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






 
                          GO-LIVE MARCH 2020:.
                      THE STATUS OF EHRM READINESS

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

                                HEARING

                               before the

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      WEDNESDAY, NOVEMBER 20, 2019

                               __________

                           Serial No. 116-48

                               __________

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


                    Available via http://govinfo.gov
                    
                    
                    
                    
                          ______

             U.S. GOVERNMENT PUBLISHING OFFICE 
41-378                WASHINGTON : 2022 
                     
                    
                    
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

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

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                     SUSIE LEE, Nevada, Chairwoman

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

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

                         C  O  N  T  E  N  T  S

                              ----------                              

                      WEDNESDAY, NOVEMBER 20, 2019

                                                                   Page

                           OPENING STATEMENTS

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

                               WITNESSES

Honorable James Byrne, Deputy Secretary, Department of Veterans 
  Affairs........................................................     4

        Accompanied by:

    Dr. Robert J. Fischer, Director, Mann-Grandstaff VA Medical 
        Center, Department of Veterans Affairs

    Mr. Michael Tadych, Director, VA Puget Sound Health Care 
        System, Department of Veterans Affairs

    Dr. Steven Lieberman, Acting Principal Deputy Undersecretary 
        for Health, Veteran Health Administration, Department of 
        Veterans Affairs

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

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

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

                                APPENDIX
                     Prepared Statement Of Witness

Honorable James Byrne Prepared Statement.........................    29


                          GO-LIVE MARCH 2020:

                      THE STATUS OF EHRM READINESS

                              ----------                              


                      WEDNESDAY, NOVEMBER 20, 2019

              U.S. House of Representatives
              Subcommittee Technology Modernization
                             Committee on Veterans' Affairs
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 1:36 p.m., in 
room 210, House Visitors Center, Hon. Susie Lee [chairwoman of 
the subcommittee] presiding.
    Present: Representatives Takano, Cunningham, Schrier, 
Kilmer, Larson, Banks, Watkins, Rodgers.

           OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN

    Ms. Lee. Good afternoon. This hearing will come to order. 
Before we begin, I would like to ask for unanimous consent for 
members of the Washington delegation to participate in today's 
hearings, should they be able to attend, and, without 
objection, so ordered.
    Today, the subcommittee continues its oversight of the 
Department of Veterans Affairs implementation of the Electronic 
Health Record Modernization (EHRM) program. We have reached a 
critical juncture in the implementation. We are now a little 
more than 4 months from the plan go live in Spokane, 
Washington, on March 28th, 2020.
    Over the last 18 months, many activities have occurred in 
support of this effort. I commend the VA and thank you for 
being here for your approaching this as much more than an IT 
upgrade. It is an opportunity to modernize the way the VA 
provides healthcare to veterans and has the potential to 
improve healthcare outcomes throughout our Nation.
    However, many questions remain about VA's readiness to 
operate the Cerner Millennium system in a clinical environment. 
The outstanding punch list of configuration, interface 
development, testing, and training does not fully express just 
how complex and necessary each of those elements are. If any of 
those items are not completed in a timely manner, it will be 
very difficult for the VA to bring the system online in a 
manner that does not compromise patient care.
    In just a couple weeks, the VA will need to pass through a 
major milestone, the first of two integrated validation events 
or dry runs. These events will essentially allow the VA to 
assess how the new system works and if the VA is ready to go 
live.
    I know that Cerner has been engaged in testing individual 
modules, but we need the entire integrated system to be tested 
so that it can be used for training. We cannot make the same 
mistake that the Department of Defense (DOD) did in its Initial 
Operational Capability (IOC) where it tested on a mock-up 
system.
    As I have said since I became chair of the subcommittee, 
the most important thing is that the VA get this right, not 
that it hits an arbitrary deadline. I am concerned that the VA 
has not given itself enough time to fully test the system, nor 
have they allowed time for all users to adequately train on it.
    I think the full complexity of this project became apparent 
when the VA decided to roll out capabilities in two different 
sets. While it certainly makes it more digestible to make two 
smaller bites, that does not alleviate the pressure of 
infrastructure, staffing, and community-access concerns at 
Mann-Grandstaff. Those issues need to be resolved or mitigated 
for a successful rollout to occur.
    This subcommittee needs an honest assessment of where 
things stand with readiness at the individual facilities. There 
are also joint decisions and actions that the VA and DOD must 
make together, including data strategy and rules governing the 
connection to existing systems. I believe that if the VA and 
DOD had invested more fully into joint governance, these 
potential pitfalls could have been mitigated, yet here we are 
right now and must take the necessary steps to address these 
issues moving forward.
    I am also concerned about the level of communication 
between the VA and our veterans. While having an integrated 
health record someday will improve veteran care, the process of 
implementing it will be far from painless for its users.
    As I learned when I traveled to Madigan Army Medical Center 
earlier this year, there were a lot of patient-care pain 
points, including referral management, pharmacy access, and 
patient communication. I still have not seen enough information 
from VA to understand how these issues have been addressed for 
the VA go live.
    Before us today we have accountable officials from each 
level of implementation. I am pleased to have the deputy 
secretary joining us today as the lead accountable official on 
this program. I especially want to hear your perspective on the 
State of readiness.
    We also have officials representing the clinical operations 
of the VA, the program office, and most important, the facility 
leadership. I look to our facility leadership as the last 
bastion of patient care and safety.
    Both, Dr. Fischer and Dr. Tadych have been observing the 
day-to-day process of EHRM implementation and I want to hear 
your perspectives on your facilities' preparations. I expect 
each official at the witness table to provide an honest 
assessment of where things stand and what more needs to be 
done.
    While there are no certainties in any IT implementation, 
there should be no surprises, due to a lack of preparation. We 
will judge whether this program is ready to meet the needs of 
clinicians and veterans by what we hear today.
    I thank all of you for being here and I look forward to 
your testimony. I would now like to recognize my colleague 
Ranking Member Banks for 5 minutes to deliver his opening 
remarks.

