last couple of months. We are 
down to about three or 400 left that had to go through manual 
checks, because someone with a similar name had similar Social 
Security numbers and they have to manually double check those.
    So that has been put together and in the next couple of 
months that will go into testing, so that service is together, 
that way we feed one system of one identity service to the 
common EHR. Since you have the same population or very similar 
populations, you needed a common interface for identity going 
to the system for patient safety. So we engineered that early 
on in the system, we have put it in place, and testing will 
start in a couple months.
    Ms. Lee. Great, thank you.
    Now that the MISSION Act has been implemented and more 
veterans are going to be receiving their care in the community, 
has there been any conversation around standardizing patient 
identifiers with the VA and community providers?
    Mr. Short?
    Mr. Short. I'm sorry, ma'am, I didn't know who the question 
was to. So we currently today, we work with the HIEs, as I 
mentioned earlier, the health information exchanges, and Cerner 
has Common Well, which General Payne mentioned. So currently 
today, when we send someone out in the community, we have the 
advantage, we have already identified them before we send them 
out, so that part is taken care of. When it is accepted, when 
the community partner accepts them, that our community partner 
exchanges that we work with validate those identities also.
    So we have the advantage of we kind of manage that 
process--or don't kind of, we manage that process through the 
community care referral process. So, from that standpoint, we 
keep that. We have the Social Security number, as well as the 
Veteran identifier I mentioned earlier. We actually track a 
number of identifiers on everybody and we double check that 
inside the VA system, the Identity and Access Management Team 
under VA OI&T, they have a whole process where they use all--a 
large number of identifiers to validate those from the outside.
    Ms. Lee. Okay, thank you.
    After--I would like to now turn to some infrastructure 
questions and after the contract between VA and Cerner was 
signed last year, Cerner completed a current-state review. The 
reports generated indicated the obvious concerns with 
infrastructure, including insufficient network capability, 
outdated hardware, necessary facility modifications. Did the VA 
conduct their own assessment in concert with Cerner?
    Mr. Short. Ma'am, the VA staff went with Cerner when they 
did their current-state review, so it was done in partnership 
along with our government and contract staff. And then, once 
that was completed, there was subsequent reviews done by VA OIT 
for the technical pieces of it and VHA facilities as well.
    Ms. Lee. So I understand now that VA has plans with MITRE 
to perform an assessment as well; has that assessment been 
completed?
    Mr. Windom. Ma'am, I know of no plans with MITRE to conduct 
a technical assessment. We are using a number of other 
entities, but MITRE has not been one. We have got MITRE 
personnel on our staff who participate in some of these 
assessments, but we have not contracted specifically with MITRE 
to go do these assessments.
    Ms. Lee. Okay, so no MITRE request to do an assessment?
    Mr. Windom. No, ma'am.
    Ms. Lee. Have there been any updates made to these 
assessments?
    Mr. Windom. Ma'am, I am going to defer to John Short, my 
CTIO, for that.
    Mr. Short. Yes, ma'am. Cerner did their initial review, we 
had some feedback, we did our review and, as we completed that, 
Cerner updated those current-state reviews. And again, as I 
mentioned, OIT and VHA facilities also did those reviews. Since 
then, we had a meeting in the Pacific Northwest to go over all 
the facility work that needed to be done and put that all under 
plan and action.
    Ms. Lee. Thank you.
    I now recognize Dr. Roe.
    Mr. Roe. Thank you, Madam Chair. A couple of quick 
questions.
    Any concerns about the 10-year rollout, because technology 
changes so fast now, are we afraid--do you think that the 
rollout now is going to look like in 2019 like it is going to 
look in 2027 or '28? Are you going to be able to adapt and make 
those changes as inevitably technology will change?
    Mr. Windom. Dr. Roe, I think you have highlighted an 
important element of the IDIQ contract, indefinite delivery, 
indefinite quantity, where we get to leverage the commercial 
advancements that Cerner undertakes in its commercial 
environment with our own portfolio without incurring additional 
expenses. So we expect to evolve with the commercial market; to 
stay current, we will evolve with the market. And technology, 
as you just highlighted, moves very quickly, so we intend to 
use things like cloud computing and APIs and things that may 
become the prevailing methodologies in the technological arena.
    Mr. Roe. And, Mr. Tinston, I hope that the mentality to 
listen to providers in the MHS system about why they don't like 
it, I think we should, and not just reeducate them about what 
is good about it, but have these providers out there that can 
change it and make it a better system. Are you doing that? Have 
you all done that?
    And, Dr. Payne, you also may want to jump in.
    Mr. Tinston. So the way the DoD has set the program up 
subsequent to the IOC sites, it is designed to do exactly that. 
I have a team of IT business system implementers who make sure 
the IT is right and make sure that it reflects what the medical 
facilities need, and the clinicians need, and then General 
Payne takes care of that. So we are two elements of getting 
this right and he works with the clinicians to make sure that 
on the implementation side we are doing the right thing.
    Mr. Roe. What I found out in implementing an electronic 
health record was you had the IT people that didn't really know 
what we needed, so they put everything in there. And I know I 
would get a stack of paper this much and I am thinking 
somewhere in this pile of you know what there is some 
information I might be able to use if I can find it. And that 
was the frustration I had with it, because we have these cut-
and-paste things that you end up with misinformation being in 
there and you never can get it out.
    And so are you listening to providers to say, look, I need 
this amount of information in my little silo right here, I 
don't need every question that has ever been asked anybody in 
their life every time I see them, which is what these records 
did. And it wasn't--I don't think it was the IT folks' fault, I 
think they just didn't understand what was clinically important 
to me as a doctor.
    General Payne. As I mentioned to you about our Sprint 
sessions, I think the front-line clinicians, we also have 
clinical communities that are working with the VA councils in 
configuring the record. One of the great things about MHS 
GENESIS is it is configurable; we can adjust the system. As a 
provider, you can adjust it to your likes and dislikes.
    We are working--the other part I really like about this is 
we are part--we are not an isolated--just isolated in DoD, we 
are participating with the Cerner client universe. We visited 
the University of Missouri, the Tiger Institute, to see how 
they are operating. We are about to go to Memorial Hermann 
Hospital in Texas to see how they are implementing MHS GENESIS, 
that is one of the safest hospital systems in the country. And 
we are also, our ophthalmologists are working with Cerner to 
help devise the ophthalmology workflows.
    So I think this record gives us an opportunity we have 
never had before and, with our VA colleagues, I think there is 
a huge amount of power in that.
    Mr. Roe. And this is just a question, Mr. Windom, I read 
this last night, I have no idea what it means. ``VA is 
leveraging several efficiencies, including revised contract 
language to improve trouble ticket resolution based on DoD 
challenges.''
    Could you translate that into something English?
    Mr. Windom. Yes, sir. Sir, that was pre-contract award, so 
there is no contract modification. Basically, our partners in 
DoD shared with us very forthright and honestly some of the 
challenges they were dealing with, with trouble ticket 
management in the Pacific Northwest, and we were able to add 
terms and conditions to our contract to facilitate a high level 
of performance and review by Cerner in adjudicating ours sooner 
rather than later. So, it really is just a lesson learned, sir.
    Mr. Roe. Thank you.
    Mr. Windom. I will be more clear next time.
    Mr. Roe. Thank you. The last couple things. One is a big 
challenge, Dr. Thompson, you know this, across the country is 
interoperability. It is not DoD and VA; it is the private 
sector: how do we share information? And, unfortunately, a lot 
of people don't want to share information, because the 
information they have is power and they can leverage it for 
money. But it is critical for us to be able--as clinicians to 
be able to share clinical information across VA to the 
private--look, it does me no good to have a MISSION Act if I am 
sitting out here and I can't get any information from the VA. 
And, by the way, after I see the patient, if that information 
doesn't end up back at the VA, it doesn't do the patient any 
good.
    I am going to leave one question, you can think about it, 
both of you, because my time is expired, but in this rollout, 
what is the major thing that keeps you up at night?
    And I will end on that. I yield back.
    Ms. Lee. Thank you, Dr. Roe.
    I now recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Thank you. And if you would like to answer Dr. 
Roe's question, that is I think a major question on all of our 
minds, just sort of a current assessment right now, what is our 
biggest obstacle? Mr. Windom, if we could start with you. 
Between now--let's say between now and March 2020, what is the 
biggest thing that keeps you up at night?
    Mr. Windom. Sir, I have listened to this Committee and I 
have listened to the end users intently, and it is about user 
adoption. The technology will work, the technology will 
support, the embracing of the end user to our change management 
strategies, our education strategy, training strategy, that is 
