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



 
VISTA TRANSITION: ASSESSING THE FUTURE OF AN ELECTRONIC HEALTH RECORDS 
                                PIONEER

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

                                HEARING

                               before the

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                 of the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, JULY 25, 2019

                               __________

                           Serial No. 116-28

                               __________

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



        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                            ______
 
             U.S. GOVERNMENT PUBLISHING OFFICE 
40-857                WASHINGTON : 2021         


        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

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

                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 
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both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
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further refined.


                            C O N T E N T S

                              ----------                              

                        Thursday, July 25, 2019

                                                                   Page

Vista Transition: Assessing The Future Of An Electronic Health 
  Records Pioneer................................................     1

                           OPENING STATEMENTS

Honorable Susie Lee, Chairwoman..................................     1
Honorable Jim Banks, Ranking Member..............................     2

                               WITNESSES

Dr. Paul Tibbits, Executive Director, Office of Technical 
  Integration Office of Information and Technology, Department of 
  Veterans Affairs...............................................     4
    Prepared Statement...........................................    21

        Accompanied by:

    Mr. Charles C. Hume, Acting Assistant Deputy Under Secretary 
        for Health for Office of Health Informatics, Veterans 
        Health Administration, Department of Veterans Affairs

    Dr. Thomas O'Toole Senior Medical Advisor, Office of the 
        Assistant Deputy Undersecretary for Health for Clinical 
        Operations, Veterans Health Administration, Department of 
        Veterans Affairs

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

Ms. Carol Harris, Director, Information Technology Acquisition 
  Management, Government Accountability Office...................     5
    Prepared Statement...........................................    28


VISTA TRANSITION: ASSESSING THE FUTURE OF AN ELECTRONIC HEALTH RECORDS 
                                PIONEER

                              ----------                              


                        Thursday, July 25, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:15 a.m., in 
Room 210, House Visitors Center, Hon. Susie Lee [Chairwoman of 
the Subcommittee] presiding.
    Present: Representatives Lee, Lamb, Cunningham, Banks, and 
Watkins.

           OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN

    Ms. Lee. Good morning. Thank you all for being here. This 
hearing will now come to order.
    During the '70s, a dedicated group of programmers and 
clinicians began a health care transformation as they built 
what would become the Veterans Health Information Systems and 
Technology Architecture, or what we know as VistA. It was the 
beginning of an age of personal computer and these IT pioneers 
saw the potential for bringing computing power to the health 
care space. The Department of Veterans Affairs was an early 
innovator and adopter of the electronic medical record, and 
established itself as a leader in health care IT.
    Today, we have clinicians and researchers across VA using 
IT tools and powerful health data to improve care and find 
medical breakthroughs. However, the VA is at a technology 
crossroads and what began as a guerilla IT project has sprawled 
into a massive, decentralized system in an archaic coding 
language, and within the VA, there are at least 130 versions or 
instances of VistA across 1500 sites. No version is the same 
and the system connects to various applications and devices 
through interfaces.
    VistA serves many offices, programs, staff, and veterans, 
but it has surpassed its technology life span.
    VA has struggled to modernize VistA and past attempts to 
replace it or update it have not been successful, and now the 
VA is pursuing an approach with the acquisition of a commercial 
electronic health records system. However, the transition from 
one system to another is not a simple matter of just flipping 
the switch; it is a painstaking process that you all are aware 
of and that involves technical challenges, as well as policy 
changes. There are many stakeholders who want to understand the 
impacts of the transition and how their equities in VistA will 
be affected.
    VA has told the Subcommittee that there is a plan in draft 
to address both the technical and policy side of the transition 
from VistA to Cerner's electronic health record, but that plan 
is not expected to be completed until the fall of 2019. This 
plan will require the concurrence of the Office of Information 
and Technology, the Veterans Health Administration, and the 
Office of Electronic Health Record Modernization.
    There are many unknowns in this transition. It is important 
that the VA's strategy be well timed to identify those unknowns 
and to mitigate potential disruptions to the health care and 
research. The fact that this plan is still being formulated is 
concerning. Further, as the Government Accountability Office 
will discuss today, the VA does not yet have a reliable 
accounting of all the costs associated with VistA management, 
and there is still ongoing work to understand all of the 
instances of VistA and to define them. We also need the VA to 
arrive at a transparent and accountable decision as to what 
VistA management will mean going forward, so that there are not 
gaps in care, that valuable research is not disrupted, and that 
expectations are established and met.
    VistA cannot remain a static system over the 10 years that 
EHRM implementation will take. And, additionally, at least 40 
percent of VistA will not be in Cerner, and this Subcommittee 
would like more information how VA will manage those 
functionalities and potentially modernize them in the future.
    We think there are opportunities for VA to be forward-
thinking in the transition and to harness the innovative 
approach that drove the creation of VistA. The pilot to move 
instances of VistA to the cloud has potential, but we need more 
information to understand its feasibility from a cost and 
impact perspective. At minimum, we need to maintain the legacy 
system until it has been fully replaced or modernized, but if 
there are potential efficiencies and health care innovations to 
be gained, we should identify them and also consider those 
opportunities.
    I thank all of the witnesses for being here today and look 
forward to your testimony. And I now would like to recognize my 
colleague Ranking Member Banks for 5 minutes to deliver his 
opening remarks.
    Mr. Banks?

         OPENING STATEMENT OF JIM BANKS, RANKING MEMBER

    Mr. Banks. Thank you, Madam Chair.
    It is no longer possible to talk about VistA without 
discussing Cerner and vice versa. Although the goal of VA's 
electronic health record modernization is to replace VistA and 
CPRS, these legacy systems will exist alongside Cerner for at 
least the next 9 years; that means they have to interoperate. 
This mixed environment will be extremely challenging, in which 
some medical centers will still use VistA while others use the 
Cerner EHR.
    Up until now, this Subcommittee has focused on the total 
cost of ownership of VistA versus the total cost of 
implementing and operating Cerner. I still believe that is an 
important question and one we have yet to receive a 
satisfactory answer to, but the complexity of the mixed 
environment is the biggest difficulty confronting VA.
    Some key questions are, how will the Cerner data flow back 
into VistA? How will scheduling information be integrated 
across the two environments? Will referrals be transmitted 
uniformly in both systems? And how will different data be 
aggregated for reporting an analysis?
    We are still in the middle of the beginning of the EHRM 
overall, but VA is nearing the end of its plan design and 
configuration process; in other words, the rubber is hitting 
the road.
    With the MISSION Act implementation deadline behind us, the 
Veterans Health Administration and the Office of Information 
Technology appear to be reallocating personnel and executive 
attention to EHRM, and that is very good news. VA just 
completed the sixth of eight National Workflow Council 
meetings. New technical obstacles are being identified, 
especially with the data migration into Cerner and 
interoperability in this mixed environment.
    At the outset of EHRM, the team made ambitious promises to 
migrate substantially more patient data into Cerner than DoD 
determined was feasible in MHS GENESIS. That optimistic plan 
seems to have run into technical difficulties. This is not a 
foregone conclusion and there may be good reasons why; I hope 
to get explanations for that this morning.
    Relatedly, Cerner's Healthy Intent Population Health 
Software seems to have morphed from a vehicle for feeding data 
into the Millennium EHR to another repository of patient data 
that clinicians may have to access alongside community. Without 
a doubt, snags like this are inevitable in a project of this 
magnitude. The timeline is getting tight, but the important 
thing is that constraints are acknowledged and any tradeoffs 
that must be made to resolve them are presented transparently.
    On the other hand, everyone in VA always expected that 
created the system interfaces between VistA and Cerner would be 
a tall order. There are 73 different groups of interfaces 
ranging in size and difficulty.
    I am glad to see OIT assign more personnel, including some 
of their very best people, to this effort. I want to know how 
this work is being organized and whether it is being approached 
in a manner that will reduce rather than add complexity in the 
mixed environment. I am skeptical, though, that all the 
technical constraints are known and there aren't more 
intractable difficulties waiting to be discovered.
    As we pass through September and the end of the plan design 
and configuration process for EHRM, VA may be presented with a 
choice, a choice to take the system live more quickly with 
initial, some would say limited sets of capabilities, or 
proceed more gradually with a complete set of capabilities. I 
expect that decision to be made in VHA based on input from the 
affected medical centers and I will support the decision 
wholeheartedly if I believe it is made for the right decisions.
    So with that, Madam Chair, I yield back.
    Ms. Lee. Thank you, Mr. Banks.
    I would now like to introduce the witnesses we have before 
the Subcommittee today. Dr. Paul Tibbits is the Executive 
Director of the Office of Technical Integration within the 
Office of Information and Technology at the Department of 
Veterans Affairs. Dr. Tibbits is accompanied by Charles Hume, 
Assistant Deputy Under Secretary for Health for the Office of 
Health Informatics, and Dr. Thomas O'Toole, who is the Senior 
Medical Advisor both within the Veterans Health Administration, 
as well as John Short, Chief Technology and Integration Officer 
in the Office of Electronic Health Record Modernization.
    I would also like to introduce Carol Harris, who is the 
Director of Information Technology Acquisition Management at 
the Government Accountability Office.
    We will now hear the prepared statements from our panel 
Members. Your written statements in fact will be included in 
the hearing record. And, without objection, Dr. Tibbits, you 
are recognized for 5 minutes.

                   STATEMENT OF PAUL TIBBITS

    Dr. Tibbits. Good morning, Chairwoman Lee, Ranking Member 
Banks, and Members of the Subcommittee. Thank you for the 
opportunity to testify today about the Department of Veterans 
Affairs IT modernization efforts, including the electronic 
health record modernization and VistA, also the program you 
mentioned earlier.
    The Office of Information and Technology pioneered VistA to 
support the clinical, administrative, and financial operations 
of the Veterans Health Administration. Since its creation, 
VistA has evolved into an enterprise planning tool, used by 
multiple VA administrations. Today, VistA supports over 150 
applications and the operations of more than 1500 VA clinics 
and VA medical centers. There are 130 unique instances of VistA 
nationwide that share core functionality, but are customized to 
each VAMC's needs and populations.
    VistA has served VA and veterans for over 40 years, but it 
does not possess the modern capabilities that medical providers 
and veterans deserve. VistA's required critical upgrades alone 
could cost several billion dollars over the years and 
maintenance costs are higher. It is not interoperable with the 
Department of Defense, which keeps the health information of 
servicemembers and future veterans; instead, VA staff must use 
separate viewers to see the DoD data.
    In May of 2018, VA awarded Cerner a contract to replace 
VistA with Cerner Millennium, a commercial, off-the-shelf 
solution currently deployed by the Department of Defense. VA is 
working with Cerner to achieve initial operating capability and 
deploy Cerner Millennium beginning in the spring of 2020 in the 
Pacific Northwest.
    As the nationwide Cerner rollout progresses, VA will 
decommission VistA instances as necessary. However, during the 
transition period, VA must maintain VistA to ensure current 
patient record accessibility and continued delivery of quality 
care.
    The cost of sustainment. GAO's report projects VA will 
spend $426 million to sustain VistA in fiscal year 2019. VA is 
currently developing a methodology to update the cost data and 
thereby define VistA, a recommendation in the GAO report.
    We expect VistA to run without service degradation until 
all VAMCs are running in the new electronic health record 
solution. Sustainment costs during the transition include 
development for new capability and interfaces, congressional 
mandates, maintenance, and other costs.
    The estimated minimum costs for VistA during the 10-year 
transition period is $4.89 billion, excluding any new required 
development.
    Our long-term strategy. VA is leveraging more efficient 
means of sustainment, including OI&T's shift to a development 
and operations approach that develops, enhances, maintains, and 
rolls out better products more quickly. VAMCs will be required 
to run the nationally-released gold version of VistA, creating 
a common set of software routines where possible.
    OI&T follows VA's guidance on needed patches and upgrades 
to VistA. These will continue as normal throughout the rollout 
of Cerner.
    The newly-formed Office of Technical Integration 
facilitates communication and planning between program offices 
that are implementing the systems to replace VistA. OI&T is 
currently piloting a program to migrate all 130 instances of 
VistA to the cloud.
    In conclusion, until the new electronic health record 
solution is implemented across the VA enterprise, VistA remains 
VA's authoritative source of veteran data. Sustaining VistA for 
the duration of the electronic health modernization ensures 
that VA continues to provide uninterrupted care and services.
    Madam Chair, Ranking Member, Members of the Subcommittee, 
thank you for the opportunity to appear before you today to 
discuss OI&T's progress towards VistA transition. I look 
forward to continuing to work with the Subcommittee to address 
our greatest priorities.
    This concludes my testimony and I look forward to answering 
your questions.

    [The prepared statement of Paul Tibbits appears in the 
Appendix]

    Ms. Lee. Thank you.
    Now Ms. Harris?