         OPENING STATEMENT OF JIM BANKS, RANKING MEMBER

    Mr. Banks. Thank you, Madam Chair.
    First, I want to thank our witnesses for joining us this 
afternoon. This is a large and distinguished panel. I 
especially want to thank Deputy Secretary Byrne and Directors 
Fischer and Tadych.
    Dr. Fischer and Mr. Tadych, our goal is to make sure you 
have everything you need to be successful.
    I am cautiously optimistic that a March 28, 2020, go live 
is still achievable in Spokane. That being said, a few weeks 
may make the difference between a relatively smooth go live and 
a rough go live. A rough go live is clearly not in anyone's 
interests.
    The schedule is a tightly linked series of milestones from 
now until March. Configuration and design decisions were made 
to be made even after the end of the workshops. Dozens of more 
systems interfaces must be built and authorizes to connect to 
the network must be received from DOD. Each of the precursors 
must be completed in order to proceed with testing and 
training.
    It is easy to imagine some of these targets may slip. If 
that happens, I urge VA and Cerner to take the time necessary 
to get it right, rather than adhering to a symbolic deadline. I 
understand VA's rationale for going live with an initial set of 
Cerner capabilities known as block one in Spokane. Somewhere 
has to go first and Spokane is first.
    The need to navigate back and forth between Vista and 
Cerner will undoubtedly impact this user experience. That is 
why it is so important that the Spokane employees be able to 
train on the actual production system before go live, not 
merely a mock-up training system. If a few more weeks are 
needed to make the training more meaningful, I take the VA to 
take it.
    Similarly, if an interface cannot be completed in time or 
DOD does not grant an authority to connect when needed, I hope 
VA will seriously consider taking additional time to complete 
the task, rather than allowing that particular Cerner module to 
fall out of block one and into block two.
    There is no question that the Spokane Medical Center has a 
bumpier road ahead of it and by virtue of going first than the 
medical centers that will follow. That means Spokane needs 
resources. I have been hearing VHA leaders make significant 
commitments to provide Spokane with the resources and that is 
encouraging. Little time remains before March 2020 to translate 
these commitments into action.
    I very much appreciate Dr. Lieberman joining us today and I 
hope to get some conclusive assurances as to when additional 
funding and personnel will be provided to mitigate the 
disruptions.
    Finally, I would like to turn to the subject of the Federal 
EHR Modernization Office. It is clear to me that the firm's 
interim leaders, Dr. Evans and Ms. Jowers, are making a 
positive impact. Notwithstanding their tiny staff and 
shoestring budget, they have taken the initiative to unblock as 
many decisions as they can between VA and DOD.
    However, after several letters, staff meetings, a hearing, 
and a roundtable discussion with leaders from both departments, 
I am still uncertain what the ultimate plan for the Federal 
Electronic Health Record Modernization (FEHRM) is, and the 
behind-the-scenes maneuvering that I have observed in recent 
months over which department will control the office concerns 
me. After being assured since the summer that the signing of 
the firm's charter was close at hand, I was surprised to 
receive a letter last week informing me that its organizational 
structure will be finalized over the next 6 months and its 
processes will be forthcoming over the next year.
    If that is the case, given where we are in the calendar, I 
think the size and scope of the FEHRM should be scaled 
according to what is achievable at this point. The original 
vision of a large, centralized program management office 
sitting on top of the existing VA and DOD Electronic Health 
Record (EHR) program offices and absorbing their joint 
functions no longer seems realistic. An empowered, small, agile 
firm seems to be more realistic.
    Regardless of when the FEHRM takes shape and how big or 
small it may be, the one thing that has always been clear is 
its mission should be broadly focused on the exchange of health 
information for patient-centered care. It was a mistake to 
narrowly focus the Interagency Program Office's mission on EHRs 
and we would be foolish to repeat that mistake.
    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. Mr. Jim Byrne, the deputy secretary of 
the Department of Veterans Affairs. With the deputy secretary 
is Dr. Steven Lieberman, acting principal deputy under 
secretary for health within the Veterans Health Administration; 
Mr. John Windom, executive director of the Office of Electronic 
Health Record Modernization (OEHRM); Dr. Laura Kroupa, chief 
medical office, OEHRM; and Mr. John Short, chief technology and 
integration officer for OEHRM; Dr. Robert Fischer, director of 
Mann-Grandstaff VA Medical Center; and Mr. Michael Tadych, 
director of Puget Sound's VA Medical Center.
    We will now hear the prepared statements from our panel 
members. Your written statement in full will be included in the 
hearing record, without objection.
    Secretary Byrne, you are now recognized for 5 minutes.