our critical path element. So the critical path element keeps 
me up.
    I think Dr. Kroupa and her team are doing a great job. I 
would like to pass the question over to her, if you don't 
mind--
    Mr. Lamb. I appreciate that. I was--
    Mr. Windom [continued]. --and--
    Mr. Lamb. --going to move to her anyway.
    Mr. Windom. --but that is what keeps me up.
    Mr. Lamb. And, Dr. Kroupa, are you the one who oversees the 
18 councils and the input from the clinicians?
    Dr. Kroupa. Yes.
    Mr. Lamb. Okay. So if you could just let me know sort of 
what is at the forefront of your mind, but also what are the 
most recent examples that you are hearing from them of issues?
    Dr. Kroupa. I think that the biggest challenge for us in VA 
is, as has been mentioned, we are going from a CPR system, 
which people are very accustomed to, to a commercial system. So 
there has been a lot of education about what does that mean, 
how does the commercial system work, how do we even speak the 
same language as the commercial system.
    I think we are now getting into a phase where the councils 
understand that. They are really hitting their stride in terms 
of understanding how the system works and are able to really 
see the places where we can accept commercial best practice and 
places where there are specialized things that VA needs to do 
for our patient population and for our mission.
    Mr. Lamb. And what are some specific things that they have 
identified recently?
    Dr. Kroupa. So there are some things, some basic things 
like service connection. No one else in the world cares about 
service connected veterans, except for VA. That is not 
something that is in the commercial system to start with. We 
have a lot of programs in VA that other commercial systems 
don't have. We do things with PTSD, with blind rehab, you know, 
a lot of comprehensive--
    Mr. Lamb. No, I am sorry to interrupt. I understand why the 
VA system is different than the commercial clients. What I am 
asking is there a recent example you know of where a clinician 
has flagged for Cerner and for you this thing that you already 
have programmed will not work for me for this reason?
    Dr. Kroupa. There has certainly been a--probably in every 
council, there is something that has been flagged that says we 
need development in this. We need configuration in this to make 
sure that it meets the VA standards.
    Mr. Lamb. But do you know what those are?
    Dr. Kroupa. There is a whole list of those. So those are 
all the things that we are working on now with Cerner to 
rectify.
    Mr. Lamb. Okay. And is there a--is it planned in the 
schedule where before March 2020, some of these clinicians, 
either on the councils or otherwise, are actually going to go 
through like a dry run testing in front of the computer?
    Dr. Kroupa. Yes.
    Mr. Lamb. How is--can you tell me how that is scheduled?
    Dr. Kroupa. Sure, sure. So part of the council process is 
that they validate their decisions from the last time around. 
So they are constantly validating and reviewing the decisions 
they made before they move forward with the next phase. Then we 
have an extensive testing time frame. People from the council 
has already been identified that will be the testers. So that 
we will make sure that their intentions are met in the product 
when it is--before it is ready to go out. And then we will have 
extensive testing in Spokane and Seattle, including mock 
GoLives and a variety of validation events to make sure that it 
is ready to go.
    Mr. Lamb. And do you know when that starts in relation to 
March of 2020?
    Dr. Kroupa. The testing will start in November.
    Mr. Lamb. Okay.
    Dr. Kroupa. That is our current plan.
    Mr. Lamb. Thank you. Mr. Windom, if you would, yes.
    Mr. Windom. Mr. Lamb, may I add just real quickly is that 
we knew at the inception, there are certain capabilities that 
aren't delivered as part of the Cerner integrated solution. We 
knew that. Things like prosthetics, things like long term care. 
These are capabilities that will be interfaced with the 
existing system as Cerner and us, to be frank, walk through the 
coding process to actually integrate it into a solution. So no 
capabilities will be lost. We may interface in the interim and 
then replace the capability in the future as part of our 
overall implementation strategy.
    Mr. Lamb. Right. No, I understand that in general terms. I 
guess, I think I am just a little bit surprised that nobody can 
name a specific instance of where an end user doctor said to 
you guys, ``Hey, the program falls short in this area of 
something that I do and we need to get it fixed,'' and how it 
was fixed. It seems to me that is what you are describing that 
you want to be taking place, but I am just a little concerned 
that we don't have specific examples of that. And you can feel 
free to get back to us later. I understand we are putting you 
on the spot.
    Madam Chairwoman, I yield back.
    Ms. Lee. Thank you. I would now like to recognize Mr. Roy 
for 5 minutes.
    Mr. Roy. I thank the Chairwoman. I appreciate you all being 
here and taking your time to address this Committee. And I 
apologize for missing the first part of it, so hopefully I 
won't repeat anything. We have got redundant duties in another 
Committee. Fortunately, this is a Committee where we actually, 
on a bipartisan basis, tend to try to do something productive. 
So I am glad you all are here.
    Mr. Windom, I might start with you. I understand that the 
VA is pursuing a best of suite strategy with the Cerner 
contract and not a best of breed strategy. Could you please 
explain what that means to you and how you all decided to 
pursue that path?
    Mr. Windom. Sir, a best of breed is an individual set of 
capabilities that are basically daisy chained together, where 
often the government becomes the integrator of those products. 
Where a best of suite is an integrated solution that is built, 
that is developed, that is coded to perform in an integrated 
fashion such that there is no integration requirement in 
between the individual components of the solution. And so AHLTA 
and CHCS on the DoD side, that is an example of two different 
products where the DoD is the integrator between the two. So 
that is how I would describe it to you, sir.
    Best of breed is a set of solutions that are daisy chained 
together to deliver the requisite end state, where a best of 
suite is an integrated set of elements where the end state is 
delivered without the interactions in between each stage.
    Mr. Roy. So quick question, quick follow up on that, 
though, isn't the risk sort of putting all of the eggs in one 
basket, versus having other alternatives and options we might 
be able to have? Especially with modern technology, with APIs 
and all of the different ways that we can, you know, integrate 
across platforms, is that not putting all the eggs in that one 
basket or no?
    Mr. Windom. Sir, we have not restricted innovation in any 
way, shape, or form on even a best of suite platform. So if 
there is capabilities being delivered in the market that we, 
the VA, want to leverage, we have the ability to present that 
to Cerner Solutions set as a requirement in fulfillment of VA 
mission objectives and pursue integration of those, if you 
will, enhancements or improvements.
    So a best of suite does not imply you can't inject new 
capability or innovation into the product line.
    Mr. Roy. Well, on a follow up then, Mr. Tinston, I assume 
DoD also has a best of suite strategy; is that correct? And if 
so, could you please walk me through your thought process 
there?
    Mr. Tinston. We do, in fact, have a best of suite strategy. 
And the idea is that you get an integrated set of capabilities, 
as Mr. Windom said. There may be a best product in this area, 
but what works best in the combination of capabilities that we 
are delivering to clinicians and the patients. So--
    Mr. Roy. Okay. Slightly--I would love to engage on that 
probably for hours, but in our limited time, Mr. Windom, back 
to you. How do you define vendor lock in as it pertains to 
electronic health records, and health IT companies? And what 
would it mean for the VA to become locked into a particular 
company?
    Mr. Windom. Sir, very sensitive in not only my DoD life but 
now to restrictions on the use of intellectual property. You 
know, the open sourcing, the things that allow us, if you will, 
to inject capabilities and not be bound by a solution that we 
have contracted for. So the--having access to code, having 
access in an unrestricted way to bringing in the requisite 
solutions, whether it be apps, you know, applications that are 
now very prevalent, that is where I deem vendor lock is. And in 
our terms and conditions of our contract, we have greatly 
inhibited vendor lock by promoting Cerner opening up their 
gateway to allow better solutions, enhancements to the product 
line that they may not only want to incorporate on behalf of 
the VA before their commercial customers as well. So, sir, 
hopefully that gets to where you were looking for.
    Mr. Roy. Well, on a more specific basis, does buying the 
Cerner Millennium EHR pose the risk of vendor lock in?
    Mr. Windom. No, sir. The terms and conditions, again, we 
have got an innovation CLIN, contract line item number. We have 
got--again, I don't--this is a VA requirement. We drive the 
requirement. We drive the behavior of Cerner and performance of 
the terms and conditions of the contract. We have no desire to 
give up on the innovative talent that the VA brings to bear, 
nor the solutions that are being developed in the market today.
    So we believe we have that relationship in the terms and 
conditions of our contract, and we will exercise it as 
necessary down the road to support, again, our veterans.
    Mr. Roy. And relatedly, does the VA getting rid of its 
patient portal, My HealtheVet, and adopting Cerner's patient 
portal pose the risk of vendor lock in?
    Mr. Windom. Sir, that is--I am going to defer that question 
to Dr. Kroupa, but that is not our strategy. So I am going to--
we are not getting rid of our patient portal.
    Mr. Roy. Okay.
    Mr. Windom. We have a methodology that we are going to move 
forward with that leverages the qualities of both patient 