                   STATEMENT OF CAROL HARRIS

    Ms. Harris. Thank you. Chair Lee, Ranking Member Banks, and 
Members of the Subcommittee, thank you for inviting us to 
testify today on VA's health information system, referred to as 
VistA. As requested, I will briefly summarize the findings from 
our report on this very mission-critical system.
    VA provides health care services to roughly 9 million 
veterans and their families and relies on VistA to do so; 
however, the system is over 30 years old, is costly to 
maintain, and does not fully support exchanging health data 
with DoD and private health care providers. As such, VA has 
work underway to replace the system with a commercial one; 
however, the Department plans to continue using VistA during 
its decade-long transition to the new system. This morning, I 
would like to highlight three key points from our report.
    First, VA lacks a comprehensive definition of VistA, but 
additional work is planned that could address the gaps. To 
maintain internal control activities over an IT system and its 
related infrastructure, organizations should be able to define 
the physical and performance characteristics of the system, as 
well as the environment in which it operates.
    VA maintains multiple documents and a database that 
describes parts of VistA; it has also conducted multiple 
analyses to better understand customization of the system 
components at various medical facilities, yet the existing 
information in aggregate does not provide a thorough 
understanding of the local customizations reflected in about 
130 versions of VistA that support health care delivery at more 
than 1500 sites. According to program officials, the 
decentralization of VistA's development is a reason why they 
have not been able to fully define it.
    Cerner's contract to provide the new electronic health 
record system calls for the company to conduct comprehensive 
assessments to identify site-specific requirements where its 
system is to be deployed. Three site assessments have been 
completed thus far and additional ones are planned. If these 
assessments provide a complete understanding of the 130 VistA 
versions, the Department should be able to define VistA and be 
better positioned to transition to the new system.
    Now my second point. VA believes VistA has cost $2.3 
billion between 2015 and 2017, but this figure is neither 
reliable nor comprehensive. VA can only reliably account for 1 
billion of the $2.3 billion total. The source data for the 
remaining $1.3 billion, which largely accounted for VistA's 
infrastructure, related software, and personnel costs were not 
well documented. As a result, VA's subject matter experts were 
unclear on how to account for VistA versus non-VistA costs. 
Furthermore, the Department omitted costs related to additional 
hosting and data standardization and testing from the total 
spend.
    Given these issues, the Department is not in a position to 
accurately report annual costs to develop and sustain VistA. As 
such, VA lacks reliable information needed to make critical 
management decisions for sustaining the many versions of VistA 
over the next 10 years until Cerner is fully deployed.
    My third point. VA has initiated a number of activities to 
transition from VistA to the Cerner system. Among other things, 
VA has taken steps to establish and staff a program office, as 
well as form a governance structure. The Department's actions 
in these critical areas are ongoing. Furthermore, additional 
actions are in progress to address our recommendations from 
September 2018 to clearly define the role and responsibilities 
of the Joint DoD and VA Interagency Program Office.
    As the Department continues to work toward acquiring a new 
electronic health record, it will be important for VA to fully 
implement the recommendation we made in our report for 
improving the reporting of VistA costs. Doing so is essential 
to helping ensure that decisions related to the current system 
are informed by reliable cost information.
    That concludes my statement and I look forward to 
addressing your questions.