                    STATEMENT OF JAMES BYRNE

    Mr. Byrne. Madam Chair Lee, Ranking Member Banks, 
distinguished members of the subcommittee, good afternoon, and 
thank you for this opportunity to testify about VA's 
transformation of our electronic health record system, and 
thank you, also, for your unyielding support of veterans and 
their families.
    It has now been about 18 months since VA awarded a contract 
to implement the same EHR solution being deployed by the 
Department of Defense. We awarded this contract because this 
solution keeps patient data in a single hosting site using a 
common system. It enables easier and more efficient sharing of 
health information between VA and DOD, creating seamless 
transitions and servicemembers become veterans. It improves 
delivery and coordination of care, scheduling of appointments, 
reimbursement to providers, and efficient healthcare research, 
and it provides clinicians with the data and tools to support 
timely, safe, quality care.
    Our goal at VA is to improve veterans' lives. We can do 
that by delivering an EHR that is easier for veterans, VA 
clinicians, employees, and Community Care providers to 
understand and use. This is the right thing to do for veterans.
    VA has accomplished several key milestones in support of 
our electronic health record modernization effort. First, we 
have awarded and are executing 20 task orders, leveraging the 
indefinite delivery, indefinite quantity contract structure, 
which assures firm, fixed pricing, as requirements are 
validated. This strategy affords us the flexibility to 
efficiently moderate work and deployment plans.
    Second, we have continued to refine our organizational 
structure for success. In June 2018, we established our VA 
Office of Electronic Health Record Modernization, OEHRM, to 
ensure that we successfully prepare for and manage deployment 
of our new EHR solution.
    John Windom leads OEHRM, reporting directly to me, while 
working closely with the Veterans Health Administration and our 
Office of Information Technology and ensuring coordination with 
the Department of Defense. That coordination with DOD is 
critical for transparency between departments, open 
decisionmaking, risk mitigation, and rapid implementation of 
recommended changes.
    Our two departments have also instituted an interagency 
working group facilitated by the Federal Electronic Health 
Record Modernization Office, the FEHRM, to ensure we achieve 
interoperability objectives, address challenges, and reduce 
potential risks.
    We are working with DOD to fully develop a firm joint 
governing strategy to further promote rapid and agile 
decisionmaking. We will jointly present our final plan to 
Congress, including our implementation, phase execution, and 
leadership plans.
    Third, we are continuing to refine implementation planning 
and strategy to carry us through the decade that it will take 
to fully implement the new EHR solution and enable us to 
integrate new technical advances as they are made. Critical to 
this is working proactively with DOD and private sector experts 
to reduce potential risks by using lessons learned from DOD and 
others.
    Madam Chair, in my travels to VA sites across the country, 
I have encountered a palpable sense of excitement about our 
electronic health record modernization, and as I have said 
before, I have had hospital directors, administrators, and 
clinicians ask me how their facility can be moved up on the 
schedule for fielding the EHR solution. Because they work 
closely with veterans and their families, they recognize the 
vast potential for improvements in timeliness, quality of care, 
reducing risk, treatment of chronic conditions, research, and 
in many other areas of care. They want it now because they know 
it will help veterans.
    Fourth, we established 18 EHR councils to support the 
development of national standardized clinical and business 
workflows. These councils are primarily comprised of clinicians 
who provide care for our veterans and represent each of the 
functional areas of the EHR solution, including behavioral 
health, pharmacy, ambulatory, dentistry, and business 
operations. The council members supported the 8 national 
workshops we planned and executed to educate diverse clinical-
end users and validate workflows to ensure our EHR solution 
meets our needs. We will continue to seek information, advice, 
and recommendations from VA employees and clinicians who 
provide care to veterans every day.
    Last, VA identified infrastructure challenges at our 
initial operating capability sites to require upgrades to 
support the optimal use of VA's new EHR solution and to date, 
VA improved system performance by increasing network bandwidth 
and upgrading aging infrastructure which has led to reduced 
log-in times at our IOC sites from over 30 minutes to 15 
seconds.
    In closing, thank you all once again for your support of 
veterans and VA and for helping us tremendously with generous 
and flexible funding for this important EHR solution. We 
recognize the imperative for transparent and careful use of 
those appropriated funds and we are all committed to 
strengthening the VA system in support of veterans, their 
families, caregivers, and survivors. Our new EHR will help us 
do just that and strengthen the ties that bind veterans to 
their VA.
    Thank you, and we look forward to your questions.

    [The prepared statement of James Byrne appears in the 
Appendix]