portals in our strategy. The key is that this is not a turnkey 
solution set. We can't just turn one thing off and turn 
something on. We know there are benefits in the way our system 
performs. It is not our intent at all to reduce the 
capabilities being provided to our veterans, but to enhance the 
capabilities.
    So Dr. Kroupa, ma'am, did you want to touch on patient 
portal specifically?
    Dr. Kroupa. Certainly, so we have done a side by side 
comparison of what the Cerner portal offers versus My 
HealtheVet. We are working on a strategy of how we can assure 
that the veteran experience is as close to the same across the 
country as we can make that. There will be some transition 
time, but we are basically working with Cerner to upgrade their 
portal to make sure that it offers the information and the ease 
of use of My HealtheVet.
    So we are still working, outlining that strategy, but we 
are constantly working with Cerner to make sure that their 
product gets better to serve our veterans.
    Mr. Roy. Madam Chair, I am a minute over my time. Thank 
you.
    Ms. Lee. Thank you. The Subcommittee has copies of the 
current state reviews and we have received updates and we 
appreciate that very much. I just want to make sure that we 
have every infrastructure report. So besides the CSRs, is there 
any other analysis review about infrastructure readiness?
    Mr. Windom. Ma'am, we have a joint infrastructure plan that 
was co-authored by the OI&T office, headed by the CIO and also 
John Short and our team. We gladly share that with you, because 
what we feel is that the synergy between OI&T and our office is 
essential. They are the managers of the network today. So we 
can provide that if you don't have that.
    John, did you have any other documents that you are hiding 
from me?
    Mr. Short. No, sir, not hiding documents, but OIT, as I 
mentioned, there was other reviews that were done and the 
Office of Information and Technology did create a report on 
Seattle, Spokane, American Lake--we can get that for you.
    Ms. Lee. Can we get that? Thank you.
    Mr. Short. Yes, ma'am.
    Ms. Lee. In the past, you have indicated that you will have 
the infrastructure projects completed within six months of go 
live. And then you just stated that--I just want to ask for 
clarification, you are going to do testing in November. Do you 
need the full infrastructure done for the testing? Are you 
going to sort of test modules while you are completing--like 
how does that timing work out?
    Mr. Windom. Yes, ma'am, there is testing in the operational 
environment and testing outside. The testing outside of the 
operational environment does not require the infrastructure to 
be ready to go. We are sticking to our plan of the 
infrastructure will be ready six months prior to Go-Live. And 
so the testing environment that we build in support of testing 
in a non-operational environment is separate, with possibly 
some connections or interfaces.
    John, did you want to touch on that anymore?
    Mr. Short. Yes, ma'am. Just for clarification. The 
infrastructure needed for Go-Live will be ready in that time. 
But there is still some additional infrastructure work that 
will be completed later, not required for Go-Live, but for a 
better user experience overall, some of those things, but not 
necessarily for operation. But all of the ones necessary for 
testing onsite, necessary for operations onsite, will be done 
in time.
    Ms. Lee. Do you worry that if you implement the 
infrastructure for operation, but it is not optimal and 
ultimately, you said the thing that keeps you up at night is 
the end user experience, and so if you don't have the proper 
infrastructure in place, you actually set yourself back.
    Mr. Windom. Ma'am, I think you are right on point. It goes 
hand in hand. What we do is we build plans to support being 
ready as intended. We would owe you that transparency to your 
staff if we are not meeting what we think our objectives are in 
support of that.
    I have indicated quite a few times that IOC is a period of 
time, initial operating capability. What is available at Go-
Live, we will continue to update the infrastructure to deliver 
capabilities throughout the IOC process, which is a period of 
time, vice a single point in time. So I wanted to make sure 
that was understood.
    And then obviously tech refreshes will be ongoing to 
support the system operating at the optimal level. As you know, 
we are going to be running VistA and Cerner in parallel for a 
while. And so we know that the infrastructure will not run 
better with two systems, but we intend to--so we intend to make 
the appropriate and prioritize decisions on infrastructure 
upgrades.
    Ms. Lee. So what is your timeline on just beginning the 
infrastructure construction at IOC sites and the ordering of 
the hardware?
    Mr. Short. Ma'am, a lot of that is already taking place. 
Some devices will be arriving soon. Some cabling has been done. 
Wireless infrastructure has been replaced at one facility. So 
all the work is actually ongoing already. We can provide you a 
full schedule, ma'am.
    Mr. Windom. Yes, and ma'am, we would gladly provide you a 
full schedule so you can see all of the spreadsheets that are 
being worked. We are leveraging--this is where I compliment the 
CIO and the OIT. We are leveraging their contracts to the 
maximum extent possible. I mean, we are talking about commodity 
type hardware that they already procure, that we are simply 
being able to leverage their vehicles for efficiencies on our 
side.
    So that is actually a time saving mechanism that is giving 
us schedule back that we appreciate the CIO support in.
    Ms. Lee. Good to hear. Thank you. I now recognize Dr. Roe 
for 5 minutes.
    Mr. Roe. I thank the Chair very much. And we here on this 
Committee are here to try to help roll this out, not get in the 
way. But I would like to be invited to one of your sites, with 
no Power Point presentations, and so I could just sit down with 
nurses, and doctors, and other people using this system and 
actually see how it works. I, personally, would like to do 
that.
    And to Mr. Roy's question, to follow up on what he was 
doing, and I guess anybody can get this here, what other 
functions will this system do? I mean, is it going to--are you 
going to be able to contract with it, schedule with it, 
appointments, what else is the Cerner system capable of?
    Dr. Kroupa. So this is really very a full set of 
capabilities that we have bought from Cerner. So it will have 
the electronic health record, the clinical portions of that. It 
will have the revenue cycle side of things, so scheduling 
appointments, registration, billing, those types of things. It 
will have--we have HealtheIntent, which is the data analytics 
section--
    Mr. Roe. Did you say it would be able to do billing also?
    Dr. Kroupa. It will be part of the billing process, yes. We 
have HealtheIntent, which is the data warehouse side of that, 
where we will be able to do reporting and analytics. It has 
extensive management modules, so that it will help clinical 
managers understand the flow through clinics, the--as you 
mentioned, the time that providers use on the system. So we 
will be able to say that this particular provider is having 
trouble getting through this order set and we need to go help 
and train them, and help them understand the system better. So 
it has an extensive suite of both management and clinical uses.
    Mr. Roe. Well, this is a--look, this is a monstrous 
undertaking that you all are doing, both of you. And there are 
going to be some bumps in the road. There is no question about 
that. So please just share them with us. Look, I have been down 
that road, know how it is. It is disruptive to the practice and 
the clinicians. So if you run across things like that, don't 
sweep them under the rug. Come to this Subcommittee and let us 
know about it. We are here to try to help you, provide what you 
need to get your job done.
    And I think it is one of the most important projects that 
is going on now. At the end of the day, it is not about 
technology, it is about patient care. It is about going into 
the room and seeing a patient with their ailment, and providing 
the absolute best quality of care we can do. It is not about--
nobody cares about Wi-Fi and 5G and all of that. They just want 
to get well when they come see me. They don't care how they do 
it or come see the doctor. That is what you do and what I do 
when we go in.
    But our job is to make sure all of that other stuff works 
so we can do that. So I would encourage you to be as forthright 
with us as you can be. Mr. Windom or Mr. Tinston, either one, 
it doesn't matter, or both of you can answer this, but who 
decides, or have you all decided who is going to lead the firm? 
Has that decision been made and who made it?
    Mr. Tinston. To my knowledge, Congressman, that decision 
has not been made. So I think the two departments are in 
discussions about who is going to be the interim leadership, 
the interim director and the interim deputy director for the 
firm, and then they are going to pursue permanent hires in the 
future.
    Mr. Roe. Okay. So that hadn't been made yet. Lastly, and I 
will finish up and yield back my time, you have been very--
thank you all. It has been a very good hearing. Do you see, Mr. 
Windom, any delays that could happen right now? Looking out 
your windshield, do you see anything that would hold you up, 
because if you do, to me, that is fine, if you just--if it 
takes another month or two, I would rather have you get it 
right then get it quick and get it wrong.
    Mr. Windom. Yes, sir. And you have been clear, sir, in a 
number of hearings and we appreciate that support. I will tell 
you March 2020 is where we are tracking for Go-Live. I keep 
pointing to the clinical decision-making process that Dr. 
Kroupa leads. It is about when they are ready. When they are 
ready is when we will go deploy this thing.
    And so we have got our last workshop, I think, in September 
and we will be looking toward where we are in aligning the 
workflows with DoD being involved in those. And I think we, 
obviously, would owe you an interaction to say, ``Sir, here is 
where we are in the workflows.'' But I view that as our 
critical path item. And as you know about the integrative 