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

    Ms. Lee. Thank you. I would now like to recognize myself 
for 5 minutes to ask questions and I will first start with Ms. 
Harris.
    In your report, you just stated that the VA identified $2.3 
billion in VistA costs between 2015 and 2017, yet only--VA 
couldn't demonstrate reliability on $1.3 billion of that 
alleged VistA expenses. Can you explain the significance of 
what that lack of reliability means?
    Ms. Harris. Sure. Chair Lee, more than half of VA's 
reported $2.3 billion costs couldn't be verified based on the 
source data that we looked at in our review and this is of 
concern, because without reliable information VA will not be in 
a position to make critical management decisions about the 
system and the system will be sustained for the next 10 years. 
So that is the major problem.
    Ms. Lee. In your opinion, based on your past work with VA, 
do you expect the actual VistA-related costs to be more or less 
than the $2.3 billion?
    Ms. Harris. It will likely be more than the $2.3 billion, 
because VA has omitted key costs from that 2.3 initial estimate 
that they provided to us, things like additional hosting as one 
example.
    And just as an example of that with the additional hosting, 
last June the VA told us the cost for this particular line item 
was about $238 million per year. Shortly thereafter, they told 
us that the cost was actually $950 million, and in the end, 
they reported zero dollars per year. And so when we talked to 
VA's subject matter experts, they agreed that the $950 million 
was off base, but the fact that that additional hosting line 
item was not included in the $2.3 billion estimate suggests 
that the number is higher.
    Ms. Lee. Okay. Thank you.
    And the GAO, you made a recommendation in your report. And, 
Dr. Tibbits, I would like to ask, will the VA concur with that 
recommendation and how do you plan to address this cost-
reliability issue?
    Dr. Tibbits. Great, Chairwoman Lee. Yeah, absolutely, our 
concurrence is on the way in. I, in fact, saw the signed-out 
version a few days ago. So, yes, we intend to fully concur with 
the report and the recommendations.
    I guess I should introduce here the notion of the 
Technology Business Management framework, TBM. TBM is the 
framework that we are using with to properly categorize and 
classify information technology costs, we are working very 
closely with OMB to implement that framework. Our fiscal year 
2021, in September of this year, will be submitted in 
accordance with that TBM framework.
    As you might well imagine, a certain maturation will go on. 
The first implementation of that might require additional 
refinements and enhancements later on for sure, but we intend 
to fully comply with that TBM standard and, in so doing, 
address the GAO findings and recommendations.
    Ms. Lee. Thank you for that. I am happy to hear that, but I 
want to know, what has prevented the VA from implementing this 
cost methodology in the past?
    Dr. Tibbits. Well, let me separate my answer into two 
parts. First of all, this cost methodology that I just 
mentioned is relatively new as a commercial standard. It began 
around 2012 and I don't remember exactly when between 2012 and 
now, but somewhere in there OMB decided to make it a Federal 
standard. I don't know exactly when that happened, though, but 
I would say the TBM standard itself is relatively new. That is 
one part of my answer. The other part is, fiscal discipline 
with respect to information technology has been evolving over 
time; we are very interested in improving it all the time. We 
have been on a trajectory to try to improve it over time, 
hence, we fully agree with the GAO recommendations.
    Some of the methodology we have used, for example, on the 
personnel cost that the GAO representative mentioned, we have 
not up to now seen the need, I guess I would say, to classify 
personnel costs by system. So we have personnel costs and we 
have system costs, but mapping personnel costs to system costs 
is not something we have done up to now. So we will in the 
future, obviously, consistent with this TBM framework, but that 
is a matter of those mappings and things that just were not 
considered necessarily high priority at the time. I can't tell 
you further why that was, it is just about I have exhausted my 
knowledge on the subject.
    Ms. Lee. All right, thank you. And I am out of my time and 
I now recognize Congressman Banks.
    Mr. Banks. Thank you, Madam Chair.
    Dr. Tibbits, in your testimony you seem to have adopted 
figures that GAO says is unreliable: four hundred and twenty 
six million dollars to sustain VistA for 2019 and $4.89 billion 
over the next 10 years, which is roughly ten times the 2019 
number. Do you stand by the VistA cost information that VA gave 
to GAO?
    Dr. Tibbits. Yes, it is the using the--for the parts that 
GAO is referring to that are unsubstantiated, we had to use 
some form of estimation methodology; we did that, and it is the 
best we can do at the time up to now. That will certainly 
improve over the future as we move further into implementation 
of this TBM framework, but--
    Mr. Banks. Ms. Harris--
    Dr. Tibbits [continued]. --those are the best numbers we 
have at the time, yes.
    Mr. Banks [continued]. --do you have a response to that or 
anything to add to that?
    Ms. Harris. The number that was reported, the $2.3 billion 
number, was never intended to be projectable, because it is 
not, and the $2.3 billion number is not reliable; only 1 
billion of that figure was found to be reliable. So the 
projections that Dr. Tibbits stated does not come from the GAO 
report.
    Mr. Banks. Okay, interesting.
    Dr. Tibbits, the purpose of figuring out how much VistA 
costs is to compare it to Cerner, but I don't see VA making 
much effort to argue that EHRM is going to save money, all 
things considered. Is there ever going to be a business case 
demonstrating savings even over the very long term or is that 
just unrealistic?
    Dr. Tibbits. Well, obviously, with--first of all, with 
respect to the TBM framework, again, certain Cerner costs will 
be incorporated into that TBM framework. So, from a 
transparency perspective, it will be included in all of our IT 
reporting. That said, the major motivation for going to Cerner, 
as I think all of you are aware of from the determination and 
findings, is to strengthen information interoperability with 
the Department of Defense.
    So, yes, what the cost will turn out to be is very 
important. We certainly will make a great effort to make that 
very clear to whoever needs to know what that is, for our own 
internal management purposes as well. But, as I say, it is the 
well-being of the servicemember and veteran that is our 
principal motivation for going to Cerner, not necessarily an 
economic argument.
    Mr. Banks. Okay, let's move on.
    Mr. Short, has it been decided whether to keep VA's My 
Healthy Vet patient portal and integrate it with Cerner, or 
adopt the Cerner patient portal and integrate it with VistA, in 
the mixed environment?
    Mr. Short. Sir, at initial IOC go-live we will be rolling 
out the Cerner patient portal the same as DoD rolled out. While 
we are doing that, there is the initial enhancements going on 
in the patient portal for all the requirements that the 
Connected Care My Healthy Vet team has laid out with our 
program office.
    In addition to that, Dr. Kroupa, myself, and the Office of 
Connected Care are doing a review currently and we will over 
the next couple months on what is the final answer to your 
question, and that is, will we integrate into My Healthy Vet or 
will we take all that functionality and put it in the 
commercial platform to make sure that it is a seamless, 
integrated view for the veteran.
    Either way that goes, it will be integrated into the VA.gov 
portal, so all the veterans can go to one place, have one 
experience to access their health care.
    Mr. Banks. Okay. So, Dr. O'Toole, is VHA confident that the 
Cerner patient portal can integrate with VistA in all respects 
and meet your needs?
    Dr. O'Toole. The driving force for all of this is to 
ensure, particularly during the IOC Block 1 and Block 2 
implementations, is that the local facilities and local 
facility leadership and front-line providers are going to be 
comfortable with the interface with Cerner and that front-line 
clinicians will feel confident that patient safety will not be 
compromised, and that is really our driving force.
    To date and through the workshop processes and through the 
local workshop efforts, all indications are that the patient 
safety and patient care will not be compromised and will be 
done efficiently, but this is something that we are monitoring 
closely, and this is something that clearly is of highest 
priority moving forward.
    Mr. Banks. Okay. So, Mr. Short, I would be remiss if I 
didn't ask you about the firm, it still has not been 
established. When is this supposed to happen? And, given the 
continued delay, how has the timeline for it to evolve into its 
various stages of operating capability changed?
    Mr. Short. Sir, I can tell you that there is continual 
meetings on a weekly basis with DoD and VA. There may be a week 
or two here and there because of schedules that they did not 
meet, but routinely they meet on a regular basis and they are 
continuing to make progress. I know that some of the dates and 
announcements haven't come that the Hill has requested. I will 
have to take that question for the record; I don't have any new 
dates.
    Mr. Banks. My time has expired.
    Ms. Lee. Thank you.
    I now recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Dr. Tibbits, I think it is a little hard for 
veterans in particular to understand how we are going to spend 
$5 billion over 10 years on a legacy system that we are trying 
to replace when the cost of the new system is $10 billion. I 
mean, essentially, we are spending half of what we are doing on 
the new system to just maintain the old one and that may not 
even represent all the costs.
    So can you explain to me how I can explain to veterans in 
my community, what are the drivers of that cost to maintain and 
upgrade and sustain VistA over the next decade? What is making 
us spend the bulk of that $5 billion?
    Dr. Tibbits. Yes, certainly. Thank you for your question.
    Well, first of all, I think everyone understands and we 
have had this, I think, out there for broad-based 
understanding, the complexity of VistA itself due to its age 
and that complexity drives costs. So understanding the 
interconnections--understanding and deal with the 
interconnections inside of VistA, understanding what to put a 
new capability into VistA, understanding break-fix work in 
VistA is complicated. However, to your point, that high 
maintenance cost, if you will, is part of the concern of what 
led us to the conclusion on top of the information 
interoperability, which was our primary reason, but getting out 
of the complexity and costs driven by that complexity is part 
of the reason why we wanted to move out of VistA.
    That said, it is a 10-year period. We have to account for 
time to learn lessons as we go through this implementation 
process and at the same time, as you recognize, we have to 
continue to deliver quality care to veterans at the sites that 
have not yet received Cerner--
    Mr. Lamb. But I guess are there any particular tasks or 
contractors that drive that $5 billion cost more than others? I 
mean, it is one thing to say it is complexity, yes, I 
understand that, but how does it end up being $5 billion? It 
just seems like so much.
    Dr. Tibbits. Well, that is not dramatically different in 
any way than our past experience and I would say, no, there is 
not any particular one contractor. The answer to the veterans' 
question that you asked me is to maintain quality service for 
those veterans at the places that haven't received Cerner, that 
is the bottom-line answer to a veteran. But, no, it is not one 
particular contractor; it is the overall complexity.
    We have a network, a mosaic of contractors that are 
supporting VistA, keeping it up and running, and we--I guess I 
should hasten to add here, however, our migration to the cloud 
for VistA, we are anticipating cost savings from that migration 
to the cloud, which the first instance we have now successfully 
completed. So we believe that the remaining will be an equally 
efficient and effective migration. That will serve to keep the 
ongoing maintenance costs under control, I guess I can say.
    Mr. Lamb. Okay. Ms. Harris, I know this is an issue you 
have stayed with for a long time, the EHR implementation and 
everything, was this foreseen 5, 10, 15 years ago, whenever? 
Did we understand in the past what we were spending on VistA 
and was that used as an argument that maybe we should have 
started this whole replacement earlier? Can you give me a 
little bit of the history on that?
    Ms. Harris. Well, with regards to VistA, I mean, even at 
this time right now, VA is unable to draw a circle around it 
and that is something that has persisted over the past 10--
since the inception of VistA, because of the decentralized 
nature of how VistA was developed. And as a result of that 
decentralization, which began in the '80s, VA is not in a 
position to be able to at least effectively draw that circle 
and that perimeter around what is and isn't VistA, and, as a 
result, they aren't able to accurately report the annual 
development and sustainment costs.
    So, because of that lack of, I guess, management in the 
beginning where there was a disciplined approach to 
understanding and documenting the physical and performance 
characteristics of the system, that is why they are in the 
position that they are in at this time. And the inability to be 
able to draw that perimeter is why they don't have accurate 
costs and why at this time they don't have an accurate basis 
for an ROI as to, you know, for moving to the Cerner system.
    Mr. Lamb. Thank you.
    I am out of time; I will yield back.
    Ms. Lee. Thank you. I will now ask a few more questions.
    I wanted to follow up with Ms. Harris. This TBM methodology 
that Dr. Tibbits discussed, do you believe that this approach 
will be sufficient?
    Ms. Harris. I do not believe so. Until VA can fully define 
VistA, they will not be in a position to be able to accurately 
report the costs. I think the two go hand in hand and the 
definition of VistA is foundational. So, whether they use TBM 
or another type of methodology, the core issue remains that the 
definition of VistA is not fully defined and that is the 
problem.
    Ms. Lee. And can you be a little more specific when you 
base it--you know, it sounds like just defining the nature of 
the beast is the real issue here--just improving that accuracy, 
what do you foresee needs to be done?
    Ms. Harris. Understanding the 130 versions of VistA, the 
performance characteristics, as well as the environment in 
which those instances of VistA are operating. So having those 
clearly detailed and defined, adequately defined, is critical, 
so that is what I mean.
    Ms. Lee. All right, thank you.
    Dr. Tibbits, you have a plan to transition into the Cerner, 
but also continuing to support VistA. Why is--you are making 
this plan for the transition, but after you have already begun 
the implementation, why is that?
    Dr. Tibbits. Well, I would say right now what we are 
doing--and I will ask John Short to elaborate in a moment, but 
actually the thinking and planning for that transition began 
long ago when the determination and findings was written and 
the Department decided to go in this direction for a lot of 
reasons, which I will skip over right now, but the principal 
one being information interoperability for the benefit of 
servicemembers and veterans.
    So the planning itself began, what IO--the proximity to the 
initial operating capability, as we get closer and closer to 
that, interact more and more with Cerner itself, with the 
health care professionals in VHA, we are learning more as we go 
long. We have demonstrations, you have heard already about the 
workshops, we have had six of them already. So those are 
intensive interactions with respect to understanding clinical 
workflows and all those things, data migration, et cetera, all 
that is going to go into the actual documented plan.
    So there is a lot of learning that has had to happen in 
order to actually put a pen to paper on a document called a 
plan, a pivot, we call it a pivot plan, but the process of 
thinking and gathering the information to do that has been 
going on for several years already during this entire ramp-up 
leading to the award decision, the award, and now the 
interactions with Cerner.
    Ms. Lee. Yeah, I guess, you know, my concern is looking at 
all of the costs. Like we have a cost estimate that Cerner is 
going to cost $10 billion, you have a cost estimate of $4.8 
billion to maintain VistA. We don't have any confidence, A, in 
what VistA actually entails, so I don't think we any confidence 
in that $4.8 billion. But then, more importantly, that makes me 
have less confidence in the $10 billion estimate for Cerner as 
well, and at what point do we sit down and really lay out 
exactly what this is going to cost? I mean, money does not grow 
on trees. So at what point do we lay out exactly what the costs 
are?
    Dr. Tibbits. So I think, as Ms. Harris pointed out earlier, 
part of this learning process, you mentioned I think the on-
site surveys that are done in anticipation of the Cerner 
rollout, they are called current-state reviews. So, at those 
current-state reviews happen, certainly in a very definitive 
way we will understand everything about VistA interfaces and 
everything else at that site in anticipation of Cerner being 
implemented at that site.
    So, as the waves roll forward, we will become more and more 
definitive about the cost estimates that we have to live with 
now. So that process is ongoing. As the GAO pointed out, we 
have conducted that process already at the first three sites. 
We are very confident that that process is going to yield very 
complete information based on the actual experience we have 
with it to date.
    Ms. Lee. Thank you. I am out of my time and I will now 
recognize Ranking Member Banks.
    Mr. Banks. Thank you, Madam Chair.
    Mr. Short, please give us an update on the data migration. 
What data in terms of types and magnitude do you currently plan 
to migrate into Cerner?
    Mr. Short. Sir, the data we have identified was identified 
by the Chief Medical Officer and her clinical staff working 
with VHA. All the clinically relevant data, which includes 73 
billion records--let me explain what a record is: it is an 
encounter, a lab report, a vital sign, each one of those is an 
individual record in VistA. So, initially, the initial load 
from VA to Cerner is 77 billion of those records. The oldest 
one is back from the early '80s, a lab report, and we can give 
you more details on that for the record, if you would like. Of 
those, in terms of 21 different clinical domains that were 
identified by VHA and CMO office, those records moved from VA 
to the Kansas City data center, into a data repository, in 
preparation for loading into the Cerner Healthy Intent 
platform. So, over the next 30 days, it is intended to move 
that data into the Healthy Intent platform.
    When we go live at a site, the current plan is for March 
2020, the initial set of data domains that would be available 
would be ten of those 21 inside the EHR itself, but all 21 
clinical domains will be available to the clinicians and other 
caregivers, MVBA, as needed, in the Healthy Intent viewer. So 
they will have the long record, all records available from DoD 
and VA that are in Healthy Intent, they will be able to see all 
those in the Healthy Intent viewer, and the initial clinically 
relevant records that they have prioritized for go-live will be 
in the EHR.
    Mr. Banks. So will all of this patient data be accessible 
in Millennium or will a user need to look in another system 
such as Healthy Intent?
    Mr. Short. The CMO office in VHA determines some of the 
domains they don't want in Millennium. The initial set of data 
that will go in Millennium is ten data domains, within 5 to 8 
months after we go live, we will add additional data domains. 
So at that point 18 of those 21, the most clinically relevant 
ones that they want in Millennium, will be in there.
    Additionally, they have identified to have 3 years of 
records as the baseline that they want in there. For different 
purposes and reasons, that is the baseline they determined, and 
they briefed to the Under Secretary of Health's office.
    And so that way all those records will be in Millennium to 
trigger clinical decision support and other information. 
However, if they need to pull in additional data further back, 
they can do that, or they can just view it in Healthy Intent.
    Mr. Banks. Okay. How many of the VistA-to-Cerner interfaces 
have been completed now and when is the deadline to complete 
all of them? My understanding is that this deadline has come 
sometime before the go-live deadline.
    Mr. Short. Sir, there is 73 go-live minimum interfaces, 
system interfaces required; of those, there are a number of the 
interfaces that were already completed that we are reusing from 
DoD and a number of them from a commercial. So 12 of those 
system interfaces were already developed for DoD, so except for 
the testing in the end for VA use from the user level, those 
are complete.
    And then, additionally, there is 25 interfaces that are 
commercial system interfaces that they are going to be able to 
reuse. And so, except for the testing and then validation by 
the user, those are already complete because they are reusing 
those.