    Ms. Lee. I will now recognize Chairman Takano for 5 
minutes.
    Mr. Takano. Thank you, Chairwoman Lee, Ranking Member 
Banks. Thank you for letting me join you today. Unfortunately, 
I have another obligation so I cannot stay very long, but I am 
committed to the success of this project and I wanted to be 
here for as much time as I am able.
    I was in a chairman's or chairperson's meeting this morning 
and I brought up the Tech Modernization Committee meeting and 
our chairwoman of appropriations leaned over and said, I want 
more details on this, because she remembers the previous times 
that the integration did not work. I want you to know that 
senior members of this Congress have burned in their memory, 
the failure of our previous attempts to integrate the records.
    Mr. Deputy Secretary and all witnesses, thank you for 
joining us today and thank you for your commitment to this 
project and our veterans and I hope we are going to get it 
right. Our committee has been tracking the progress of VA's 
modernization efforts for almost 20 years. We are cautiously 
optimistic that VA is engineering the goal of a single health 
record for servicemembers and veterans with its implementation 
of the Cerner Millennium product.
    I echo Chair Lee's concern that it is critically important 
that VA get this right. Budgets and timelines are important, 
but we cannot afford to get this wrong; our veterans expect and 
deserve better.
    For Secretary Byrne, I want to ask you: How confident are 
you that Mann-Grandstaff is going to be ready to go live in 
March and that it will be a successful go live?
    Mr. Byrne. I am very confident, sir.
    Mr. Takano. What makes you say that?
    Mr. Byrne. We have a governance construct that is in place 
that provides oversight and drills down into the various issues 
and challenges we have. We very much appreciate that this is a 
major, major undertaking for any agency or any healthcare 
system, but we have metrics that we are tracking very closely. 
We have go to green plans for those that are behind or not on 
track and at this point, I have a tremendous amount of 
confidence in the team that we have assembled to do this.
    The cooperation between Office of Information and 
Technology (OIT), Veterans Health Administration (VHA), and the 
OEHRM office is superb. What I can also share with you, too--it 
may have been by circumstance that I can explain if you would 
like--that we picked Veterans Integrated Services Network 
(VISN) 20 in Washington State and the facility in Spokane. I 
have had an opportunity to visit with the director, his 
leadership team, and many of the employees. If I had to pick a 
facility to launch it in, I would have picked that site.
    Mr. Takano. All right. Thank you.
    Dr. Fischer, Mann-Grandstaff in Spokane, when--this is 
about Mann-Grandstaff, the Spokane site--when the committee 
staff visited your facility this summer, they heard from your 
staff that there were grave concerns about staffing shortages 
in productivity loss during the go live process. Is there a 
plan to bring temporary staff onboard at Mann-Grandstaff or to 
use staff from other VA or DOD facilities to cover gaps?
    Dr. Fischer. Sir, we have a plan to augment our staffing by 
hiring permanent staff to the tune of 108 full-time 
equivalents. Many of these staff members are in high-turnover 
areas, so depending on the requirements at 6 months, 9 months, 
12 months after go live, we would allow those positions to 
attrition over time.
    We also are leveraging telehealth. We have a telehealth hub 
in Boise. We are bringing 30 traveling nurses to the campus. If 
asked, I would say I am optimistic, as well.
    Mr. Takano. I am pleased to hear you have augmented your 
staff with permanent full-time equivalents and there must be, 
then, what exists is a plan anticipating this loss of 
productivity that would happen at a go live.
    Would you share that plan with the committee.
    Dr. Fischer. Sure. The augmentation plan is under execution 
right now. I do not want to misdirect the committee. We have 
hired roughly 50 percent of that 108 Full Time Equivalency 
(FTE) augmentation and we continue to recruit right up through 
go live.
    Mr. Takano. Not only do you have a plan, but you are 
executing the plan?
    Dr. Fischer. Yes, sir.
    Mr. Takano. Just have us--if you could get us the plan----
    Dr. Fischer. Sure.
    Mr. Takano.--and the sort of fuller, flushed-out plan that 
you have so the committee could review it.
    Dr. Fischer. Along with the VISN and Veterans Affairs 
Central Office (VACO) leadership, we started to model what we 
thought efficiency loss would be as we went live as the first 
pilot site for EHR modernization. We know in speaking with 
Fairchild leadership after I arrived, they had recently 
implemented the DOD solution, Cerner solution, and we felt that 
a 30 percent estimate for some periods of time seemed quite 
reasonable.
    Based on that we went service by service and looked at what 
that would mean in terms of augmented staff to limit purchased 
care during that period of transformation.
    Mr. Takano. My time is up. What I just want is your 
assurance you will get us the plan.
    Dr. Fischer. Oh, no problem. It has been written and 
established for many months.
    Mr. Takano. That is what I am asking. Thank you, sir.
    Dr. Fischer. You are welcome, sir.
    Mr. Takano. I yield.
    Ms. Lee. Thank you, Mr. Chairman.
    I now recognize Ranking Member Banks for 5 minutes for his 
questions.
    Mr. Banks. Thank you, Madam Chair.
    Deputy Secretary Byrne, I believe you coined the term 
``purple people'' or ``purple person'' earlier this year in 
testimony to another committee. I understand that a purple 
person is meant to mean someone who represents the priorities 
of DOD and VA equally and is an honest broker in inter-
departmental debates.
    Am I describing that correctly?
    Mr. Byrne. Yes, sir. It is modeled off of a concept of as, 
the joint chairman--the chairman of the joint chiefs of staff 
and DOD--exactly right--they may wear the uniform or be paid by 
a particular service, but they watch out for the broader 
interest of our Nation's military.
    Mr. Banks. Great. Do you believe that Dr. Evans, the 
interim director of the FEHRM is a purple person?
    Mr. Byrne. He is an incredible person and he was not 
necessarily selected for his purple characteristics, per se, 
nor was Ms. Joers, but they have proven to be an incredible 
team that, together, I think give the balance that we need for 
the decisions that need to be made during this interim period 
of time.
    To answer your question, the focus was not on looking at 
them as a purple person. I would suggest it is possible that he 
has grown into that purple person as we look for a more 
permanent leadership going forward.