master schedule process, my critical path--we can work a myriad 
of things in collateral and parallel, and we are doing that. So 
that critical path element for me is the clinicians and their 
embracing of the solution coming forward.
    So I will--can I come back and see you in November?
    Mr. Roe. Absolutely.
    Mr. Windom. Yes, sir. Okay.
    Mr. Roe. I hope so. I hope I am here in November. One last 
question. When will you know it is interoperable? When will a--
because we are going to have folks separating from the military 
during this time and they are going to be leaving? When will we 
know you can punch a button and move that medical record over 
from DoD to VA?
    Mr. Windom. I think, and I will defer to John after I make 
just two remarks, is that, sir, I think that is one of the 
benefits of us being in the Pacific Northwest simultaneously 
with the Department of Defense is that you should be able to 
walk from Madigan--after Go-Live, you should be able to walk 
from Madigan and into American Lake and to Seattle Medical 
Center, and to Mann-Grandstaff, and you ought to be able to 
bring up each other's records. That is where we are striving, 
what we are striving for. Let me turn this over--
    Mr. Roe. Yes, I should be able to make a three foot putt, 
but I can't a lot of times and so--
    Mr. Windom. Well, so that is what our testing is going to 
be in support of. That is what our strategy is going to be in 
support of. And we will welcome you out there for the Go-Live 
session to prove that to you.
    Mr. Roe. When will that be?
    Mr. Windom.'' Yes, sir.
    Mr. Roe. When will that be?
    Mr. Windom. March of 2020, sir.
    Mr. Roe. March of 2020?
    Mr. Windom. Yes, sir.
    Mr. Roe. I yield back. Thank you.
    Ms. Lee. Thank you, Dr. Roe. I now recognize Mr. Roy.
    Mr. Roy. Thank you, Madam Chairwoman. Just to follow up 
with a few more questions. I started with Mr. Windom. Does 
using Cerner's HealtheIntent product as the repository for all 
veteran health data pose the risk of vendor lock in, just 
continuing the conversation about lock in?
    Mr. Windom. Sir, we selected a solution to benefit the 
veterans and the active duty servicemembers. So the vendor lock 
thing, I don't know enough about the inter-workings of 
HealtheIntent to be able to give you, and so if you don't mind, 
I will take the look up--
    Mr. Roy. Okay.
    Mr. Windom[continued]. --and I will defer to John and Dr. 
Kroupa for maybe their assessment of the product.
    Mr. Short. Sir, when we were negotiating the contract, we 
required Cerner, upon VA's request, to extract the data from 
Millennium and HealtheIntent into the form and structure that 
we require it in. So if in the future we decided to go 
somewhere else, we could have the data extracted to go 
somewhere else. And obviously that would be a whole effort in 
itself. But we do have that ability, so it is not locked into 
their system.
    Mr. Roy. Okay. And relatedly, you know, in general terms, I 
just want to go back to Mr. Tinston. I understand DoD plans to 
buy HealtheIntent but has not done it yet and is vendor lock in 
a consideration in this decision?
    Mr. Tinston. So we are, in fact, we have a joint team with 
the VA for the implementation of HealtheIntent. We are setting 
up the environments now. I am not worried about lock in with 
HealtheIntent. As John Short just mentioned, the data is not 
Cerner's, but importantly with HealtheIntent, it is a set of 
capabilities built on other products, some of them even open 
source products that are not Cerner exclusive products. So I 
don't see a risk of vendor lock in here.
    Mr. Roy. So just to clarify, you know, the questions that I 
am asking about vendor lock in are not meant to be critical of 
Cerner or anything along those lines. You know, I think, you 
know, obviously, one of the leading companies out in the 
industry. It is meant to just focus in on some of the concerns 
that we might have. This project is very large and difficult, 
and we want to complete the basics before turning attention to 
other stuff.
    But I believe innovation is really important. And as I 
know, I think all of you do, believe it or not, I have a 
masters in Management Information Systems from my previous 
life, which was in 1995, so it is about as useful as, you know, 
having a putter in my hand right now.
    But I do care about these issues and think about them, at 
least analytically, in the way that I would when I was in that 
realm of my life. So the question I would have here that I am 
trying to understand is how we are getting the kind of 
competition and innovation that needs to continue through this 
process, right? And particularly for veterans, I know I hear in 
my district all the time about their concerns, about under 
choice and mission, being able to go access private sector 
health care and having trouble doing so, and trying to make 
sure that we have got the best health records to make that 
process as smooth as possible.
    So one question here, Mr. Windom, is do you know what 
Cerner's market share is now?
    Mr. Windom. I do not, sir.
    Mr. Roy. Okay. My basic understanding is it would sort of 
be in the upper 20s or something in that zip code of the market 
and then do--I assume the answer will be no, but do you know 
what the market share would be if the military health system 
and VA both finish implementing Cerner nationwide? Do you have 
an estimate of what that market share might look like?
    Mr. Windom. I do not, sir.
    Mr. Roy. Okay. We have some rough estimates that that might 
put it in the sort of mid to upper 30s. And again, nothing 
inherently wrong with that per se. We have got a lot of 
industries where there is some significant market dominance. I 
think it is just a question that should influence at least some 
of our thinking about making sure that there is the kind of 
innovation that is necessary. And you know, we are not talking 
about monopoly here, obviously, but we are talking about 
concerns about making sure there is continued innovation.
    So this seems to have been one of VA's considerations when 
it negotiated the contract with Cerner. And so I want to ask 
you one question. The contract says VA will have access to 
Cerner's data architecture, not just the data in the system, 
which VA should already own. VA hailed this as a big victory 
when the contract was signed. What is Cerner doing differently 
to give VA this access and how is VA using it?
    Mr. Short. Sir, on the access to the data models and the, 
so what we have done already, data migration is the main area 
where this hits first. And that is--and there is many elements 
to data migration, many steps. So when we did this, we had to 
map VistA data to the HealtheIntent data model, which CMO staff 
did with--Dr. Kroupa's staff did with Cerner. And then they had 
to be mapped to the Millennium data model so Cerner can move 
that data.
    So the first steps that have been done, and now Cerner is 
taking the next steps over the next couple of months to move 
that into the HealtheIntent model and to the Millennium model. 
And by having access to the data models to be able to map that, 
we can actually make use of all of VA's Legacy data and VistA 
back to 1981 so it can be used by DoD and VA.
    Mr. Roy. Anybody else have any other, anything to add to 
that? Okay. Well, okay. Well, thank you, Madam Chairwoman.
    Ms. Lee. Thank you. Well, this wraps it up. I just want to 
thank you all for your time today and your testimony. 
Certainly, we understand how incredibly complex and important 
this project is and the opportunity to improve care for not 
only our active servicemembers, but our veterans. And, 
certainly, the example that Mr. Tinston provided with the 
nursing, rapid response that helped save a life is obviously 
what we look for as the future of this project and the great 
opportunity we have, not just within the VA and the Department 
of Defense, but for health care, not just across this country, 
but throughout the world. So, not a small undertaking.
    You know, last week--I just want to reiterate this--last 
week, the contractors said that their single greatest risk to 
their success was the timing and their ability to make 
decisions. And, you know, we had the IPO and now--then it was 
the JEHRM and now it is the FEHRM. But still, today, my 
understanding from the questions that were answered today, that 
this is really just still a concept and not an actionable plan, 
at this point.
    And then, layered on top of that, we have the IDIQ contract 
which, you know, according to Mr. Windom, you have clear 
responsibilities that are Cerner's versus yours. So, we are 
happy to hear that you are confident you are on schedule for 
the March 2020 rollout.
    So, my concern is as we get closer and closer and if we 
start to miss deadlines, there is going to be a clear decision 
point when we want to understand who is responsible. And 
without a clear plan on this FEHRM, and I am going to reiterate 
that again, it really puts us and the taxpayers at risk. 
Because, you know, there is going to be a point where Cerner is 
going to say, No, it is your fault. We are going to say, No, it 
is your point.
    That is why it is so important that we have this governance 
structure in place, so we can understand, and we have one point 
of decision-making and one point that can say, this is what 
happened. And we are either going to hold Cerner accountable or 
we are going to hold ourselves accountable.
    And, clearly, especially as Dr. Roe said, you know, we know 
this is an undertaking and when we come up to bumps in the 
road, we would rather than understand them than find out about 
them after the fact.
    And so, I just need to close this out by reiterating, as 
soon as we can see the actionable plan on the FEHRM, it will 
give us a lot more clarity and comfort as we move forward and 
work together with you to try to meet the March 2020 rollout.
    So, best of luck. Continue the great work. Thank you all 
for your service to our country and our veterans and our active 
military members, and we look forward to continuing the 
conversation. Thank you.
    Oh, Members, before we end, will have 5 legislative days to 
revise and extend their remarks and include extraneous 
material. This hearing is now adjourned.