    Mr. Banks. Okay. What is the deadline to determine which 
VistA modules get replaced by which Cerner's software package 
or other companies' software, and which VistA modules have you 
yet to determine a plan for?
    Mr. Short. So all the clinical VistA modules with the 
exception of prosthetics will be replaced by the Cerner 
platform between the initial go-live and the IOC period. At the 
initial go-live, the different modules that will either be 
integrated versus replaced is being determined over the next 2 
weeks. Dr. Kroupa, CMO for OEHRM, is meeting with Spokane and 
Puget Sound functional staff and facility directors to go over 
the 313 Cerner capabilities and validating which ones they will 
have at go-live. And at that point we will know whether it 
would be two or five modules of VistA we will still integrate 
with, but by the end of the IOC exit it will be either one or 
no VistA models clinically relevant that we will use.
    Mr. Banks. All right. Dr. O'Toole, really quick, what is 
VHA's expectation for the Cerner data from the early sites 
coming back into VistA at the later sites? In other words, how 
seamless should the view of patient data be for VistA users in 
the mixed environment?
    Dr. O'Toole. The expectation is that it is possible that 
one will need to use multiple systems in the context of a 
clinical encounter, whether it is looking at past chest X-rays 
to determine, you know, how things looked previously, or other 
clinical examples of that sort. The challenge for us, though, 
is to ensure that it can be done efficiently, whether it is 
going to the joint legacy view or other mechanisms, or being 
able to look at the Cerner interface. This is what the Spokane 
and Seattle IOC visits are going to be looking at within this 
context of specific clinical scenarios and clinical needs to be 
able to determine if it could be done efficiently and timely. 
And, if it can and it is sanctioned and agreed to by local 
leadership and front-line providers, then it will be 
proceeding, but the expectation is that there will be clinical 
scenarios where both interfaces are going to be needed.
    Mr. Banks. All right. My time has expired.
    Ms. Lee. Thank you. I would now like to recognize Mr. 
Watkins for 5 minutes.
    Mr. Watkins. Thank you, Madam Chairwoman.
    Ms. Harris, your testimony indicates the VA could not give 
you accurate numbers as to the costs to maintain VistA, because 
there is not an adequate methodology to determine the costs 
belonging--what costs belong to VistA. What kind of methodology 
does the VA need and how is it going to be developed?
    Ms. Harris. Mr. Watkins, thank you for the question. So the 
finding that we had was that VA lacks a documented methodology 
for accounting for what is and isn't VistA. We don't have any 
recommendations related to the type of methodology that is 
necessary, but what is most important is that, whatever process 
that they choose, that it is documented and vetted throughout 
the organization.
    Mr. Watkins. Okay, thanks.
    Dr. Tibbits, where are you in the process of developing 
this methodology?
    Dr. Tibbits. Yes. As I said earlier, we completely agree 
with the GAO report and the representative's current remarks.
    I did mention earlier TBM and, as indicated in the prior 
discussion, TBM is only part--the Technology Business Manager 
framework was only part of the answer; the definitional 
boundary of CHS is clearly an important part of the answer as 
well. The two of those combined together is what is going to 
wind up with being our methodology.
    I would say, in our response to GAO, we have indicated that 
I think at the next update, I believe that is 120 days from 
now, we will have a final answer as to what that methodology 
will be.
    Mr. Watkins. Thank you. Dr. Tibbits, your testimony 
references a pilot program to move VistA data to the cloud. 
Apparently, this has already been successfully accomplished at 
one location. What is the scope of this pilot program? How much 
VistA data are you considering eventually moving to the cloud?
    Dr. Tibbits. So, let me be clear, it is not just VistA 
data. We are moving VistA in its entirety, so the ultimate 
scope of whatever instances of VistA remain operational as the 
Cerner platform rolls out. So, as things stand today, the scope 
would be 130 instances, but by the time we get VistA actually 
moving and Cerner rolled out, it is probably going to be a 
smaller number than that. The initial wave we are envisioning 
right now is 70, seven zero, 70. Because of their current 
location, the DoD facility, which is closing, we have to make 
sure we get those initial 70 moved first, because there is a 
date certain by which that facility will close.
    Mr. Watkins. And how long and how much will it cost to move 
all 130?
    Dr. Tibbits. I will have to get back to you on the exact 
cost figures. And we do have a schedule, again, driven by the 
DISA data center closure. I just happen not to remember that 
date right now, I will be happy to get that back to you, but 
the schedule for that first 70 is absolutely fixed because of 
that first closure date by DISA.
    Mr. Watkins. So I have got to yield my time.
    Ms. Lee. Mr. Hume, we have heard from the VA on multiple 
occasions that Cerner's Millennium will only replace 60 percent 
of VistA's capabilities or functionality, and then that the EHR 
may have to link back to VistA to fulfill the other 40 percent. 
Can you address what functions make up this other 40 percent?
    Mr. Hume. Yes, ma'am. The bulk of those other 
functionalities are being replaced by other modernization 
systems, the financial management modernization system and the 
supply chain modernization with the Defense Medical Logistics 
Standards support system. I will defer to Mr. Short for the 
details, but there is a small percentage of capabilities beyond 
that are not being replaced by one of those three modernization 
systems and we are in the process of identifying the solution 
to that. It may be an interface to VistA for some time, a 
replacement by a commercial product; we have yet to work that 
out.
    Mr. Short, do you want to comment?
    Mr. Short. Yes, thank you.
    Ma'am, initially at IOC go-live, five to seven of the VistA 
clinical modules will be interfaced to, but the IOC exit the 
plan is to only have a dependency on one VistA modules being 
prosthetics and the solution for that, Cerner is developing 
additional clinical content and some IP development to make 
sure that all the nuances of prosthetics that VA has could be 
added to their platform, which will be beneficial to anyone 
else using that platform as well.
    The other portions of VistA, the other 40 percent, a large 
portion of that are base core functionalities of VistA, it has 
nothing to do with any functionality at all. Like an XML 
parser, you know, like to be able to split out data, that is 
something that only if you need to use a system is that 
capability necessary, like an operating system is only 
important for an application. So those things go away when the 
application functionality goes away.
    The other items Mr. Hume mentioned are business systems, 
accounting, acquisitions tracking, not medical-related, but 
tied into health care.
    Ms. Lee. So just thinking about the costs. So you have 
these other capabilities, you have plans to modernize or 
replace those capabilities, where is that cost coming from? Is 
that included in the $10 billion that we have planned for 
Cerner, is that outside of it? Is that part of the $4.89 
billion projected for VistA? Where are those costs coming from?
    Dr. Tibbits. Well, Madam Chair, if I understand your 
question correctly, with respect to the major efforts that 
address the 40 percent, FMBT, Financial Management Business 
Transformation, that is our ERP replacement, and DMLS, which is 
our supply chain modernization, they have their own cost 
boundaries and cost definitions. So that would not be part of 
the VistA boundary--
    Ms. Lee. So it is in addition?
    Dr. Tibbits [continued]. --no--or the Cerner boundary, no. 
Those are all--
    Ms. Lee. But it is not included in your $5 billion--
    Dr. Tibbits. Correct.
    Ms. Lee [continued]. --to maintain VistA. So this is we 
have another cost on top of that to take care of this 40 
percent?
    Dr. Tibbits. Right. Those are programs of record and have 
been in our budget submission now for a few years, the ERP 
replacement, FMBT, and DMLS, yes, those are separate programs 
already included in our budget submissions.
    Ms. Lee. Okay. So just a question, then will Cerner be 
responsible for addressing any of this 40 percent, or is this 
all being taken care of?
    Dr. Tibbits. No, the 40 percent are the other systems.
    Ms. Lee. The other stuff?
    Dr. Tibbits. So that is FMBT, Financial Management Business 
Transformation, DMLS, and then the remaining things that John 
Short just talked about, which might actually no longer be 
needed at all, some technical things, XML parser and whatnot. 
So, no, the Cerner is the 60 percent part of the question.
    Ms. Lee. Okay, all right. So at go-live, how is the VA 
going to address these capabilities in Cerner that are not 
going to meet clinical needs such as prosthetics and where 
there is no alternative product?
    Dr. Tibbits. So I am going to ask perhaps Chuck Hume to 
comment on that in a minute. The prosthetics community, of 
course, is working very intensively with us. I have personally 
sat in on many of those meetings. I think the short-term 
approach, if I can say that, is to maintain a prosthetic system 
and build an interface over to that prosthetic system, until 
such time as that functionality is adequately developed and 
represented in the Cerner product itself.
    So, as I think all of you are well aware of, prosthetics is 
a very well developed, very sophisticated capability at the VA, 
not something that Cerner necessarily encounters to that extent 
in their commercial practice, and so it is not surprising to us 
that they have to beef up that capability. But, in the 
meantime, I believe our short-term answer is to maintain our 
prosthetics system and interface that as necessary.
    Ms. Lee. Thank you.
    I now recognize Ranking Member Banks.
    Mr. Banks. Thank you, Madam Chair.
    Dr. O'Toole, I want to make sure that I understand the data 
migration answer that we discussed a little bit ago. Are you 
saying that the VHA physicians don't want all patient data to 
be in Millennium?
    Dr. O'Toole. No, sir, I am not saying that. I think the 
issue is some--as we roll out and, obviously, with the 
staggered rollout across sites, and for veterans who may be 
migrating across systems, there may be instances where data may 
not initially be available on the Cerner platform, but it is 
available on the legacy platform, particularly longitudinal 
data going back. And from a clinical perspective and seeing a 
patient where having that longitudinal history is going to be 
necessary to provide their care, it is going to be important to 
be able to have access to both the legacy systems, as well as 
the current systems of care. So it is not an issue of 
preference, it is a matter or issue of practicality and good 
care.
    Mr. Banks. Okay. Mr. Hume and Mr. Short, how many other 
technology projects in VA have dependencies with EHRM? And can 
you list them, if you can, and tell me who is responsible for 
each set of dependencies?
    Mr. Hume. Well, the predominant systems would be those we 
talked about, the financial management modernization and the 
supply chain modernization, each of those programs. The 
immediate relationship is with the supply chain modernization, 
the Defense Medical Logistics Support System, that system is to 
roll out to the sites that are modernizing to Cerner 4 months 
in advance of that, so that we can make sure that those 
interfaces are functioning.
    We are fortunate that we are adopting the Defense Medical 
Logistics Support System, which they have already interfaced 
with Cerner as part of their rollout under MHS GENESIS.
    Mr. Short, do you want to add anything?
    Mr. Short. The two programs Mr. Hume mentioned, Terry 
Riffel and Harry Oland are the two people, the first FMBT and 
second one the DMLS, that are the SES executives over those 
programs. So both those programs have a dependency on some of 
our functionality and OHEM has a dependency on theirs. OHEM 
also has a dependency on the joint legacy viewer during the 
transition period, because there is some functionality that for 
some work-arounds until all capabilities are released and 
tested and validated that they will need to use the joint 
legacy viewer at the transitional sites.
    There are some ancillary systems that we have some 
dependencies on, and we can take that for the record and 
document that for you.
    Mr. Banks. Okay. Mr. Short, I read the Secretary a letter 
last month about patient matching. As you know, it is key to 
quality and interoperability. I appreciate the thorough 
response, but I would like you to explain one of the 
statements. It says, quote, ``A single EHR solution between VA 
and DoD will guarantee 100 percent patient matching within the 
new EHR solution for servicemembers and veterans,'' end quote. 
Does that pertain to VA and DoD or VA and the MISSION Act 
providers?
    Mr. Short. Sir, I am not sure if it pertains to the MISSION 
providers, I would believe it pertains to the first, DoD and 
VA. I can get back to you for the record on the second 
question.
    To answer part of that question, the Joint Patient Identity 
Management Service that we developed with DoD and we have 
tested out, what we have used to make sure that we have 
maintainability, we have a single EHR with an overlapping 
customer base, as you can imagine. DoD and VA and beneficiaries 
and veterans, servicemembers can go back and forth, Active duty 
members are seen at VA hospitals at times, et cetera, you could 
have a mismatch if you had different identity systems saying, 
no, this is John Short or that is John Short. And so by having 
one system with everything worked out in the background 
maintains we do that.
    But for the record, on the other part of your question, I 
will take that back.
    Mr. Banks. Okay. Last question. What is VA's--Mr. Short, 
for you as well--what is VA's goal for patient matching with 
the MISSION Act providers in Cerner and how are you going to 
achieve it?
    Mr. Short. Our goal is to have complete patient matching to 
ensure that everything is completely safe, accurate for every 
patient, that the veterans that deserve care get the care, and 
get the right care and the right prescriptions. So, for the 
record, I can take it back on our plans; I don't have that with 
me today.
    Mr. Banks. Thank you very much. I yield back.
    Ms. Lee. Thank you.
    Dr. Tibbits, there are many entities outside of VA using 
VistA that have agreements, like OSEHRA and World VistA. This 
Committee has heard from several of these groups with concerns 
about the future of their access to VistA code and possible 
future innovations. And I wanted to ask you, how is the VA 
leveraging outside experience through these groups to further 
the instances of VistA?
    Dr. Tibbits. Well, as we mentioned earlier, first of all, 
maintaining VistA over the 10-year roll-out period of Cerner is 
very important to us, critical to veteran care. So we are going 
to continue to focus on doing that. I can say that in the past 
from the open-source community we have certainly obtained very 
valuable contribution to FileMan, which is the underlying 
database in VistA. How that relation--so there have been 
additions and actually that FileMan upgrade was a substantial 
one, not some minor tweaks, from the open-source community--how 
that will play out in the future, I am not sure I know enough 
to exactly tell you that yet, other than we will continue to 
maintain VistA for the roll-out period; number two, we will 
continue to make available whatever the VistA code is at that 
point in time to those communities, we have no reason to stop 
any of that.
    Since there is a 10-year roll-out period and since the 
roll-out process is geographic, not functional, the additional 
functionality and patching will have to continue for the 
majority of that 10 years until the last site gets turned off. 
So, with respect to those outside entities that are using 
VistA, they certainly have plenty of time to prepare for what 
might eventually happen 10 years from now, it is not going to 
be a surprise to them in any way.
    Ms. Lee. Do you have an agreement; do you have any 
licensing agreements with those groups and is there like a stop 
date at 10 years?
    Dr. Tibbits. Licensing, I think I am going to--we would be 
best advised to take that for the record. Licensing is very 
complicated when you get into Apache II licenses and commons 
and all that sort of stuff. So OSEHRA is quite expert at 
license management. I think we should take that for the record 
and get back to you on the license questions.
    Ms. Lee. Okay. Thank you.
    Dr. O'Toole, while the VA is using the electronic--the dual 
records, what clinical impacts are expected and tolerated, and 
which ones would be unacceptable?
    Dr. O'Toole. Thank you. It is an extremely important issue 
and challenge for us. I think the expectation is that there 
will be workflows that require dual system use for different 
clinic scenarios. The challenge point and the things that we 
are going to be looking for are, one, clearly, how will that 
impact in terms of efficiency of patient care and the amount of 
time that it takes to care for a patient within those clinical 
settings. The expectation with the initial IOC roll-out sites 
is that clinical time needs to be extended for each clinical 
visit to ensure that adequate time is made available. We are in 
the process of expanding the traveling nursing corps at our IOC 
sites to enhance the staff capabilities there in order to 
ensure that.
    The biggest challenges and the biggest risks to us, I 
think, are really related to complex clinical scenarios where 
patients may be migrating across multiple settings or where 
longitudinal care is critical to clinical decision making, and 
that is something that we are in the process of looking at very 
closely within the context of the IOC capabilities to ensure 
that those workflow processes are identified in advance, that 
clinicians up front know what to expect and what the workflow 
processes will be, but it is something we will be monitoring 
and watching very closely through this process.
    Ms. Lee. Thank you. Just one last question.
    Ms. Harris, obviously, there are a lot of uncertainties in 
the potential solutions that we are hearing today and, from a 
management perspective, do you have concerns and is the VA 
taking on risk that it may not be aware of, in your opinion?
    Ms. Harris. Well, we have ongoing work for the Subcommittee 
related to the transition plans and activities that are 
underway. I think that having effective plans is a very 
critical thing and having plans that are at the right level of 
detail is certainly very critical.
    I think that one of the things that we have some questions 
about at this time relates to the clinical workflows and when 
that will be completed and the level of granularity of those 
workflows in time for the IOC deployment. The timing of those 
two activities is something that we have some questions on and 
whether the VA will be in a position to be able to complete 
those workflows in time for the deployments at those IOC sites, 
that is something that we have some questions about at this 
time.
    Ms. Lee. Thank you.
    Well, this now concludes the Subcommittee hearing. I wanted 
to thank all of the witnesses for being here today, thank Ms. 
Harris for your report. We are heartened that the VA will take 
the recommendation of the GAO and has begun implementing the 
methodology, and we look forward to having transparent updates 
as we go along.
    From my point of view, you know, continuing, Mr. Short, a 
lack of plan on joint governance continues to be a problem with 
the rollout of this program and our lack of having knowledge of 
what the plans are, when we can expect to see a joint 
governance really continues to concern us. And it is really, 
mostly for me about the risk of the rollout in this contract. I 
mean, this was a fixed-price contract, VA implemented it with 
indefinite deliverable, indefinite quality, which really would 
have shifted a lot of the risk onto the contractor, but with 
lack of knowledge of really what the extent of VistA is, to me, 
shifts a lot of that risk back onto the VA.
    And when we start to talk about the cost, you know, the 
billions and billions of dollars of cost of this project, I 
just have concern and I hope that we can continue to have some 
transparency as we roll out. And when we get to specific 
decision points, to be able to stand up and make the proper 
decision based on the status of where we are at the time would 
be my hope as we move forward, especially given the track 
record that we have had in trying to update VistA multiple 
times in the past. And ultimately, you know, improved health 
care for our veterans is really the focus that we all and I 
know, Dr. O'Toole, we are all focused on, and obviously the 
interoperability being the number one objective in this 
rollout.
    And so as we move forward, again, we thank you all for 
being here and continue to want to have that transparency, so 
we can make sure that ultimately, we are delivering the best 
care possible to veterans in our country. And thank you all for 
being here.
    And I would like to thank the witnesses. I hope that we 
will work together with this Subcommittee as we continue this 
oversight.
    All Members will have 5 legislative days to revise and 
extend their remarks and include extraneous material. And this 
hearing is now adjourned.
    Thank you.