    Mr. Banks. They do not necessarily fit the description or 
the intent of what you meant by a purple person?
    Mr. Byrne. For the interim, that was not, from my 
perspective, was not one of the major, driving factors.
    For the permanent position, that is a requirement; 
something we will demand from that. Yes, there was a look at 
both of those individuals who are now in the interim FEHRM to 
ensure that they were mature, professional, balanced; they 
could embrace making the decision for the best.
    I guess I do not want to put too much of an emphasis that 
we hired them because they were purple; they very much come 
with stripes from their respective organizations. The big focus 
will be on the permanent positions. That is where the purple is 
a requirement.
    Mr. Banks. As I said in my opening remarks, I commend Dr. 
Evans and Ms. Joers for their initiative and I am interested in 
how the strategic vision for the FEHRM has changed over the 
course of this year.
    Is the FEHRM now intended to be a decisionmaking authority, 
similar to how it functions now or a program management office 
in your best estimation?
    Mr. Byrne. The first: a decisionmaking body. We have a 
program management office that is in place led by John Windom, 
seated to my left.
    Mr. Banks. Good. Got it.
    Secretary Byrne, in February and March of next year, the 
EHR program in the Spokane Medical Center is supposed to go 
through the final milestones in a go/no-go indicators to 
determine whether everything is in order for the March 28 go 
live.
    What is your role and authority in making that decision?
    Mr. Byrne. You are talking about a delay or a stop 
production is what I presume you are asking?
    Mr. Banks. A go/no-go decision ongoing live.
    Mr. Byrne. I have the authority as the accountable official 
under the Appropriations Act of 2018, but a go or no-go 
decision would be made by the secretary with the 
recommendations coming from me and several people on this panel 
today.
    Mr. Banks. What would you say Dr. Evans' role in authority 
would be in making those decisions?
    Mr. Byrne. He does not have the authority to stop the 
trains, but he is in a position like a lot of people are, 
particularly those who are out in the field, particularly those 
who are seated to my right, that if there is a patient-safety 
issue, we expect and demand that they raise their hand and we 
address whether we need to have a delay or stop things in 
process.
    Dr. Lieberman, I ask you this as Dr. Stone's 
representative. What is Dr. Stone's role in authority in making 
that decision?
    Dr. Lieberman. Dr. Stone is very involved with this 
process, all of our meetings; is just so involved, so invested 
in this. We all want to see this program succeed.
    Certainly, we are supporting the field leadership, again, 
sitting to my right. We are looking for them to tell us whether 
they think that they have what they need to go live or not go 
live and we will certainly advocate for their recommendations.
    Mr. Banks. Dr. Fischer, what would you like to add about 
your role in making the go live decision?
    Dr. Fischer. Well, Dr. Stone and the Office of EHR 
Modernization have made it clear that I would have an 
opportunity to make a recommendation whether we were prepared 
or not.
    I am an obstetrician by training. I know what it is to 
assess risks and to make difficult decisions and I am prepared 
to do so in this case.
    Mr. Banks. All right. My time is expired. I yield back.
    Ms. Lee. Thank you. I will now recognize myself for 5 
minutes.
    Secretary Byrne, what has been--and this is more for the 
record--what has been your role in the preparations for go 
live?
    Mr. Byrne. I have been intimately involved in the 
governance construct that we have set up metrics, milestones, 
to move this initiative forward; mostly, at the strategic and 
operational level, but I have had some involvement at the 
tactical level, as well.
    What I mean by that is we have, three times a week, we have 
a meeting of over 200 folks that have an equity in this matter 
to work through and wrestle on particular focused issues. I 
have also had the good fortune of visiting the Cerner facility 
where they have hosted workshops for workflows in Kansas City, 
at least twice. And then as I mentioned earlier, I had the 
opportunity to visit both of the sites. I met the leadership 
team in Spokane and Seattle, the leaders, and many of the 
employees.
    My job is an oversight role--give direction, be sure we are 
on the right track, support those leaders that are actually 
making decisions and making things happen--but I am the 
accountable official and I very much understand and appreciate 
that role.
    Ms. Lee. Thank you. So, given that--your involvement, 
looking forward to March 2020, what do you envision as the 
process that you will undergo to finally sign off on go live?
    Mr. Byrne. So----
    Ms. Lee. Let me follow up, and I just want to ask one more 
question: And what scenario would you not sign off?
    Mr. Byrne. The easy answer to that second question is if 
anything is going to impact a patient's safety, that is a no-
go; that rules over everything.
    We are going to stay on the current trajectory and path 
that we are on. We are on a go to green, go live for March 28th 
trajectory right now with the governance structures that I can 
burrow into as deep as you would like to discuss.
    The answer to your question is, I want to keep it on the 
path and the trajectory that we are on right now.
    Ms. Lee. OK. Earlier in response to Ranking Member Banks' 
questions, you said, well, you do not have the authority. I 
want to know, are you comfortable telling leadership that EHR 
deployment needs to be delayed?
    Mr. Byrne. Yes, that is correct, and maybe I should put 
some context on the authority. I have not had that specific 
discussion with the secretary about it because it has not 
ripened yet.
    He may well say, you are the accountable official, you make 
the final call, but it will be one of the two of us to be 
making that final decision and we are both accountable for it, 
regardless of who makes it.
    Ms. Lee. Great. Thank you.
    Dr. Fischer, in the event that you believe things are not 
ready, do you have the authority or are you comfortable telling 
departmental leadership that EHR deployment needs to be delayed 
at Mann-Grandstaff?
    Dr. Fischer. Extremely comfortable.
    Ms. Lee. Mr. Tadych, the same question: In the event that 
you believe things are not ready, do you have the authority and 
are comfortable telling leadership that EHR deployment needs to 
be delayed?
    Mr. Tadych. Yes, I am.
    Ms. Lee. Dr. Lieberman, in the event that you believe 
things are not ready, do you have the authority and are 
comfortable telling leadership that the deployment needs to be 
delayed?