    [Whereupon, at 11:51 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

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

Background

    On May 17, 2018, VA awarded an Indefinite Delivery/Indefinite 
Quantity (ID/IQ) EHR contract to Cerner. Given the complexity of the 
environment, VA has awarded this ID/IQ to provide maximum flexibility 
and the necessary structure to control cost. Through this acquisition, 
VA will adopt the same EHR solution as the Department of Defense (DoD). 
The solution allows patient data to reside in a single hosting site 
using a single common system to enable the sharing of health 
information; improve care delivery and coordination; and provide 
clinicians with data and tools that support patient safety. VA believes 
that implementing a single EHR solution will allow for seamless care 
for our Nation's Servicemembers and Veterans. Since contract award, VA 
has accomplished several key events outlined below.

Task Orders

    As mentioned earlier, VA awarded the Cerner contract on May 17, 
2018. VA also awarded the first three Task Orders (TO), which are 
project management, Initial Operating Capabilities (IOC) site 
assessments, and data hosting. In September 2018, VA awarded three TOs 
for Data Migration and Enterprise Interface Development, and Functional 
Baseline Design and Development and IOC Deployment. VA leverages the 
ID/IQ contract structure awarding firm-fixed-price TOs as requirements 
are validated. This strategy affords VA the flexibility to moderate 
work and modify implementation and deployment plans efficiently. Since 
contract award, VA has awarded additional TO's to begin activities 
around data migration and IOC deployment. Additional details about the 
TOs are as follows:

      TO 1 - EHRM Project Management, Planning Strategy, and 
Pre-IOC: Cerner will provide project management, planning, strategy, 
and pre-IOC build support. More specifically, the scope of services 
included in this task order are project management; enterprise 
management; functional management; technical management; enterprise 
design and build activities; and pre-IOC infrastructure build and 
testing.
      TO 2 - EHRM Site Assessments - Veterans Integrated 
Service Network (VISN) 20: Cerner will conduct facility assessments, to 
prepare for the commercial EHR implementation, for the following 
Veterans Integrated Service Network 20 IOC sites: Mann-Grandstaff VA 
Medical Center (VAMC) in Spokane Washington; the Seattle, Washington 
VAMC; and the American Lake VAMC in Tacoma, Washington. Cerner will 
also provide VA with a comprehensive current-state assessment to inform 
site-specific implementation activities and task order-specific pricing 
adjustments.
      Task Order 3 - EHRM Hosting: Cerner is funded to deliver 
a comprehensive EHRM hosting solution and start associated services to 
include hosting for EHRM applications, application services, and 
supporting EHRM data.
      Task Order 4 - Data Migration and Enterprise Interface 
Development: Cerner will provide data migration planning refinement, 
analysis, development, testing, and execution. Cerner will support 
enterprise interface planning refinement, design, development, testing, 
and deployment. Cerner will provide a commercially available registry 
selected by VA for IOC as well as details and updates on the progress 
of IOC data migration and enterprise interface development.
      Task Order 5 - Functional Baseline Design and 
Development: Cerner will provide project management, workflow, 
training, change management, and EHRM stakeholder communication.
      Task Order 6 - IOC Deployment: Cerner will provide 
project management; IOC planning and deployment; test and evaluation; 
pre-deployment training; go-live readiness assessment, deployment, and 
release; go-live event; post-production health check and deployment 
completion; post-deployment support; and continued deployment decision 
support.
      Task Order 7 - Technical Baseline: Cerner will provide 
project management; adherence to enterprise technical plans and 
strategies; technical training plans and materials; technical and 
functional analysis; system integration; Health Information Exchange/
Veteran Health Information Exchange modification; forward-deployed 
hardware; VA-specific functionality integration; and additional 
technical support.
      Task Order 8 - Additional Interface Development for IOC: 
Cerner will provide additional interface development, testing, and 
execution in support of interfaces required for VA's IOC sites. These 
tasks include interface development, integration, testing, deployment, 
sustainment, and maintaining the EHR Master System Integration list.

Current State Review

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

Model Validation Event

    In September 2018, VA held its Model Validation Event, where VA's 
EHR Council met with Cerner to begin the national and local workflow 
development process for VA's new EHR solution. There was a series of 
working sessions designed to examine Cerner's commercial recommended 
workflows and evaluate the current workflows used at VAMCs. This allows 
VA to configure the workflows to best meet the needs of our Veterans, 
while also implementing commercial best practices.
    Because of Model Validation, VA planned eight national workshops to 
educate diverse clinical end-users and validate workflows to ensure 
VA's new EHR solution meets the Department's needs. During the events, 
VA collaborates with front-line clinicians across VA's enterprise to 
validate workflows ensuring VA's new EHR solution meets the 
Department's needs. To date, VA has completed five national Workshops. 
The remaining workshops are scheduled to occur throughout the rest of 
this fiscal year.

Cerner Baseline Review

    VA is committed to aligning its workflows closely with commercial 
best practices. As such, VA commissioned Cerner to complete a baseline 
assessment of how closely DoD's Military Health System GENESIS aligns 
with these practices. In September 2018, Cerner presented the results 
of the assessment. VA learned that DoD has a high adoption of 
recommendations and system configuration, which are generally in 
alignment with commercial best practices.