    [Whereupon, at 11:23 a.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                   Prepared Statement of Paul Tibbits
INTRODUCTION

    Good morning Chairwoman Lee, Ranking Member Banks, and 
distinguished Members of the Subcommittee. Thank you for the 
opportunity to testify today about the Department of Veterans Affairs' 
(VA) IT modernization efforts, including the Electronic Health Record 
Modernization (EHRM) initiative and the Veterans Health Information 
Systems and Technology Architecture (VistA): the system at the center 
of that effort.
    I am accompanied today by Charles C. Hume, Assistant Deputy Under 
Secretary for Health Informatics, Veterans Health Administration; John 
Short, Chief Technology and Integration Officer, Office of Electronic 
Health Record Modernization; and Dr. Thomas O'Toole, Senior Medical 
Advisor, Office of the Assistant Deputy Undersecretary for Health for 
Clinical Operations, Veterans Health Administration.

OVERVIEW

    VA is committed to providing exceptional care, services, and a 
seamless, unified experience to our Veterans. The Office of Information 
and Technology (OIT) collaborates with various VA offices to achieve 
this mission through the delivery of state-of-the-art technology, 
including a modernized Electronic Health Record (EHR).
    VA was an early pioneer of the EHR. We developed VistA to support 
the clinical, administrative, and financial operations of the Veterans 
Health Administration (VHA). Today, VistA and its integrated systems 
provide an integrated EHR for Veteran care and services. It supports 
over 150 applications, including the operations of more than 1,500 VA 
facilities, from small outpatient clinics to large VA Medical Centers 
(VAMC). There are 130 unique instances of VistA nationwide at four 
Regional data centers, apart from Manila which has an onsite instance. 
Each of the 130 VistA instances share a standard core of functionality 
but are customized to each VAMC's needs and patient population. VistA 
is also enhanced by many third-party commercial off-the-shelf (COTS) 
products which further customizes the environment. One instance of 
VistA, at Valley Coastal Bend, was successfully migrated to the cloud 
on June 22, 2019, which is the future direction for VistA instance 
maintenance until they are subsumed by Cerner Millennium.
    Like any IT system, VistA requires updates and maintenance to keep 
it functioning at a high level. Critical upgrades to the system could 
be extremely costly over the years, and maintenance costs are even 
higher. Often, it becomes more expensive to maintain a legacy system 
than to replace it.
    VistA has served VA and Veterans well, but after nearly 40 years in 
operation, we are also aware of its limitations. It does not possess 
the modern capabilities, analytics, and functionalities that medical 
providers and Veterans expect and deserve. It is not interoperable with 
other Federal records systems, including those at the Department of 
Defense (DoD) which contain the health information of Servicemembers 
who will eventually enter our system as Veterans. Instead, VA staff 
must use a separate viewer to see DoD's data and yet another system to 
provide allergen and medication alerts to VistA.
    To modernize VA's legacy EHR systems and achieve interoperability 
with DoD and community care providers, VA decided to transition to a 
new EHR solution. In May 2018, VA awarded Cerner a contract to replace 
VistA with a COTS solution, Cerner Millennium, which is also currently 
being deployed by DoD.
    VA is working with Cerner to achieve Initial Operating Capability 
(IOC) in the Pacific Northwest, where DoD has already deployed the MHS 
GENESIS system, which is at its core, Cerner Millennium. Beginning in 
Spring 2020, VA will deploy its new EHR solution in that region. 
Through the IOC period, VA will maximize efficiencies by building upon 
lessons learned from DoD. VA will then deploy its new EHR solution 
across the VA enterprise. During implementation of the new EHR 
solution, VA will need to maintain VistA systems for a period of time. 
This ensures that current patient records remain accessible and that 
there will be no interruption in the delivery of quality care.
    Keep in mind the Pacific Northwest region is only a small fraction 
of the VistA ecosystem. Instances occur across the country and it's 
even more important during the pre-deployment reviews that VA 
identifies the unique differences to effectively reach IOC on schedule. 
OIT has completed infrastructure readiness assessments for the IOC 
sites. More importantly, VistA is not only an EHR system; it is a 
complex system more like an Enterprise Resource Planning (ERP) with a 
variety of capabilities and functionalities, including financial, 
administrative, and supply chain management functions. It supports not 
only VHA but may be used by the Veterans Benefits Administration (VBA) 
and the National Cemetery Administration (NCA).

FACILITIES USE OF VISTA DURING EHRM

    For the aforementioned reason, VA can only fully retire VistA when 
every capability and functionality used by a facility is replaced by a 
modernized replacement system, whether by Cerner or additional systems.
    During the transition to VA's new EHR solution, VA facilities will 
continue to use their instance of VistA. VA is undertaking several 
concurrent modernization projects such as the following:

      Defense Medical Logistics Standard Support (DMLSS), a 
system that will manage all VHA supply chain functionality except for 
pharmacy, patient specific prosthetics, and possibly IT equipment; and
      Financial Management Business Transformation (FMBT), 
which will replace VA's current Financial Management System.

COSTS OF SUSTAINMENT

    For the purposes of ensuring uninterrupted health care delivery, VA 
will continue to use VistA until all legacy systems are replaced by the 
new solution. It currently costs VA $426 million to sustain VistA 
through Fiscal Year (FY) 2019 based on the GAO-19-125 report. VA is 
developing projected sustainment costs over the course of VA's new EHR 
solution implementation.
    Currently, there is no VistA sustainment cost reduction directly 
tied to the new EHR solution rollout. VistA is expected to run without 
service degradation until all VAMCs have been migrated to the new EHR 
solution, at which time the redundant VistA modules will be 
decommissioned. VistA modules that are not replaced by the new solution 
will be maintained until replacement capabilities are developed. The 
cost to maintain VistA will increase as we must include development for 
new capabilities and interfaces, Congressional mandates, cloud costs, 
hiring and retention of VistA support resources, and maintenance. The 
estimated minimum cost for VistA during this 10-year transition period 
is $4.89 billion, not including any required development. VA is 
currently developing a methodology to update the cost data and thereby 
define VistA, which was also a recommendation by GAO in a recent draft 
report.

LONG-TERM STRATEGY FOR SUSTAINMENT

    VA is constantly looking for more efficient ways to sustain VistA 
throughout the course of the EHRM effort. The following are some of the 
key strategies:

      Development Operations Approach - OIT is shifting to a 
DevOps approach focused on collaboration, innovation, Agile principles, 
and automation-so that it can develop, enhance, maintain, and roll out 
better products at a faster pace than using the existing separate 
development and operations processes.
      VistA Standardization - VAMCs will be required to run the 
nationally released ``Gold'' version of VistA. A waiver process will 
allow for critical modifications. In addition to having a common set of 
software routines for each VistA instance, there are some additional 
normalization activities that includes the work on terminology 
extensions to account for local differences and others that will need 
to be addressed to ensure complete standardization of as much of the 
VistA database/file system as possible. VA's goal is for all VistA 
instances to be standardized.
      Merging Resources - OIT is merging VistA teams and 
resources for maximum efficiency throughout OIT.
      Maintain excellent customer support - Responding to 
patient safety issues; hiring and retention of VistA support resources; 
maintaining security and compliancy (scans and remediation, 508, ATO, 
etc.); refreshing hardware (life-cycle upgrade, hardware, cloud etc.); 
maintaining software versions/upgrades; decommissioning of VistA 
products as appropriate.
      Office of Technical Integration (OTI) - OTI facilitates 
communication and planning between OIT and various program offices that 
are implementing the systems that will replace VistA. OTI will track 
and report progress from these program offices, facilitate real-time 
conflict resolution, and manage risks between programs.
      VA Enterprise Cloud (VAEC) - OIT is currently piloting a 
program to migrate all 130 instances of VistA to the VAEC. Last month, 
OIT successfully migrated the first VistA instance to the cloud-a 
historic milestone and strong first step toward full cloud migration 
for VistA. Over the next year alone, VA will migrate 70 more instances 
of VistA from the St. Louis Defense Information Systems Agency (DISA) 
data center into the cloud.

CONCLUSION

    As VistA functionality is replaced by a COTS solution and other 
systems, VA can decommission VistA products as appropriate. Until the 
new EHR solution is implemented across the VA enterprise, VistA remains 
VA's authoritative source of Veteran data. Sustaining VistA for the 
duration of our EHRM effort ensures that Veterans continue to receive 
uninterrupted care and services while VA looks to the future and 
improves the Veteran experience.
    Madam Chair, Ranking Member, and Members of the Subcommittee, thank 
you for the opportunity to appear before you today to discuss OIT's 
progress toward VistA transition. I look forward to continuing to work 
with this Subcommittee to address our greatest priorities. This 
concludes my testimony, and I look forward to answering your questions.
1. Acknowledgement of GAO Report

2. Definition of VistA

    a. Definition of VistA

    i. Electronic Health Record
    ii. Interoperability
    iii. Other Functionalities

    b. Definition of Instances of VistA

    c.Explanation of Variation in Instances

    d.Plans to Further Define VistA

3. Assessment of Costs of VistA Sustainment

    a.Note on GAO Report Assessment

    b.Methodology

    c.Comprehensive Total Cost Assessment

    d.Limitations

4.Need for Sustainment

    a.Facilities Use of VistA During EHRM

5.Long-Term Strategy for Sustainment

    a.Consolidation of Teams and Resources

    b.OTI

    c.Cloud Migration

6.Activities to Prepare VistA Transition

    a.Establishment of Program Office

    i.Governance Structure

    b.Role of OIT

    c.Assessment of Initial Sites

    d.Initial Operating Capability

    e.System Implementation

1. Acknowledgement of GAO Report

    The Department of Veterans Affairs (VA) Office of Information and 
Technology (OIT) acknowledges the Government Accountability Office's 
(GAO) report released in July 2019, titled ``ELECTRONIC HEALTH RECORDS: 
VA Needs to Identify and Report System Costs'' regarding the costs and 
requirements of sustainment of the Veterans Health Information Systems 
and Technology Architecture (VistA) system during VA's transition to 
Cerner Millennium and other systems intended to replace VistA 
functionality.
    Under the section titled ``Recommendation for Executive Action,'' 
GAO recommended that the Assistant Secretary for Information and 
Technology and Chief Information Officer work with the Under Secretary 
for Health to develop and implement a methodology for reliably 
identifying and reporting the total costs of VistA sustainment. The 
report states that this methodology should include steps to define 
VistA and include planned sustainment activities. OIT acknowledges this 
recommendation and is currently developing such a methodology and 
continues to conduct current, ongoing, and planned sustainment 
activities. OIT presents this written testimony to provide further 
information regarding current and ongoing efforts related to VistA 
sustainment and the Electronic Health Record Modernization (EHRM) 
effort.

2a. Definition of VistA

    VistA is VA's comprehensive information system for Veteran care and 
services. It supports a complex set of clinical, administrative, and 
financial operations for the Veterans Health Administration (VHA).
    VistA is an architecture that includes servers, personal 
workstations, and a variety of applications within the supporting 
infrastructure including data centers, storage, and messaging 
technologies. It provides a wide variety of functionalities and 
therefore may also support functions outside of VHA.
    VistA supports over 150 applications and the operations of more 
than 1,500 VA facilities. Applications focus on clinically-relevant 
record keeping that improves patient care by improving clinical and 
administrative decision-making. Facilities range from small clinics 
that provide solely outpatient care to large medical centers with 
significant inpatient populations and their associated specialties. 
VistA is deployed across VHA at more than 1,500 sites of care, 
including Veterans Affairs Medical Centers (VAMC), Community Based 
Outpatient Clinics (CBOC) and Community Living Centers (CLC), as well 
as at nearly 300 VA Vet Centers. VistA was designed and often developed 
and implemented jointly by VHA clinicians and IT personnel at VHA 
facilities. It has been in use since 1983, nearly 40 years.

2ai. Definition of VistA: Electronic Health Record

    VistA is VHA's full-featured Health Information System and 
electronic health record (EHR). It contains an EHR for each patient and 
supports the clinical, administrative, and financial functions of VAMCs 
and VA facilities across the country. VistA interfaces with 
applications through messaging protocols and reporting mechanisms.

2aii. Interoperability

    As an EHR, VistA sends and exchanges stored health data with other 
VA systems, other Federal agencies (e.g., Department of Defense), 
health information exchange networks, community care providers, and 
more than 100 commercial off-the-shelf (COTS) products. VistA is not 
currently interoperable with the Department of Defense (DoD), so VA 
users instead use the DoD/VA Joint Legacy Viewer (JLV), a Web-based 
graphical user interface. Additionally, VA and DoD share allergens and 
medication data with each other in a system called the Health Data 
Repository (HDR) which feeds data to other systems that can alert VA 
clinicians while using VistA.

2aiii. Other functionalities

    As the GAO report notes, VistA provides functionality beyond 
traditional EHRs. It exchanges information with many other applications 
and interfaces. It provides a variety of other functionalities 
including asset management, financial transaction management, a billing 
system, and supply chain management. These functions primarily support 
VHA facilities, but instances of VistA may also be used by local 
Veterans Benefits Administration (VBA) and National Cemetery 
Administration (NCA) facilities and cemeteries. For example, a local 
cemetery may use VistA for its supply chain management needs.

2b. Definition of Instances of VistA

    There are 130 instances of VistA across the VA enterprise. An 
instance of VistA is an occurrence of the system that serves a VAMC and 
its associated clinics, and other potential VA facilities within a 
defined geographical region. Generally, there is one instance of VistA 
per health care system or VAMC and associated clinics. However, over 
the years, some VAMCs have been consolidated onto the same VistA 
instance, so there is not exactly a 1:1 ratio of instance and site. 
Each instance also consists of the hardware and software used to 
provide VistA capabilities for a health care system.

2c. Explanation of Variation in Instances of VistA

    Each instance of VistA may have slight modifications and variations 
that serve requirements unique to that geographical region. However, 
the code between instances has been made nearly identical through work 
over the last 6 years through the VistA Evolution Program. 
Implementation of the new EHR solution will help consolidate and 
standardize VistA instances. OIT is working to avoid any changes to 
VistA which could needlessly alter VistA's configuration prior to full 
implementation of the new EHR solution would complicate and delay 
implementation efforts.

2d. Plans to Further Define VistA

    VA is currently developing a methodology to refine the definition 
of VistA.

3a. Note on GAO Report Assessment

    The GAO report examined cost data provided by OIT and VHA 
associated with the development and sustainment of VistA for FYs 2015, 
2016, and 2017 only.

3b. Methodology

    VA is currently developing a methodology to update the sustainment 
cost data.

3c. Comprehensive Total Cost Assessment

    Cost data has been updated. It currently costs VA $426 million to 
sustain VistA through FY 2019. VA is developing projected sustainment 
costs over the course of the new EHR solution implementation. VA's 
estimated minimum cost for VistA during this 10-year transition period 
is at least $4.89 billion, not including newly required development. VA 
is currently developing a methodology to update the cost data and 
redefine VistA.

3d. Limitations

    During the transition from VistA to the new EHR solution, the two 
systems will need to be operated in parallel. In addition, VistA is 
expected to run without service degradation until all VAMCs have been 
migrated to Cerner, at which time the redundant VistA modules will be 
decommissioned. For these reasons, there is currently no VistA 
sustainment cost reduction directly tied to the EHRM effort.

4. Need for Sustainment

    Further, VistA modules whose functionality is not replaced by 
Cerner Millennium will need to be maintained until replacement 
solutions are developed and deployed. For example, Cerner Millennium 
does not replace some financial management and supply chain management 
functions provided by VistA. Other programs, such as Financial 
Management Business Transformation (FMBT) and Defense Medical Logistics 
Standard Support (DMLSS) will replace those functionalities. VistA 
cannot be decommissioned until all current functionality is replaced by 
a modernized replacement system, whether Cerner Millennium or 
otherwise. However, these other programs are expected to be developed 
and implemented on a shorter timeline (i.e., less than 10 years). Since 
implementation of the new EHR solution is currently projected to take 
10 years, the EHRM effort is the ultimate driver of VistA sustainment 
and full transition.