    Dr. Lieberman. Absolutely. We all work really well together 
and we are very transparent about this, and we make it clear 
that if anybody has a concern, we want to hear about it.
    Ms. Lee. Dr. Windom, I am sure you are wondering what I am 
going to ask you: Do you have the authority and are you 
comfortable?
    Mr. Windom. Well, I do appreciate you elevating me to 
doctor status, ma'am----
    Ms. Lee. Oh, yes, sorry.
    Mr. Windom.--but I am not a doctor.
    Ma'am, I have had a number of chances to appear before you 
and the committee and this remains an end-user decision. This 
remains a clinical decision. This is about end-user adoption.
    I am very comfortable with the teamwork here on the panel 
and back at VA is that it will not be a decision that is--
surprises any of us because we are talking every day, and so we 
will understand how we migrated to the point and we would owe 
you that engagement and I know----
    Ms. Lee. But are you comfortable calling for a delay, 
should you personally feel that?
    Mr. Windom. I would be comfortable, but I would make sure 
that the delay--I am not a doctor. I have doctors around me who 
I would be counting on to advise me appropriately. I would be 
comfortable, but would be seeking their counsel.
    Ms. Lee. Thank you. And Dr. Kroupa, same question: Do you 
feel you have the authority and are comfortable asking for a 
delay, should you believe that it is needed?
    Dr. Kroupa. Absolutely.
    Ms. Lee. Thank you. My time is now expired and I am going 
to recognize Mr. Watkins for 5 minutes for questions.
    Mr. Watkins. Thank you, Madam Chair. Thank you.
    Mr. Windom and Dr. Lieberman, VHA staff has a significant 
amount of mandatory training, in addition to the Cerner 
training. That said, the Cerner training absolutely must 
happen, so what will you be doing to monitor and support VHA 
staff to make sure that they are participating and actually 
benefiting from the training?
    Mr. Lieberman. As you stated, the training is critical and 
no one can use the system until they complete the training and 
they will also have to complete an examination. That is just 
critical; nobody should be touching the new system without that 
kind of training.
    We have planned--I have actually led the national effort to 
come up with how we can mitigate the known loss in productivity 
that will occur for months before going live, and so we are 
prepared to staff up in response to that, to make sure 
everybody has the time to go through the complete training.
    Mr. Windom. Sir, we have got a change management team led 
by Dr. Jill Durant under the auspices of Dr. Kroupa's team. 
They have been putting many, many hours into developing a 
training portfolio in coordination with Cerner.
    I can tell you, we had a chance to observe the DOD go live 
at Wave Travis from the headquarters. One of the major emphasis 
points was you have to have the training prior to accessing the 
system. We intend to follow suit. The efficiencies of their 
deployment reflect that that is the right way to do business.
    Mr. Watkins. Right. How heavily have you and the VHA 
leadership been involved in establishing the Cerner training 
domain and the training programs?
    Mr. Windom. Sir, I am going to defer to Dr. Kroupa after 
this remark is that Dr. Kroupa leads--Dr. Kroupa is a Title 38 
employee; she effectively works for Dr. Stone and Dr. 
Lieberman. The tie-in between her efforts and the council's, 
who are largely VHA employees, makes our integrated efforts 
just that more integrated.
    If I could defer to Dr. Kroupa on maybe some details, I 
would appreciate it.
    Dr. Kroupa. Certainly. The training program for our users 
has been designed by Cerner with our team intimately involved 
and for every role, they get a certain number of hours of 
training. You know, a registration clerk may get 8 hours of 
training. A specialized cardiac nurse may get 40 hours of 
training. We have gone through the math of assigning roles to 
all of the staff at Mann-Grandstaff and laying out how many 
hours of training they will need.
    Then they, as Dr. Lieberman mentioned, they have to pass a 
competency test at the end of that training. If they do not 
pass, they get more training, they get more support, and more 
help until they are comfortable with the record.
    Mr. Watkins. Thank you. Now, I am have Kansas and Topeka, 
Leavenworth, and Kansas City are all in the later waves of the 
Cerner implementation, but we will be watching the Spokane go 
live closely for lessons learned.
    How will you and your team be monitoring and responding to 
situations that arise during and after the March 2020 go live? 
That is for anybody--perhaps, Mr. Windom or Dr. Lieberman.
    Mr. Windom. I come from 33 years in the Navy. This is 
probably the most dynamic environment I have ever been in. 
Medicine is constantly evolving.
    I think the flexibility we have in our relationship with 
Cerner and that the contract affords us those lessons learned 
should always be brought forward and will always be brought 
forward to subsequent deployments. So, really, no matter where 
you are on the deployment cycle, you will benefit from the 
lessons learned of previous deployments, and not only the 
previous deployments, but our relationship with DOD and, oh, by 
the way, the innovation of not only VA, but the commercial 
environment.
    We think we have got a multi-pronged approach, sir, that is 
going to support us making sure we deliver to VISN 15 what they 
will need in the best possible way at the best possible time.
    Mr. Watkins. Thank you. Dr. Lieberman, the same question, 
please: What role will you and the VHA leadership play in the 
monitoring and responding to issues during the Spokane go live?
    Dr. Lieberman. We have meetings with Spokane and Puget 
Sound three times a week--``we'' being the larger we--for an 
hour, talking about what are the challenges that are being 
faced, what is it going to take to get us over the finish line. 
Those meetings will continue afterwards; they are very detailed 
and very helpful.
    We will be studying lots of things after go live and these 
folks here will know how to approach us. If anything needs to 
be raised, we quickly will raise it up the ranks. We will be 
studying everything, including even how we mitigated the 
productivity, so we can learn for future deployments, did we do 
it right, should we modify it for the future.
    Mr. Watkins. Thank you. I yield.
    Madam Chair, I yield. Thank you.
    Ms. Lee. Thank you. I now recognize Ms. Schrier for 5 
minutes for questions.
    Ms. Schrier. Thank you all for coming. I am from Washington 
state--not from Spokane--but I am excited that this pilot is 
happening in our State and it sounds like you are putting a lot 
of effort into launching this. Frankly, if there was ever a 