Organizational Structure and Strategic Alignment with DoD

    On June 25, 2018, VA established OEHRM to ensure that we 
successfully prepare for, deploy, and maintain the new EHR solution and 
the health information technology (IT) tools dependent upon it. OEHRM 
reports directly to VA Deputy Secretary and works in close coordination 
with the Veterans Health Administration and Office of Information 
Technology.
    I currently serve as the program's Executive Director and have 
supported this effort at a leadership-level since its inception. Prior 
to joining VA, I served as the Program Manager for the Defense Health 
Management Systems Modernization, the organization which competitively 
and successfully acquired the Cerner EHR solution on behalf of DoD.
    To ensure appropriate VA and DoD coordination, we emphasize 
transparency within and across VA through integrated governance and 
open decision-making. The OEHRM governance structure has been 
established and is operational, consisting of technical and functional 
boards that will work to mitigate any potential risks to the EHRM 
program. The structure and process of the boards are designed to 
facilitate efficient and effective decision-making and the adjudication 
of risks to facilitate rapid implementation of recommended changes.
    At an inter-agency level, the Departments are committed to 
instituting an optimal organizational design that prioritizes 
accountability and effectiveness, while continuing to advance unity, 
synergy, and efficiencies between VA and DoD. The Departments have 
instituted an inter-agency working group, facilitated by the 
Interagency Program Office, to review use-cases and collaborate on best 
practices for business, functional, and IT workflows, with an emphasis 
on ensuring that interoperability objectives are achieved between the 
two agencies. VA's and DoD's leadership meet regularly to verify the 
working group's strategy and course correct when necessary. By learning 
from DoD, VA will be able to address challenges proactively and reduce 
potential risks at VA's IOC sites. As challenges arise throughout the 
deployment, VA will mitigate adverse effects to Veterans' health care.

Federal Electronic Health Record Modernization

    DoD and VA are developing a Federal Electronic Health Record 
Modernization (FEHRM) joint governance strategy to further promote 
rapid and agile decision-making. This structure will maximize DoD and 
VA resources, minimize EHR deployment and change management risks, and 
promote interoperability through coordinated clinical and business 
workflows, data management, and technology solutions while ensuring 
patient safety. The FEHRM program office will be responsible for 
effectively adjudicating functional, technical, and programmatic 
decisions in support of DoD and VA's integrated EHR solutions. DoD and 
VA will jointly present the final construct of the plan to Congress, 
including our implementation, phase execution, and leadership plans.

Implementation Planning and Strategy

    It will take OEHRM several years to fully implement VA's new EHR 
solution and the program will continue to evolve as technological 
advances are made. The new EHR solution will be designed to accommodate 
various aspects of health care delivery that are unique to Veterans and 
VA, while bringing industry best practices to improve VA care for 
Veterans. Most medical centers should not expect immediate major 
changes to their EHR systems.
    VA's approach involves deploying the EHR solution at IOC sites to 
identify challenges and correct them. With this IOC site approach, VA 
will hone governance, identify efficient strategies, and reduce risk to 
the portfolio by solidifying workflows and detecting course correction 
opportunities prior to the deployment at additional sites. As 
mentioned, VA and Cerner have conducted Current-State Reviews for VA's 
IOC sites. These site assessments include a current-state technical and 
clinical operations review and the validation of the facility 
capabilities list. VA started the go-live clock for the IOC sites, as 
planned, on October 1, 2018.
    Further, VA is continuing to work proactively with DoD and experts 
from the private sector to reduce potential risks during the deployment 
of VA's new EHR by leveraging DoD's lessons learned from its IOC sites. 
Most recently, on May 29, 2019, VA held an Industry Day with over 750 
registered industry executives and leaders. OEHRM presented a status 
update on the program. Cerner and Booz Allen Hamilton joined OEHRM to 
inform eligible vendors on ways to potentially provide contracting and 
subcontracting support to the EHRM effort.
    VA is leveraging several efficiencies including revised contract 
language to improve trouble ticket resolution based on DoD challenges; 
optimal VA EHRM governance structure; fully resourced program 
management office with highly qualified clinical and technical 
oversight expertise; effective change management strategy; and using 
Cerner Corporation as a developer and integrator consistent with 
commercial best practices.
    During the multi-year transition effort, VA will continue to use 
Veterans Information System and Technology Architecture and related 
clinical systems until all legacy VA EHR modules are replaced by the 
Cerner solution. For the purposes of ensuring uninterrupted health care 
delivery, existing systems will run concurrently with the deployment of 
Cerner's platform while we transition each facility. During the 
transition, VA will ensure a seamless transition of care. A continued 
investment in legacy VA EHR systems will ensure patient safety, 
security, and a working functional system for all VA health care 
professionals.

Change Management and Workflow Councils

    Because the program's success will rely heavily on effective user-
adoption, VA is deploying a comprehensive change management strategy to 
support the transformation to VA's new EHR solution. The strategy 
includes providing the necessary training to end-users: VAMC 
leadership, managers, supervisors, and clinicians. In addition, there 
will be on-going communications regarding deployment schedule and 
anticipated changes to end-user's day-to-day activities and processes. 
VA will also work with affected stakeholders to identify and resolve 
any outstanding employee resistance and any additional reinforcement 
that is needed.
    VA has established 18 EHR Councils (EHRC) to support the 
development of national standardized clinical and business workflows 
for VA's new EHR solution. The Councils represent each of the 
functional areas of the EHR solution, including behavioral health, 
pharmacy, ambulatory, dentistry, and business operations. VA 
understands that to meet the program's goals we must engage frontline 
staff and clinicians. Therefore, the composition of the EHRCs will 
continue to be about 60 percent clinicians from the field who provide 
care for Veterans, and 40 percent from VA Central Office. As VA 
implements its new EHR solution across the enterprise, certain Council 
memberships will evolve to align with contemporaneous implementation 
locations. While deploying in a particular VISN, the needs of Veterans 
and clinicians in that particular VISN will be incorporated into 
national workflows.

Funding

    With the support of Congress, OEHRM has not experienced funding 
shortfalls that would impact the success of the EHRM initiative. 
Additionally, OEHRM appreciates Congress for providing the program with 
three-year funding availability. This flexibility in funding execution 
is critical, as it allows OEHRM to fund key operations on a timeline 
that aligns with a successful implementation.
    OEHRM's enacted fiscal year (FY) 2019 budget has allowed the 
program to continue the preparation of VA's EHR solution at VA's three 
IOC sites. VA's FY 2020 budget request of $1.6 billion would provide 
the necessary resources for the post Go-Live activities of the IOC 
sites, the in-process deployment of seven sites, 18 new site 
assessments, and 12 site transitions scheduled to begin in 2020.
    OEHRM reviews its lifecycle cost estimate at least once per month 
to reflect actual execution and to fulfill its programmatic oversight 
responsibilities. OEHRM will continue to provide Congress with regular 
updates to ensure that the program is fully funded and to support our 
commitment to transparency.

Conclusion

    Again, the EHRM effort will enable VA to provide the high-quality 
care and benefits that our Nation's Veterans deserve. VA will continue 
to keep Congress informed of milestones as they occur. Madam Chair, 
Ranking Member, and Members of the Subcommittee, thank you for the 
opportunity to testify before the Subcommittee today to discuss one of 
VA's top priorities. I am happy to respond to any questions that you 
may have.