4a. Facilities Use of VistA During EHRM

    Facilities will continue to use their instance of VistA until other 
concurrent modernization projects have replaced all functionalities of 
that VistA instance. Only then can the facility fully transition from 
VistA to the new EHR solution and other replacement solutions.

5. Long-Term Strategy for Sustainment

    Despite the need to maintain Vista over the course of the EHRM 
effort and the development and implementation of additional modernized 
replacement systems, there are current and ongoing efforts to reduce 
some costs of sustainment and make transition efforts more efficient. 
For example:

5a. Consolidation of Teams and Resources

    OIT is consolidating teams and resources between Transition, 
Release and Support (TRS) and Enterprise Program Management Division 
for maximum efficiency.

5b. OTI

    The newly established Office of Technical Integration (OTI) 
facilitates communication and planning between OIT and various program 
offices that are implementing the systems that will replace VistA. OTI 
will track and report progress from these program offices, facilitate 
real-time conflict resolution, and manage risks between programs.

5c. Cloud Migration

    OIT is currently piloting a program to migrate all 130 instances of 
VistA to the VA Enterprise Cloud (VAEC). Last month, OIT successfully 
migrated the first instance of VistA to the cloud. This is a 
significant achievement which will support VA's ``Cloud First'' policy 
and modernization initiatives as established by the Federal Chief 
Information Officer.
    Over the next year alone, VA will migrate 70 more instances of 
VistA from the St. Louis Defense Information Systems Agency (DISA) data 
center into the cloud. Hosting VistA in the cloud is more cost-
effective than hosting in physical data centers. It allows OIT to make 
updates more quickly, saving labor hours. It also improves system and 
application speed and performance and is more scalable, making it more 
valuable to OIT's business partners.

6. Activities to Plan for Transition

    VA is working closely with DoD during this major business 
transformation. DoD and VA have appointed co-chairs for all efforts. VA 
is collaborating with Cerner to understand the technical support 
requirements to connect to the Cerner Millennium Cloud Data Center and 
to develop the processes necessary to accommodate emerging 
technologies. VA is also working with its community care partners, 
focusing on interoperability and bidirectional information exchange.
    To allow for seamless interoperability between Cerner and VistA 
over the course of implementation, JLV will be enhanced to include a 
Cerner viewer. This will allow sites that have not yet transitioned to 
access new electronic data repositories and to create stand-alone 
technical solutions to share data with the new EHR solution. In 
addition, the requisite interfaces with VistA and the new product 
capabilities and related workflows will be fully tested before 
transitioning to the operational environment.
    During this time, Cerner HealtheIntent will become the 
authoritative data store for Veteran health care information, since it 
is populated with all Veteran information and since information from 
VistA sites will be written into HealtheIntent real-time through VDIF, 
the middleware.

6a. Establishment of Program Office

    To establish a leadership accountable for planning and executing 
the EHRM effort and addressing difficulties to ensure program success, 
VA established the Office of Electronic Health Record Modernization 
(OEHRM) in June 2018. OEHRM's initial Program Management Plan guides 
management and defines program policies and processes.

6a. Governance Structure

    OEHRM is comprised of three management structures. The Chief 
Medical Office oversees strategy and planning; communication efforts 
for business process changes; and user testing, training, and 
deployment. The Technology and Integration Office provides technical 
leadership, management, and oversight and supports interoperability 
with DoD. Lastly, the Program Management Office provides program 
support through adherence to cost, schedule, and performance 
objectives. OEHRM has a governance structure that is intended to allow 
leadership to address technical and functional issues as well as joint 
management issues that may arise between VA and DoD during the process 
of their respective EHR implementation efforts. The structure consists 
of a Steering Committee; a Governance Integration Board, which oversees 
a Technical Governance Board and Functional Governance Board; and the 
Electronic Health Record Councils.
    OIT is also working closely with DoD on the organizational 
development of the Federal Electronic Health Record Modernization 
(FEHRM) Program Office. The FEHRM Program Office will serve as the re-
chartered DoD/VA Interagency Program Office (IPO). In short, OIT is 
working collaboratively with VHA, OEHRM, IPO/FEHRM, and their 
associated partners to achieve successful implementation, leverage 
lessons learned and best practices, leverage common infrastructure, 
innovate to improve business processes, and facilitate effective 
adjudication of issues.

16b. Role of OIT

    OIT plays several roles in this business transformation process. 
According to established baseline standards for initial operating 
capability (IOC), OIT is responsible for upgrades to the IT 
infrastructure and local area network infrastructure. These 
infrastructure upgrades are critical to success of the deployment of 
the new EHR solution.
    OIT is also involved in the following areas:

      Coordination, planning, and budgeting: OIT works 
collaboratively with OEHRM, based on requirements submitted in VA IT 
Process Request (VIPR), to provide planning, budgeting, project 
management, infrastructure assessments, and other support to EHRM.
      Fielding: In support of VHA and the IOC/VAMC sites, OIT 
focuses on the infrastructure line of effort to ensure that all aspects 
of the network architecture will support accessing the new EHR solution 
and associated systems, within VHA-defined service levels response 
times.
      Access Management: OIT coordinates closely with Office of 
Operations, Security, and Preparedness in development and 
implementation of access control (PIV cards), and with OEHRM and DoD 
for secure access to Cerner Millennium resources in the DoD Medical 
Community of Interest (MedCOI) environment.
      Cybersecurity: OIT is in close coordination with DoD 
regarding shared network security standards and reciprocity between DoD 
and VA systems.
      End user experience with system performance: OIT 
organizes activities among multiple stakeholders to manage service 
provision and system access.

    OIT is working closely with VHA and OEHRM to plan an accelerated 
implementation of the Cerner Standalone Scheduling module; design 
system interfaces between legacy applications and the Cerner Millennium 
suite; adjudicate requests for legacy VistA upgrades against pending 
Cerner Millennium functionality; and design service desk interface 
tools and business rules to improve collaboration with end user 
reported issues.
    6c. Assessment of Sites
    VA is currently conducting site assessments at IOC sites to refine 
requirements and prepare for implementation. VA has identified three 
primary IOC sites for assessment: VA Puget Sound Health Care System, 
American Lake Division; VA Puget Sound Health Care System, Seattle 
Division; and Mann-Grandstaff VA Medical Center. During assessment at 
these sites, VA determined that some infrastructure and workstations 
would need to be updated to achieve compatibility with Cerner 
Millennium. In addition, sites that offer such VA services as 
telehealth and behavioral and mental health services would need 
additional attention from Cerner to meet business and system 
requirements. These site assessments are intended to produce lessons 
learned and ease deployment and implementation efforts at the rest of 
the sites Nation-wide.
    In the Pacific Northwest, there are the following:

      5 VA Health Care Systems;
      6 VA Medical Centers (VAMC);
      9 Outpatient clinics;
      17 Vet Centers; and
      34 Community-based outpatient clinics (CBOC).

6d. Initial Operating Capability

    VA is working with Cerner to implement the new EHR solution at 
three IOC sites in the Pacific Northwest. As DoD has already deployed 
to this region, VA selected the Pacific Northwest to maximize 
efficiencies through DoD's lessons learned. This strategy also allows 
VA to leverage DoD's data hosting environment and adopt enhanced 
cybersecurity protocols to facilitate interoperability.
    For FY 2019, OIT is accessing OEHRM infrastructure funding to 
support IOC with network switch upgrades, bandwidth upgrades, Wi-Fi 
implementation and upgrades, new endpoint devices, surge implementation 
support, and monitoring tools and licenses.

6e. System Implementation

    After implementation at the IOC sites in the Pacific Northwest, VA 
will deploy the new EHR solution across the enterprise. As previously 
discussed, VA will maintain and support VistA until full Cerner 
implementation. This ensures that current patient records are 
accessible and that there will be no interruption in the delivery of 
quality health care to our Nation's Veterans.

                                 
                 Prepared Statement of Carol C. Harris
ELECTRONIC HEALTH RECORDS

    VA Needs to Identify and Report Existing System Costs

    Chair Lee, Ranking Member Banks, and Members of the Subcommittee:

    Thank you for the opportunity to participate in today's hearing 
regarding the Department of Veterans Affairs' (VA) health information 
system-the Veterans Health Information Systems and Technology 
Architecture (VistA)-which has been essential to the department's 
ability to deliver health care to veterans. This technically complex 
system has been in operation for more than 30 years, is costly to 
maintain, and does not fully support exchanging health data with the 
Department of Defense (DoD) and private health care providers.
    VA has initiated a major program to replace the VistA electronic 
health record (EHR) with a commercial-off-the-shelf (COTS) product. The 
department plans to start deploying its new EHR system in March 2020. 
However, VA sites are to continue using VistA until they receive the 
new system during a phased transition over the next 10 years.
    We recently reviewed key aspects of VistA in response to a request 
from the House Committee on Veterans' Affairs. We examined, among other 
things, the extent to which VA has defined VistA and the department's 
annual costs to develop and sustain the system.
    At your request, my testimony for this hearing summarizes the 
findings discussed in our report on VistA, which is being released 
today.\1\ More detailed information on our objectives, scope, and 
methodology for that work can be found in the issued report.
---------------------------------------------------------------------------
    \1\ GAO, Electronic Health Records: VA Needs to Identify and Report 
System Costs, GAO 19 125 (Washington, D.C.: July 25, 2019).
---------------------------------------------------------------------------
    We conducted the work on which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

Background

    VA's mission is to promote the health, welfare, and dignity of all 
veterans in recognition of their service to the Nation by ensuring that 
they receive medical care, benefits, social support, and lasting 
memorials. In carrying out this mission, the department manages one of 
the largest health care delivery systems in the United States that 
provides enrolled veterans with a full range of services. These 
services may include primary care; mental health care; and outpatient, 
inpatient, and residential treatment. The Veterans Health 
Administration (VHA), one of the department's three major components, 
is responsible for overseeing the provision of health care at all VA 
medical facilities.
    Information technology (IT) is widely used and critically important 
to supporting the department in delivering health care to veterans. As 
such, VA operates and maintains an IT infrastructure that is intended 
to provide the backbone necessary to meet the day-to-day operational 
needs of its medical centers and other critical systems supporting the 
department's mission. The infrastructure is to provide for data 
storage, transmission, and communications requirements necessary to 
ensure the delivery of reliable, available, and responsive support to 
all VA staff offices and administration customers, as well as veterans. 
The Office of Information and Technology (OIT) is responsible for 
managing the majority of VA's IT-related functions. The office provides 
strategy and technical direction, guidance, and policy related to how 
IT resources are to be acquired and managed for the department.

VistA's Role at VA

    VA provides health care services to approximately 9 million 
veterans and their families and relies on its health information 
system-VistA-to do so. VistA has been essential to the department's 
ability to deliver health care to veterans. It was developed based on 
the collaboration between staff in the VA medical facilities and VHA IT 
personnel. Specifically, clinicians and IT personnel at the various VA 
medical facilities collaborated to define the system's requirements 
and, in certain cases, carried out its development and implementation. 
As a result of these efforts, the system has been in operation since 
the early 1980s.\2\
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    \2\ VistA began operation in 1983 as the Decentralized Hospital 
Computer Program. In 1996, the name of the system was changed to the 
Veterans Health Information Systems and Technology Architecture, 
referred to as VistA.
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    VistA supports a complex set of clinical and administrative 
capabilities. It is comprised of an architecture that ties together 
servers and personal computer workstations with various applications 
within VA facilities and the supporting infrastructure, such as data 
centers, storage, and messaging technologies. The core system and 
database code are programmed in the MUMPS programming language.\3\ 
Among other things, VistA contains an EHR for each patient and supports 
clinics and medical centers.
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    \3\ The Massachusetts General Hospital Utility Multi-Programming 
System, now referred to as M, or MUMPS.
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    In addition, the system provides functionality beyond the EHR and 
exchanges information with many other applications and interfaces. For 
example, the system also provides the functionality of a time and 
attendance program, asset management system, library, and billing 
system, among other things.
    Users interact with VistA through a number of interfaces that 
connect stored health data. These interfaces enable the system to 
communicate (send or exchange data) with other VA systems, as well as 
with other Federal agencies (e.g., DoD), health information exchange 
networks, and COTS products. According to OIT officials, applications 
either interface with VistA directly through a messaging protocol\4\ or 
extract data from the system via a reporting mechanism.
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    \4\ VistA uses, for example, application programming interfaces, 
remote procedure calls, and Health Level 7 messaging to communicate 
with COTS software, selected IT systems of other Federal agencies, and 
health information exchange networks.
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    The Computerized Patient Record System is a graphical user 
interface to VistA that runs on workstations, laptops, and tablets and 
enables the department to support clinical workflows. Specifically, the 
Computerized Patient Record System enables the department to create and 
update an individual EHR for each VA patient. Among other things, 
clinicians can order lab tests, medications, diets, radiology tests, 
and procedures; record a patient's allergies or adverse reactions to 
medications; request and track consults; enter progress notes, 
diagnoses, and treatments for each encounter; and enter discharge 
summaries.
    According to VHA officials, there are also more than 100 COTS 
products that interface with VistA. In addition to these commercial 
products, medical equipment or devices at local facilities may also 
require interfaces to the system, and these vary on a site-by-site 
basis.