group of people or veterans who needed a smooth launch and the 
best care in this transition, it is our veterans. We have about 
a half a million veterans in Washington State, about a tenth of 
them in my district.
    Now, I am also a doctor, so I am probably the only person 
up here who is used Cerner and has been through some of these 
go lives and however smooth you want them to be, there is bumps 
in the road. I am thrilled to hear about superusers and to have 
Cerner staff onsite and even anticipating lower productivity, 
because that does happen.
    I wanted to get a sense of how this will feel for the 
patient, for our veterans, and also for the doctors, like, how 
this really plays out in the exam room, and so, I as I was 
thinking through some of the issues that we have had, a veteran 
who has had a complicated operation, for example, has a very 
thick medical record and then comes to a VA for continuing 
care, the only thing I could parallel that to would be a baby 
with congenital heart disease who is at Children's Hospital--
they have Cerner also--and that baby comes to me with a stack 
of medical records this thick. The way we had to do it was to 
literally--I would go through the record, pick out the most 
important pieces, we would scan them and then I would have this 
big, long record in Cerner.
    How will clinic notes get transferred over? Will it just 
populate the Cerner notes field or will you have a big, long 
100-page file to go through when the patient is in the office?
    Mr. Byrne. Can I answer your question, ma'am, from a 
strategic level and then, of course, pass it off to a real 
doctor--I am a doctor of jurisprudence; that does not account 
for much--you had asked the question about how this--would help 
with the veteran patient.
    The hope is that they have no idea that this is going on at 
all, but we know--you know--that they are going to be getting 
much better care and treatment as we revolutionize the amount 
of information that the providers have when they are treating 
the patient. They will have that whole picture of this veteran 
and that is where the magic is. The veteran will maybe notice 
it because they are getting better care in the big picture, but 
my understanding is they are not going to notice--I hope they 
do not notice anything when they go in for their next treatment 
and care in April, May, and June.
    Ms. Schrier. OK. I need a doctor to answer on this, because 
you know it is easier to click through note to note to note and 
see the title on it than it is to have a file of 100 pages that 
you have to scroll through.
    Dr. Fischer. Ms. Schrier, I would like to answer your 
question, and I will, but I am going to defer to Laura Kroupa, 
because she has that information, having been so active with 
our national councils.
    Laura.
    Dr. Kroupa. Yes. This is going to be different than many 
other transitions. We have spent time bringing over data, to a 
great extent, from our VistA legacy system. In addition, we 
already have the Joint Legacy Viewer (JLV), which is a viewer 
that we can read both, DOD and VA data, so that will be a tab 
within Cerner. You can just click on it and it will go right to 
that patient JLV to see old data.
    We are also bringing over every record from every veteran 
from all time in VistA. It is already in the Kansas City data 
base and so over this next year, we will be able to have 
basically 20 clinical domains of data in the record in the 
longitudinal order. You know, I think our users are going to 
find that they have much more data than they have had before, 
better organized data, and there is not going to be a lot of 
time spent bringing--transcribing old data into the record.
    Ms. Schrier. Will things like lab results come in, in table 
form so you can see old labs in the same table as new ones? The 
same thing with problem lists and medication lists?
    You have thought everything through this. I am feeling very 
optimistic. I wanted to ask if you have a backup plan? Our 
backup plan was that to a year, at least, we had the paper 
record that also came into the room, so if we really needed it 
as a crutch, we would have it.
    What is your backup plan if the electricity goes down--
whatever the headache may be?
    Dr. Kroupa. I can take that.
    The Joint Legacy Viewer is a read-only, so that is going to 
be available. In addition, we also have a backup plan where we 
have viewers that back up the Cerner system, so that if 
something gets cut, we will be able to see it on those--so 
special computers will have a backup plan--a backup copy of the 
record.
    Ms. Schrier. Well, thank you very much all for your service 
and your help and for taking care of our veterans, and I 
applaud you and wish you luck. Thank you.
    Ms. Lee. Thank you. I now recognize Ms. McMorris Rodgers 
for 5 minutes.
    Ms. Rodgers. I thank the chair and the ranking member for 
allowing me to participate in today's hearing. I also want to 
thank all the witnesses for being here, especially Dr. Fischer, 
who has been keeping me updated along the way and I appreciate 
the fact that you are on the front lines of this significant 
effort which is so important----
    Dr. Fischer. Thank you.
    Ms. Rodgers.--to the veterans that I have the privilege of 
representing in Eastern Washington.
    I represent more than 70,000 veterans. I am also proud to 
represent Fairchild Air Force Base, the Mann-Grandstaff Medical 
Center, as well as the Walla Walla Medical Centers. I recognize 
that we are on the forefront of this exciting, but also 
challenging endeavor. We have now over $16 billion in upgrades 
and investments in making this transition, and certainly this 
is an important piece of making sure that the VA is able to 
deliver efficient and effective care. My goal is to always see 
us rolling out the red carpet to our veterans and the proper 
implementation of this electronic medical record will be really 
important.
    I have a few questions that I just wanted to raise this 
morning to Dr. Lieberman, Dr. Fischer. I understand Dr. Stone 
has committed to ``flood Mann-Grandstaff with resources to 
cushion the impact of the Cerner rollout.'' I was glad to hear 
that. Certainly, you know, we have had our challenges in 
staffing up through the years.
    First, the medical center was exceeding its budget target 
by approximately 75 full-time equivalent and I do not know when 
that budget was involved, but I just wanted to ask where we are 
currently. Recognizing that we have had staffing difficulties 
through the years at Spokane, I think the worst thing would be 
for the VA to cut existing positions.
    Can you assure me there will be no cuts to existing 
positions?
    Dr. Fischer. Good afternoon. I will tell you, without 
hesitation, that there are currently no constraints on hiring 
at Mann-Grandstaff to include maintenance of our baseline 