                                 
                Prepared Statement of William J. Tinston
    Chairwoman Lee, Ranking Member Banks, and distinguished members of 
the Subcommittee, it is an honor to testify before you today. We 
represent the Department of Defense (DoD) as the Program Executive 
Officer and the Military Health System (MHS) Electronic Health Record 
(EHR) System Functional Champion responsible for modernizing the 
military's EHR and developing one EHR with the Department of Veterans 
Affairs (VA), which is also interoperable with private sector 
providers.
    The mission of the Program Executive Office, Defense Healthcare 
Management Systems (PEO DHMS) is to transform the delivery of health 
care and advance data sharing through a modernized EHR for 
servicemembers, retirees, and their families. As the information 
technology acquisition provider and part of the Defense Health Agency, 
we support the Quadruple Aim: improved readiness, better health, better 
care, and lower cost; specifically committing to three equally 
important objectives: deploy a single, common inpatient and outpatient 
EHR, eliminating the need for interoperability with the VA; improve 
data sharing with our private sector health care partners; and 
successfully transform the delivery of health care in the MHS through 
advanced tools that provide beneficiaries more control over their 
health care.
    In July 2015, the DoD competitively awarded a contract to the 
Leidos Partnership for Defense Health (LPDH) to deliver a modern, 
interoperable EHR capable of complying with DoD's high cyber security 
standards without compromising performance and designed to share data 
with our Federal and private sector partners regardless of their 
operational platform. This modern, secure, connected EHR, MHS GENESIS, 
provides a state of the market commercial off the shelf solution 
consisting, at its core, of Cerner Millennium, an industry-leading EHR, 
and Henry Schein's Dentrix Enterprise, a best of breed dental module.
    Delivering a capability of this magnitude is a monumental challenge 
and the DoD recognizes this. The deployment and implementation of MHS 
GENESIS is a complex business transformation that requires extensive 
coordination and communication with stakeholders and partners. 
Understanding the importance, the DoD worked directly with the 
functional and technical communities to capture requirements and 
standardize workflows, minimizing variation and increasing the 
capabilities available via an enterprise system.
    MHS GENESIS deployed to its pilot sites in 2017, beginning with 
Fairchild Air Force Base in February. Naval Hospital Bremerton and 
Naval Health Clinic Oak Harbor followed in the summer and our pilot 
officially concluded in January 2018 at Madigan Army Medical Center. 
These four pilot sites continue to use MHS GENESIS today and are safely 
delivering, managing, and documenting health care daily - completing 
more than 100,000 patient encounters each month.

Lessons Learned

    Deploying to the pilot sites provided an opportunity to observe the 
system and capture user feedback, the intended purpose of a pilot. No 
system is flawless, and deploying to a small clinic, progressing to a 
larger hospital allowed us to assess system performance at various 
levels of capability.
    In January 2018, PEO DHMS, along with the Defense Health Agency, 
implemented an eight week stabilization and adoption period to optimize 
MHS GENESIS, with a specific focus on improving network stability and 
medical device interfaces, governance, training, change management, and 
adoption of workflows.
    As with any transition, leadership is key. Ensuring the right 
people are in place to make decisions significantly impacts a 
successful site deployment. Understanding this, DHA established a 
clear, agile, and accountable management structure to provide guidance 
and policy for effective enterprise decisions. Further, DHA implemented 
processes to ensure network stabilization and medical device 
configuration prior to MHS GENESIS Go-Live.
    To address the change management and training challenges, we 
implemented three fundamental adjustments to the MHS GENESIS training 
strategy: functionally led workflow adoption; role based training 
configuration; and implementation of a peer expert training program.
    Going forward, MHS GENESIS will deploy using a Wave approach. This 
deployment strategy allows optimal use of lessons learned to enhance 
our efforts as we proceed through enterprise- wide deployment.

Progress and Patient Safety Enhancements

    Statistics revealed significant progress in 2018, ultimately 
improving patient care. For example, we avoided nearly 2,500 duplicate 
lab orders. Further, through new and effective decision support tools, 
MHS GENESIS equips our clinicians with the right tools and resources to 
evaluate a patient's status and quickly determine the best solution.
    Recently at Madigan Army Medical Center, the MHS GENESIS inpatient 
nursing management module alerted the staff to an emergent patient 
situation. The nurses responded to the patient's bedside, identified 
the distressed patient, and activated the rapid response team. The 
patient immediately transferred to the cardiac catheterization lab and 
received a life-saving procedure. This example illustrates the new 
record's improved capabilities over our legacy systems. There are 
markedly improved tools within MHS GENESIS to monitor care and measure 
improvement as well as monitor care to the individual provider. For 
instance, we can monitor the time a provider spends documenting care 
outside of duty hours (current less than 3% of the time). This allows 
us to identify providers experiencing challenges and focus our training 
efforts in this area. Further, with our VA partners, we are now 
connected to a wide range of commercial partners across the globe, who 
are collectively dedicated to improving care and interoperability 
within the DoD, VA, and the nation.

Joint Engagement

    The VA's decision to implement the same EHR as the DoD and the 
United States Coast Guard (USCG) will result in a single, common record 
enabling more efficient, highly reliable, safe, and quality care, 
ultimately protecting our most important asset - our people. The DoD 
does not take this lightly, and understands this decision comes with 
the practicality of implementation. A single, common record requires 
extensive collaboration and joint decision making to ensure efficient 
workflows and standardized processes.

Federal Electronic Health Record Modernization Working Group

    On September 28, 2018, the Secretaries of Defense and Veterans 
Affairs signed a Joint Commitment Statement pledging to align VA and 
DoD strategies to implement an interoperable EHR system. In response to 
this commitment, the DoD and VA evaluated program dependencies such as 
infrastructure, incorporation of clinical and business processes, and 
other requirements from the functional, technical, and programmatic 
communities. DoD and VA leadership determined the optimal and lowest 
risk alternative is to re-charter the DoD/VA IPO into the Federal 
Electronic Health Record Modernization (FEHRM) Program Office. The 
FEHRM, which will incorporate key members of the IPO as well as DoD and 
VA program office staff, will provide a more comprehensive, agile, and 
coordinated management authority to execute requirements necessary for 
a single, seamless integrated EHR.
    Another example, of the DoD and VA currently collaborating and 
sharing best practices via joint workshops which focus on system 
standardization and configuration versus customization.
    Specifically, the clinical nursing workshop recently completed an 
extensive process optimization review, identifying and agreeing to more 
than 2,300 workflow process optimizations, reducing nurse charting by 
70%. This significant time savings provides more time for our priority 
- the patient. A DoD clinical nurse at one of our pilot sites 
highlights the improvements provided via MHS GENESIS and our commitment 
to collaboration with the VA in the quote below.

    ``Modernization of the DoD Electronic Health Record was a 
necessity. MHS GENESIS became our opportunity. It shined a light onto 
the Military Health System, illuminating the best practices throughout 
the MHS and identifying areas in need of improvement. It caused us to 
breakdown not only the barriers between services and the barriers 
between the DoD and the VA, but also the barriers between all 
specialists within a hospital's or clinic's care continuum. Never 
before have I seen nurses, physicians, surgeons, and transfusion 
technicians sit side-by-side and collaborate as intensely as I witness 
daily with MHS GENESIS. Every day, multi-disciplinary teams work across 
the pilot sites and the country to bring timely, relevant, evidenced-
based practice to MHS GENESIS. This is more than an Electronic Health 
Record; it is a collaborative health record serving our nation's 
Service Members, Veterans, and beneficiaries. There is much work to be 
done to deploy and optimize MHS GENESIS, but it has been a great leap 
forward in support of the health care of this deserving population.''

Joint Solutions

    Cybersecurity, the foundation of a joint solution, demands 
practical implementation. The DoD sets the standard for cybersecurity, 
and we invested significant time and resources to satisfy those 
requirements. By co-locating personnel at one commercial DoD/VA data 
center, our people assist with continuous cyber monitoring and are 
engaged in maintaining cyber integrity. Further, this strengthens the 
collaborative Federal and commercial relationship, encouraging the VA 
to leverage these capabilities and actively participate in critical 
activities to uphold the DoD cybersecurity standards. The continuous 
collaborative cyber work will not only benefit DoD and VA users, but it 
will contribute to the development of national standards, raising the 
bar for protecting the patient health information.
    Further, the DoD and VA established workgroups which consists of 
cross-organizational representatives who resolve technical challenges 
and establish new processes to identify enterprise solutions and 
opportunities for both Departments to leverage. They work together to 
minimize the impact to both Department's schedules and ensure the most 
efficient use of program resources. For example, the DoD agreed to 
accept a Cerner software upgrade only a few weeks following its Wave 1 
Go-Live to ensure VA fields its desired baseline solution to meet its 
scheduled Initial Operational Capability Go-Live in March of 2020. The 
timing of the upgrade adds complexity and risks to DoD's Wave 1, but it 
is the right decision for the DoD and VA's successful implementation.