VA Has about 130 Different Versions of VistA

    Over the last several decades, VistA has evolved into a technically 
complex system that supports health care delivery at more than 1,500 
locations,\5\ including VA Medical Centers, outpatient clinics, 
community living centers, and VA vet centers. Customization of the 
system by local facilities has resulted in about 130 clinical versions 
of VistA-referred to as instances.\6\
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    \5\ The VHA Business Function Framework (Version 2.11, May 2016) is 
the department's architectural model that describes the core functions 
related to delivering health care services and supporting the needs of 
veterans, health care providers, and resource partners.
    \6\ A customization might include modifications required to address 
state and local laws regarding health care, such as those related to 
the inputs, outputs, and data required to produce a death certificate. 
A clinical VistA instance includes the EHR. There are a limited number 
of VistA instances that do not support clinical functions.
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    According to the department, no two VistA instances are identical. 
Further, each instance is comprised of over 27,400 routines (executable 
modules of code), which are logically grouped into products or modules. 
VistA products or modules can also be comprised of one or more software 
applications that support health care functions, such as providing care 
coordination and mental health services. The department reported that 
there are approximately 140 to 200 products or modules that comprise 
the system.\7\
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    \7\ Within VistA, nationally released and supported software are 
referred to by VA as Class I software. In addition, instances may also 
be comprised of Class II (regionally deployed and supported) and Class 
III (locally deployed and supported) software.
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    The 130 clinical instances of VistA are operated from four regional 
VA data centers.\8\ Users interact with the system through the 
Computerized Patient Record System. Aggregated clinical data from every 
instance of the system are located on servers hosted at VA's National 
Data Center.\9\
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    \8\ According to VA officials, there are about 39 additional 
instances of VistA that are older and nonoperational but contain 
records and must be maintained or have their data migrated for 
maintenance.
    \9\ The National Data Center is located in Austin, Texas.
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    Over time, VA has identified the need for enhancements and 
modifications to VistA in order to ensure that the system keeps up with 
current technology and health care delivery. However, according to the 
department, the system has become difficult and costly to maintain. 
This is a result of, for example, being programmed in MUMPS, a language 
for which there is a dwindling supply of qualified software developers. 
It is also due to years of decentralized customization of the system by 
staff members who were permitted to develop and implement applications 
at the local level.

OIT and VHA Share Responsibilities for VistA

    OIT and VHA serve as the technical and functional leaders, 
respectively, for the department's health care delivery and, together, 
they have worked to develop and maintain VistA for decades. 
Specifically, OIT is responsible for managing the majority of VA's IT-
related functions. The office provides strategy and technical 
direction, guidance, and policy related to how IT resources are to be 
acquired and managed for the department.
    According to the department, OIT's mission is to collaborate with 
its business partners (such as VHA) and provide a seamless, unified 
veteran experience through the delivery of state-of-the-art technology. 
The Assistant Secretary for Information and Technology/Chief 
Information Officer (CIO) serves as the head of OIT and is responsible 
for providing leadership for the department's IT activities.
    The CIO also advises the Secretary regarding the execution of VA's 
IT systems appropriation, consistent with the Federal Information 
Technology Acquisition Reform Act.\10\ For fiscal year 2019, the 
department has been appropriated $4.1 billion for IT. According to VA's 
budget documentation, about $1.2 billion of this amount is intended to 
support IT staffing and associated costs for approximately 8,100 full-
time employees.
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    \10\ Provisions in IT acquisition reform legislation (commonly 
referred to as the Federal Information Technology Acquisition Reform 
Act, or FITARA) require covered executive branch agencies, including 
VA, to ensure that the CIO has a significant role in the decisionmaking 
process for IT budgeting, and in the management, governance, and 
oversight processes related to IT. See Carl Levin and Howard P. `Buck' 
McKeon National Defense Authorization Act for Fiscal Year 2015 , Pub. 
L. No. 113-291, div. A, title VIII, subtitle D, 128 Stat. 3292, 3438-
3450 (Dec. 19, 2014).
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    VHA provides information and expertise to OIT to support the 
department's health-related information systems. For example, VHA 
officials help identify clinical and business needs used to inform IT 
requirements development.\11\ The Under Secretary for Health is the 
head of VHA and is supported by the Principal Deputy Under Secretary 
for Health, four Deputy Under Secretaries for Health, and nine 
Assistant Deputy Under Secretaries for Health.
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    \11\ VHA is responsible for the Medical Support and Compliance 
budget, which includes ``necessary expenses in the administration of 
the medical, hospital, nursing home, domiciliary, construction, supply, 
and research activities, as authorized by law.''.

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VA Has Begun to Acquire a New EHR System

    After nearly 2 decades of pursuing multiple efforts to modernize 
VistA, in June 2017, the former VA Secretary announced that the 
department planned to acquire the same EHR system that DoD is 
acquiring-Cerner Millennium.\12\ According to the department, it has 
chosen to acquire this product because Cerner Millennium should allow 
VA's and DoD's patient data to reside in one system, thus, potentially 
reducing or eliminating the need for manual and electronic exchange and 
reconciliation of data between two separate systems.
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    \12\ In July 2015, DoD awarded a $4.3 billion contract for a 
commercial EHR system developed by Cerner-Cerner Millennium-to be known 
as MHS GENESIS. The transition to the new system began in February 2017 
in the Pacific Northwest region of the United States and is expected to 
be completed in 2022. The former Secretary of VA signed a 
``Determination and Findings,'' to justify use of the public interest 
exception to the requirement for full and open competition, and 
authorized VA to issue a solicitation directly to Cerner. A 
``Determination and Findings'' means a special form of written approval 
by an authorized official that is required by statute or regulation as 
a prerequisite to taking certain contract actions. The 
``determination'' is a conclusion or decision supported by the 
``findings.'' The findings are statements of fact or rationale 
essential to support the determination and must cover each requirement 
of the statute or regulation. FAR, 48 C.F.R. Sec.  1.701.
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    Accordingly, the department awarded an indefinite delivery, 
indefinite quantity contract to Cerner Corporation in May 2018 for a 
maximum amount of $10 billion over 10 years. Cerner is to replace the 
130 instances of VistA with a standard COTS system to be implemented 
across VA. This new system is to support a broad range of health care 
functions including acute care, clinical decision support, dental care, 
and emergency medicine. When implemented, the new system will be 
expected to become the authoritative source of clinical data to support 
improved health, patient safety, and quality of care provided by VA.
    The Electronic Health Record Modernization (EHRM) program is 
responsible for managing the Cerner contract implementation. For fiscal 
year 2019, the program was appropriated about $1.1 billion for planning 
and managing the transition from VistA to Cerner.\13\
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    \13\ The EHRM appropriation is in addition to the $4.1 billion 
appropriated for IT in 2019.
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    Further, the department has estimated that an additional $6.1 
billion in funding, above the Cerner contract amount, will be needed to 
fund additional project management support supplied by outside 
contractors, government labor costs, and infrastructure improvements 
over the 10-year contract period.
    VA plans to deploy the new EHR system at three initial operating 
capability sites within 18 months of October 1, 2018,\14\ with a phased 
implementation of the remaining sites over the next decade. Each VA 
medical facility is expected to continue using VistA until the new 
system has been deployed. The three initial deployment sites, located 
in the Pacific Northwest, are the Mann-Grandstaff, American Lake, and 
Seattle VA Medical Centers and related clinical facilities that operate 
the same instances of VistA. These are the first locations where the 
system is expected to ``go live.''
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    \14\ Initial operating capability is the contract milestone in 
which the system is intended to meet minimum operational capabilities.
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    The task order to deploy the Cerner system at the three initial 
sites provides a detailed description of the steps Cerner needs to take 
in order to reach initial operating capability at the Mann-Grandstaff 
site in March 2020, and at the Seattle and American Lake sites in April 
2020. According to the schedule, the initial operating capability sites 
are expected to be operational by July 2020.

VA Has Undertaken Efforts to Define VistA, but Additional Work Remains

    In order to maintain internal control activities over an IT system 
and its related infrastructure, organizations should be able to define 
physical and performance characteristics of the system, including 
descriptions of the components and the interfaces.\15\ Further, 
consistent with GAO's Cost Estimating and Assessment Guide, a 
comprehensive system definition should identify customization and the 
environment in which the system operates.\16\ While defining a complex 
IT system can be challenging, having an adequate understanding of its 
characteristics will better position the organization to 
comprehensively project and account for costs over the life of a system 
or program as well as identify specific technical and program risks. 
Definition of VistA remains important because VA plans to continue 
using the system during the department's decade-long transition to the 
Cerner system.
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    \15\ GAO, Standards for Internal Control in the Federal Government, 
GAO 14 704G (Washington, D.C.: September 2014).
    \16\ GAO, GAO Cost Estimating and Assessment Guide: Best Practices 
for Developing and Managing Capital Program Costs, GAO 09 3SP 
(Washington, D.C.: March 2009).
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    VA maintains multiple documents and a database that describe parts 
of VistA, including various components and interfaces. However, despite 
these existing sources, OIT officials acknowledged that there is no 
comprehensive definition of the VistA system. Consequently, VA has 
completed a number of efforts to better define VistA and understand the 
environment in which it operates and additional work is planned in the 
future.
    Specifically, VA has documented descriptions of the system, 
including the components that comprise it. These descriptions are 
documented in multiple sources: the VA Monograph, VA Systems Inventory, 
and VA Document Library.

      The VA Monograph is a document maintained by OIT that 
provides an overview of VistA and non-VistA applications used by 
VHA.\17\ According to VHA officials, the VA Monograph is the primary 
document that describes the components of the system. The Monograph 
describes VistA in terms of modules. For modules identified, including 
VistA modules, information such as the associated business functions, 
VA Systems Inventory identification number, and a link to the VA 
Document Library for additional technical information are provided.
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    \17\ VA, VA Monograph (Washington, D.C.: February 2019).
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      The VA Systems Inventory is a database maintained by OIT 
that identifies current IT systems at the department, including systems 
and interfaces related to VistA.\18\ For systems identified, the 
database includes information such as the system name, the system 
status (i.e., active, in development, or inactive), and related system 
interfaces.
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    \18\ VA, VA Directive 6404: Department of Veterans Affairs VA 
Systems Inventory (VASI) (Washington, D.C., Feb. 23, 2016). According 
to VA Directive 6404, the VA Systems Inventory is the authoritative 
data source for VA's IT systems. OIT is responsible for the development 
and sustainment of the inventory.
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      The VA Document Library is an online resource for 
accessing documentation (i.e., user guides and installation manuals) on 
the department's nationally released software applications, including 
VistA.\19\
---------------------------------------------------------------------------
    \19\ The VA Document Library includes links to documentation on VA 
software organized into the following categories: Clinical, 
Infrastructure, Financial-Administrative, HealtheVet, and Benefits.

    VA has taken additional steps to further define the system. For 
example, EHRM program officials recognized the need to further 
understand the customization of VistA components at the various medical 
facilities and have conducted analyses to do so. These analyses 
---------------------------------------------------------------------------
include:

      Variance analysis: As part of its VistA Evolution 
program,\20\ which has focused on standardizing a core set of VistA 
functionality, the department implemented a process to compare the 
instances of VistA installed at sites to the Enterprise Standard 
version.\21\ The results of this analysis allowed the department to 
assess the criticality of each variance, which is expected to help with 
VA's transition to the Cerner system.
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    \20\ In December 2013, VA initiated VistA Evolution, a joint 
program between OIT and VHA that focused on implementing a collection 
of projects to improve the efficiency and quality of veterans' health 
care. Specifically, it focused on modernizing the VistA system, 
increasing the department's data exchange and interoperability with DoD 
and private sector health care partners, and reducing the time it takes 
to deploy new health information management capabilities.
    \21\ The Enterprise Standard version of VistA represents the 
compilation of different historical releases of VistA where patches 
have been installed.
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      Module analysis: EHRM program subject matter experts 
undertook an analysis that involved reviewing and assessing 
capabilities provided by VistA modules. This analysis enabled 
department officials to determine whether the capability provided by a 
VistA module could be provided by the Cerner system, or whether another 
COTS solution would be required to support this function going forward.
      Visual mapping: EHRM program officials also directed an 
analysis that involved developing a notional visual mapping of VA's 
health care applications, components, and supporting systems within the 
health delivery environment. The results of this analysis provided a 
description of the current state of one instance of VistA and the VA 
health environment, which is intended to inform the department of 
possible opportunities for business process and IT improvements as it 
proceeds with the Cerner acquisition.

    Nevertheless, even with these analyses, VA has not yet fully 
defined VistA, including, for example, identifying performance 
characteristics of the system and describing the environment in which 
it operates. The department's three sources that describe VistA and the 
additional analyses undertaken do not provide insight into site 
specific customizations of the system. For example, the VA Monograph 
does not include information on module customization at local 
facilities. In addition, according to OIT officials, the systems 
inventory does not reflect differences among the 130 different 
instances of VistA and does not take into consideration regional and 
local customizations of related components. Further, the visual mapping 
analysis noted that there was not full insight of the intertwined 
structure of data and applications or the various local customizations 
of VistA.
    EHRM program officials stated that they have not been able to fully 
define VistA and understand all local customizations due to the 
decentralization of the development of the system and its evolution 
over more than 30 years. They explained that VistA's complexity is 
partly due to the various instances of the system, compounded by local 
customizations, which have resulted in differences in VistA instances 
operating at various facilities.
    According to EHRM program documentation, Cerner's contract calls 
for the company to conduct comprehensive assessments to capture the 
current state of technical and clinical operations at specific 
facilities, as well as identify site-specific requirements where the 
Cerner system is planned to be deployed. As of June 2019, Cerner had 
completed site assessments for the three initial operating capability 
sites in the Pacific Northwest and had planned additional assessments 
at future deployment sites. The initial site assessments included, 
among other things, an assessment of the unique VistA instances and the 
environment in which the system operates. The continuation of planned 
site assessments should provide a thorough understanding of the 130 
VistA versions, help the department better define VistA, and position 
it for transitioning from VistA to Cerner's COTS solution.

VA Identified Total VistA Costs of about $2.3 Billion between 2015 and 
    2017, but Could Not Sufficiently Demonstrate the Reliability of All 
    Data and Omitted Other Costs

    When using public funds, an agency must employ effective management 
practices in order to let legislators, management, and the public know 
the costs of programs and whether they are achieving their goals. To 
make those evaluations for a program or for a system as large and 
complex as VistA, a complete understanding of the system and reliable 
cost information is required.\22\ By following a methodology and 
utilizing reliable data, an agency can ensure that all costs are fully 
accounted for, which in turn, better informs management decisions, 
establishes a cost baseline, and enhances understanding of a system's 
performance and return on investment.\23\
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    \22\ In the case of VistA, costs reflect the complexity of the 
system itself and the environment in which it operates, beyond a single 
program.
    \23\ GAO's Cost Estimating and Assessment Guide describes a 
methodology for compiling an exhaustive and structured accounting of 
all resources and all costs required to develop and sustain a 
particular program or, in this case, a system. Specifically, the 
methodology describes the importance of documenting which costs are 
included and how they are calculated in detail, step by step, to 
provide enough information so that someone unfamiliar with the program 
or system could easily recreate or update cost calculations. Further, 
the methodology should include all assumptions and explanations for why 
particular data sets are chosen and why these choices are reasonable to 
allow for the assessment of the total accounting and the reliability of 
the cost data.
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    Fundamental characteristics of reliable costs are that they should 
be accurate (unbiased, not overly conservative or optimistic), well-
documented (supportable with source data, clearly detailed 
calculations, and explanations for choosing a particular calculation 
method), credible (identifying any uncertainty or biases surrounding 
data or related assumptions), and comprehensive (costs are neither 
omitted nor double counted). Identification of VistA's costs remains 
important because VA plans to continue using the system during the 
department's transition to the Cerner system over the next decade.
    VA identified costs for VistA and its related activities adding up 
to approximately $913.7 million, $664.3 million, and $711.1 million in 
fiscal years 2015, 2016, and 2017, respectively-for a total of about 
$2.3 billion over the 3 years.\24\ However, the department could not 
sufficiently demonstrate the reliability of certain costs that were 
identified. In addition, VA identified other categories of VistA-
related costs, but omitted these costs from the total.
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    \24\ We previously testified in June 2018 that preliminary costs 
reported by VA for VistA and related activities included approximately 
$1.1 billion, $899 million, and $946 million in fiscal years 2015, 
2016, and 2017, respectively, for a total of about $3.0 billion over 3 
years to support the system (see GAO, VA IT Modernization: Preparations 
for Transitioning to a New Electronic Health Record System Are Ongoing, 
GAO 18 636T (Washington, D.C.: Jun. 26, 2018)). Since that time, 
updates were made in OIT's budget tracking tool and EHRM program 
officials revised the approach to estimating certain types of costs.

VA Did Not Sufficiently Demonstrate the Reliability of Data for All 
---------------------------------------------------------------------------
    VistA Costs

    Of the $2.3 billion total costs for VistA, VA demonstrated that 
only approximately $1 billion of these costs were reliable. 
Specifically, OIT officials identified VistA-related costs within seven 
categories. The officials were able to sufficiently explain why these 
categories were included in the development and sustainment costs for 
VistA and how they were documented by the department; the officials 
also presented detailed source data for our examination. As a result of 
our review, we determined that the cost data for these seven categories 
were accurate, well-documented, credible, and comprehensive and, thus, 
sufficiently reliable.\25\
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    \25\ OIT program costs excluded pay and administrative costs, which 
are not tracked within OIT by program.
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    Table 1 provides a summary of the program costs identified for 
VistA by OIT and VHA for fiscal years 2015 through 2017 that we 
determined to be reliable.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 



    As shown in the table, VA identified costs for the following seven 
categories for fiscal years 2015 through 2017:

      VistA Evolution - The VistA Evolution program costs were 
associated with VistA strategy, system design, product development, and 
program management. These costs totaled approximately $549.6 million.
      Interoperability - The Interoperability program focused 
on sharing electronic health data between VA and non-VA facilities, 
including private sector providers and DoD.\26\ For example, 
interoperability costs were associated with architecture, strategy, the 
Interagency Program Office, product development, and program 
management.\27\ These VistA-related costs totaled approximately $140.2 
million.
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    \26\ The Interoperability program was previously reported under the 
Electronic Health Record Interoperability program.
    \27\ Provisions included in the National Defense Authorization Act 
for Fiscal Year 2008 required VA and DoD to, among other things, 
jointly develop and implement fully interoperable EHR systems or 
capabilities and establish an Interagency Program Office to be a single 
point of accountability for their efforts. According to the act, the 
office was given the function of implementing, by September 30, 2009, 
EHR systems or capabilities that would allow for full interoperability 
of personal health care information between the departments. Pub. L. 
No. 110-181, Sec.  1635, 122 Stat. 3, 460-463 (2008).
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      Virtual Lifetime Electronic Record (VLER) Health - This 
program focused on streamlining the transition of electronic medical 
information between VA and DoD.\28\ These VistA-related costs were 
associated with product development and program management and totaled 
approximately $81.2 million.
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    \28\ VLER Health initially started in 2009. According to VA, this 
program is now referred to as the Veterans Health Information Exchange.
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      Contracts - Contract costs for VistA Evolution included 
VHA's obligations associated with workload management, change 
management, clinical requirements, and clinical interoperability. These 
VistA-related costs totaled approximately $202.8 million.
      Intergovernmental personnel acts - Intergovernmental 
personnel acts are agreements for the temporary assignment of personnel 
between the federal, state, and local governments; colleges and 
universities; Indian tribal governments; federally funded research and 
development centers; and other eligible organizations. These costs 
accounted for VHA's need to use outside experts from approved entities 
for limited periods of time to work on VistA Evolution assignments. The 
total VistA-related costs were approximately $2.4 million.
      Memorandums of understanding - According to VHA, 
memorandums of understanding are agreements used by the administration 
to obtain the services of personnel between VA entities for VistA-
related activities. These agreements accounted for approximately $2.3 
million.
      Pay - Costs in this category included salaries for VHA 
staff who worked on VistA-related projects as well as travel, training, 
and supply costs associated with employment. These costs totaled 
approximately $34.1 million.

    However, VA was not able to sufficiently demonstrate the 
reliability of approximately $1.3 billion in costs related to VistA. 
Specifically, OIT officials identified the additional legacy VistA 
costs that generally fell into three categories:

      Legacy VistA: Infrastructure, hosting, and system 
sustainment - Legacy VistA costs are generally related to the 
maintenance of fully operational items, such as VistA Imaging and 
Fileman-two key components related to VistA's operation.\29\ The costs 
also included obligations for costs related to hosting health data in 
both VA and non-VA facilities.\30\ The OIT officials and subject matter 
experts estimated these total costs to be approximately $343 million 
during fiscal years 2015 through 2017.
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    \29\ According to the VistA 4 Product Roadmap, VistA Imaging is the 
clinical imaging interface designed and developed by VHA to incorporate 
image and document data, and attach said data to the veteran's EHR. It 
also provides specific applications used for Telehealth. File Manager 
(referred to as FileMan) serves as the data base management system for 
VistA, providing both structure for the data in VistA's database and 
the interface to VistA's data.
    \30\ Co-location is when an instance of VistA is hosted in a data 
center with other systems and includes costs, for example, of leasing 
space and related utilities.
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    However, we were not able to determine the reliability of these 
costs because, for example, source data were not well documented; 
changes in the cost information provided to us during our review 
indicated that the cost data may not be credible; and subject matter 
experts were unclear about how to separate VistA costs from non-VistA 
costs.
      Related software - Related software costs are associated 
with the software supporting, or closely integrated with, VistA that 
were identified by EHRM officials, yet not tracked directly for one of 
the VistA-related programs. Both OIT and VHA identified software 
licensing costs as VistA-related obligations. The EHRM program reported 
these costs to be approximately $389 million in total during fiscal 
years 2015 through 2017.
    However, we were not able to determine the reliability of the costs 
in this category for a variety of reasons, including that source data 
were not well documented. In addition, VA officials were not clear 
regarding how the total amounts in each category should be divided 
between OIT and VHA. Given this confusion, we were not able to 
determine if the costs were fully accurate or credible.
      OIT personnel (pay and administrative) - According to 
EHRM officials, OIT does not track labor costs by program. Instead, the 
department provided estimations of the amount of salaries paid to OIT 
government staff working on activities such as VistA Evolution, program 
management, and overall support of VistA and related applications. OIT 
personnel costs were estimated by the EHRM program office to be 
approximately $544 million total during fiscal years 2015 through 2017.
    However, we were not able to determine the reliability of costs in 
this category because assumptions made for estimating the personnel and 
salary costs were not well documented and could not be verified.

VA Omitted Certain Costs from the Total Cost of VistA

    In addition, VA omitted certain VistA costs from the total costs 
identified for fiscal years 2015, 2016, and 2017. Specifically, VA 
omitted the following costs:

      Additional hosting - OIT officials stated that additional 
costs related to hosting health data by an outside vendor, as well as 
hosting backup VistA instances at each of the medical center sites, 
should also be included in the total costs for VistA; however, VA 
omitted these costs from the total for fiscal years 2015 through 2017. 
Specifically, according to the officials, calculating costs for these 
hosting activities requires subject matter experts to identify 
equipment, space, utilities, and maintenance costs for resources 
allocated specifically for VistA. However, the department has not yet 
developed a methodology to calculate the costs. The officials said they 
were working on identifying a reliable approach for calculating these 
costs in the future.
      Data standardization and testing - OIT officials stated 
that additional costs related to work on clinical terminology mapping 
and functional testing were not included in the total costs for VistA 
for fiscal years 2015 through 2017. This work related to mapping 
existing clinical data to national standards and making updates to 
VistA or the Joint Legacy Viewer and included mapping data and building 
test scripts and reports.\31\ OIT officials noted that this work had 
been critical to the VistA Evolution program, but they did not provide 
actual cost data in this category.
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    \31\ The Joint Legacy Viewer is a web-based graphical user 
interface, first released in 2013, that was developed jointly by VA and 
DoD. This tool provides a near real-time, integrated, and chronological 
view of EHR information contained in VistA and existing DoD systems, as 
well as data from some third-party providers. The Joint Legacy Viewer 
allows VA clinicians to view a read-only display of patient data from 
DoD as well as from a number of other medical providers.
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    The lack of sufficiently reliable and comprehensive costs indicates 
that the department is not positioned to accurately report the annual 
costs to develop and sustain VistA. This is due in part to VA not 
following a well-documented methodology that describes how the 
department determined the total costs for the system. In lieu of a 
methodology, OIT officials said that leadership and staff from the 
program took efforts to identify and track the cost components and 
contracts associated with the system. However, they noted that costs 
associated with VistA were not all clearly labeled as VistA in an IT 
system and it was necessary to estimate other costs. The officials were 
also unable to verify how VistA-related costs were separated from other 
department costs in all areas and subject matter experts were not 
consistently familiar with the estimation methods employed and how 
VistA was defined for the purposes of calculating costs. Further, VA 
officials noted that they were still working on the best approach to 
identifying and calculating omitted costs.
    Without documenting the methodology for what costs are to be 
included and how they were identified and calculated, VA's total does 
not accurately reflect the development and sustainment costs for VistA. 
As a result, the department, legislators, and the public do not have 
the comprehensive, reliable information needed to understand how much 
it actually cost to develop and maintain the system. Further, VA does 
not have the reliable information needed to make critical management 
decisions for sustaining the many versions of VistA over the next 10 
years until the Cerner system is fully deployed.

Implementation of GAO's Recommendation Could Help Ensure VA Reliably 
    Reports VistA Costs

    In our report, we are making a recommendation for VA to improve its 
reporting of VistA's costs. Specifically, we are recommending that the 
department develop and implement a methodology for reliably identifying 
and reporting the total costs of VistA. The methodology should include 
steps to identify the definition of VistA and what is to be included in 
its sustainment activities, as well as ensure that comprehensive costs 
are corroborated by reliable data. In written comments on a draft of 
the report, the department agreed with the recommendation and stated 
that it will provide the actions it plans to take to address this 
recommendation within 180 days.
    In conclusion, although VA is not likely to be positioned to retire 
VistA for at least another 10 years, the department lacks the 
comprehensive and reliable cost information needed to make critical 
management decisions for sustaining the system. As the department 
continues to work toward acquiring a new electronic health record, it 
will be important for VA to take actions to address our recommendation 
for improving the reporting of VistA costs. Doing so is essential to 
helping ensure that decisions related to the current system are 
informed by reliable cost information and that there is an accurate 
basis for reporting on the return on its investment for replacing 
VistA.
    Chair Lee, Ranking Member Banks, and Members of the Subcommittee, 
this completes my prepared statement. I would be pleased to respond to 
any questions that you may have.

GAO Contact and Staff Acknowledgments

    If you or your staffs have any questions about this testimony, 
please contact Carol C. Harris, Director, Information Technology 
Management Issues, at (202) 512-4456 or [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this testimony statement. GAO staff 
who made key contributions to this testimony are Mark Bird (Assistant 
Director), Rebecca Eyler, Jacqueline Mai, Monica Perez-Nelson, Scott 
Pettis, Jennifer Stavros-Turner (Analyst in Charge), and Charles 
Youman.

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