Patient Centered Delivery

    Patient centered delivery relies on the continued advancement of 
system capabilities, while maintaining system integrity and patient 
data throughout the life of the patient. To support this effort, the 
DoD and VA agreed to the joint execution of HealtheIntent, a data 
warehouse and analytics platform which captures all patient data and 
migrates it into a single, common record that stays with the patient 
throughout their lifetime. Once executed, the Departments agreed to 
numerous decisions, including a joint URL which required collaborative 
decision making.
    Continuous delivery demands established processes to address system 
enhancements and maintain the integrity of the system baseline and the 
hosting environment. Recognizing the significance, the DoD and VA 
established a joint decision making process to evaluate any request 
that would modify the technology solution, ensuring the practical 
implementation of an enterprise solution.

Conclusion

    MHS GENESIS is on track for full deployment by the end of calendar 
year 2023. In December 2018, the DoD EHR Defense Acquisition Board met, 
and the Assistant Secretary of Defense for Acquisition affirmed MHS 
GENESIS met the criteria for approved deployment to Waves 1-6 beginning 
with Wave 1 in September 2019. The DoD and VA remain committed to 
continued communication and collaboration to ensure the successful 
implementation of a single, common record throughout the MHS, the USCG, 
and the VA.

                                 
               Prepared Statement of Dr. Lauren Thompson
    Chairwoman Lee, Ranking Member Banks, and distinguished members of 
the subcommittee, thank you for the opportunity to testify before you 
today. As the Director of the Department of Defense/Department of 
Veterans Affairs Interagency Program Office (IPO), I am honored to be 
here today. The mission of the DoD/VA IPO is to advance data 
interoperability across DoD, VA, and other partner systems. Providing 
high-quality health care to service members, veterans, and their 
families is one of the IPO's highest priorities, and health data 
interoperability is essential to improving the care delivered. A key 
component meeting the unique needs of our beneficiaries and ensuring 
they receive the best care possible, is making certain that no matter 
their status, location, or provider, their health data is readily 
available and accurate, or in other words ensuring health data 
interoperability-the ability of two or more systems or components to 
exchange information and to use the information that has been exchanged 
in a meaningful way.
    The DoD and VA represent two of our nation's largest health care 
systems. Together, the Departments represent over 30 million eligible 
beneficiaries including service members, veterans, and their families. 
A significant amount of their care is provided via the private sector, 
providing more than 60 percent of DoD care and 30 percent for the VA. 
Currently, the Departments share more than 1.5 million data elements 
daily, and more than 430,000 DoD and VA clinicians are able to view the 
real-time records of the more than 16 million patients who receive care 
from both Departments.
    The Fiscal Year 2008 National Defense Authorization Act (NDAA) 
directed the DoD and VA to develop and implement electronic health 
record (EHR) systems or capabilities that allow for full 
interoperability of personal health care information between the DoD 
and VA, instructing the establishment of the IPO to guide both 
Departments in their efforts. In January 2009, the IPO completed its 
first charter, sharing its mission and functions with respect to 
attaining interoperable electronic health data. In March 2011, both 
Secretaries of Defense and VA instructed the Departments to develop a 
single, jointly integrated EHR. In 2013, the Departments decided to 
pursue modernization of their respective EHR systems instead. In 
December 2013, the IPO was re-chartered to lead the efforts of the DoD 
and VA to implement national health data standards for interoperability 
and to establish, monitor, and approve clinical and technical standards 
for the integration of health data between both Departments and the 
private sector.

INTEROPERABILITY AND DATA SHARING

    The IPO's goal is to support interoperability of clinically 
relevant health data in accordance with the FY 2014 NDAA, and in 
compliance with The Office of the National Coordinator for Health IT's 
(ONC) guidance on standards and interoperability for clinical records. 
Specifically, the IPO is chartered to jointly oversee and monitor the 
efforts of the DoD and VA in implementing national health data 
standards and act as the point of accountability for identifying, 
monitoring, and approving the clinical and technical data standards and 
profiles to ensure seamless integration of clinically relevant health 
data between the Departments and private sector providers who treat DoD 
and VA beneficiaries.
    In April 2016, the Departments, with the IPO's assistance, met a 
requirement of the Fiscal Year 2014 NDAA, certifying to Congress that 
their systems are interoperable with an integrated display of data 
through the Joint Legacy Viewer, or JLV. JLV integrates data from the 
clinical data repositories of both Departments, as well as data on 
beneficiary encounters with private providers who participate in 
national health information exchange networks. The Departments also 
share documents and images with each other and private providers 
through DoD and VA data exchange and access services. The IPO monitors 
the usage of JLV and other interoperability metrics across the 
Departments to track progress on health data exchange and 
interoperability.
    The IPO also serves a convening function, facilitating functional 
and technical discussions across the Departments and interoperability 
information exchange forums with industry. As executive secretary to 
the DoD/VA Interagency IT Steering Committee, a joint CIO-led body, the 
IPO works to ensure DoD and VA's technical alignment, planning, and 
implementation oversight of technical infrastructure and enterprise 
solutions meet the business needs of joint activities.
    The IPO collaborates extensively with ONC, other government 
agencies, and standards development organizations to advance the state 
of interoperability across the health industry. IPO staff participate 
in ONC work groups, and IPO and ONC leaders meet regularly to discuss 
current interoperability initiatives and future collaboration 
opportunities to support national interoperability efforts.

FEDERAL ELECTRONIC HEALTH RECORD MODERNIZATION PROGRAM OFFICE

    In 2018, Secretaries Wilkie and Mattis issued a Joint Commitment 
Statement pledging to align strategies to implement an integrated EHR 
system. DoD and VA leaders chartered the Joint Electronic Health Record 
Modernization Working Group, referred to as the JEHRM, to develop 
recommendations for an optimal organizational construct that would 
enable an agile, single decision-making authority to efficiently 
adjudicate functional, technical, and programmatic interoperability 
issues while advancing unity, synergy, and efficiencies.
    On March 1, 2019, the joint VA/DoD Executive Leadership Group 
approved a course of action, plan of action and milestones, and 
implementation plan to establish the Federal Electronic Health Record 
Modernization Program Office, or the FEHRM, in a phased manner in order 
to minimize risk. Leveraging the existing 2008 and 2014 NDAA Statute, 
the IPO will be re-chartered into the FEHRM and will provide a 
comprehensive, agile, and coordinated management authority to execute 
requirements necessary for a single, seamless integrated EHR and will 
serve as a single point of authority for Department's EHR modernization 
program decisions. FEHRM leaders will have the authority to direct each 
Department to execute joint decisions for technical, programmatic, and 
functional functions under its purview and will provide oversight 
regarding required funding and policy as necessary. This management 
model creates a centralized structure for interagency decisions related 
to EHR modernization, accountable to both the VA and the DoD Deputy 
Secretaries.
    An interim FEHRM Director and Deputy Director will be appointed to 
work with the implementation team in transitioning joint functions into 
the FEHRM once the FEHRM has an approved charter. The interim leaders 
will manage and execute joint technical, programmatic, and functional 
requirements and synchronize strategies between the two Department EHR 
program offices to ensure the single, seamlessly integrated EHR is 
implemented with minimal risks to cost, performance, and schedule. The 
interim leaders will remain in these roles until the permanent FEHRM 
Director and FEHRM Deputy Director are appointed.
    The permanent Director and the Deputy Director will report to the 
Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs.

CONCLUSION

    The IPO will continue to support the Departments in implementing a 
single EHR system to ensure a seamless patient-centric health care 
experience that will ultimately lead to improved care for our service 
members, veterans, and their families.
    Enhancing interoperability with private providers who provide care 
to DoD and VA beneficiaries will be of the utmost importance during 
this process to ensure the availability of a complete and comprehensive 
longitudinal health record.
    We will continue our collaboration with ONC and industry partners 
to ensure the DoD and VA are employing the most current industry 
standards, and our industry partners are able to learn from our 
experiences.
    Thank you for the opportunity to speak with you today. I look 
forward to your questions.

                                 [all]