mission staffing and that augmentation that I spoke about 
earlier. We understand that as the first pilot site we have to 
get this right and we have to maintain patient safety. This 
would be the exact wrong time to constrain hiring in my opinion 
and I have had nothing but full support by VHA, OEHRM, and VA, 
in general.
    Ms. Rodgers. Great. Can you just give me a breakdown right 
now of, in terms of position, permanent versus temporary staff, 
VA employees versus contractors?
    Dr. Fischer. I can give you some of that, and I am willing 
and certainly happy to provide that in writing. Right now we 
have roughly 1,235 full-time equivalents on our campus and our 
Community Based Outpatient Clinics (CBOCs). On our 
organizational chart we have somewhere around 1,400 positions.
    We have been, over the last 5 years, experiencing 
significant growth and when you do that, your vacancy rate 
tends to fluctuate somewhat until you reach a steady State. We 
are anywhere between 87 and 91 percent staffed at any given 
time, based on where we are with growth.
    Ms. Rodgers. Okay. Perhaps, you can get me that breakdown 
later.
    Dr. Fischer. Yes, ma'am.
    Ms. Rodgers. Do you have any thoughts on how we can 
expedite the hiring process, recognizing that March 2020 is 
right around the corner for some of the 108 new employees?
    Dr. Fischer. Well, VA has consolidated human resources, and 
so we can leverage our VISN and other VISNs to help us with 
expedited recruitment, which they are in the process of doing.
    Ms. Rodgers. Okay. I know there is been discussions about 
assigning up to 30 nurses from VA's Travel Nurse Corps and 
possibly--locum tenens physicians to Mann-Grandstaff on a 
temporary basis.
    Can you give me a sense as to when that is going to happen 
and how many personnel will be assigned?
    Dr. Fischer. Well, the 30 traveling nurses are--we are 
planning to have them arrive roughly 3 months before go live. 
We are exhausting all opportunities to enhance our recruitment 
and our staff onboard. But as you know, some of these solutions 
are untested in the face of EHR modernization and that is why 
we feel that permanent hires, as well as leveraging telehealth 
and some of these other somewhat untested expansion for 
clinical care, are important to exhaust all opportunities.
    Ms. Rodgers. Okay. I know there is also been discussions 
about personnel from Seattle, potentially in VISN 21 and 
California or Nevada being temporarily housed at Spokane. Do 
you believe this is going to happen?
    Dr. Fischer. I am optimistic.
    Ms. Rodgers. Do you know when?
    Dr. Fischer. I do not at this moment.
    Ms. Rodgers. Okay. Well, thank you, and I appreciate all 
your hard work and commitments.
    Dr. Fischer. I very much appreciate your support, ma'am.
    Ms. Rodgers. Thank you. I yield back.
    Ms. Lee. Thank you. I now recognize Mr. Cunningham for 5 
minutes.
    Mr. Cunningham. Thank you. Thank you to each and every one 
of you all for not only showing up here today, but for all of 
the work that you all do to improve the delivery of care to our 
veterans who deserve the highest quality of care possible. I 
appreciate all of your efforts.
    I have got the privilege of representing the low country in 
South Carolina, the first congressional district, which has the 
highest number of veterans of any district in the entire State 
and so it is incredibly important to me that the VA's health 
record modernization is well executed. To that end, I would 
like to turn to the leaders of the VA facilities, or I would 
like to refer to them as the tip of the spear of these 
modification efforts to locations across the country such as 
Ralph Johnson VA Hospital in Charleston can benefit from your 
example, specifically, on the subject of veterans outreach.
    Dr. Fischer, can you let us know what your staff is doing 
to communicate with the veterans that receive care at Mann-
Grandstaff about the go live?
    Dr. Fischer. Sure. Thank you for the opportunity.
    I meet monthly with our veteran service organizations and 
they are rather robust in the State of Washington. They are 
deeply embedded among the veteran population. We have veteran 
town halls, at the CBOC locations, rural health clinics, as 
well as in Downtown Spokane.
    I can tell you from my perception of the veteran 
perspective as I talk about Cerner Corporation and the 
complexity of modernization and typically their eyes tend to 
glaze over. A veteran only wants to know will he have access or 
will she have access to care. I believe that they assume that 
the documentation of that healthcare will exist and I do not 
know that they care whether it is through Computerized Patient 
Record System (CPRS) or through the Cerner product. We are 
outreaching frequently and I think as we get closer and have 
more granularity about what an appointment will look like at go 
live, we will absolutely share that information with our 
veterans.
    We also have a bi-weekly newsletter that is widely 
distributed and often veterans access that newsletter. We have 
Facebook. We have a button on our page for Cerner and 
electronic health record modernization. We are doing our best 
on outreach and as we learn more, we will share that with our 
veterans.
    They do know--I have represented that there will likely be 
inefficiencies at the time of go live and that we rely on them 
to help us modernize the health record and modernize VA health 
care and they are generally very, very supportive in that 
regard.
    Mr. Cunningham. Thank you for that.
    Have you communicated that veterans should consider 
reordering medication before the go live?
    Dr. Fischer. We have not yet, because we are still waiting 
for the final look at what pharmacy renewals will actually look 
like at go live. There is still lots of work being done, and I 
would defer to Laura Kroupa if she has any more information 
related to the pharmacy piece.
    Dr. Kroupa. There will be probably some changes in how they 
order their medicine just for a few months, and so we are 
planning on putting out some information through the pharmacy; 
also, we will probably send something out in their co-pay bills 
that will inform them about changes coming to both, billing and 
in-pharmacy. We are looking at a variety of different ways to 
get the word out.
    Mr. Cunningham. Okay. Thank you for that.
    Mr. Tadych, what has your staff done to communicate with 
the veterans that receive care at Seattle or American Lake?
    Mr. Tadych. Very similar to what Dr. Fischer mentioned. In 
addition, we have regular tele-town hall meetings that we reach 
out to a large number of meetings, typically, four to 500 
veterans who participate are tele-town halls. The Cerner 
implementation is a point of discussion during those town 
halls, as well as involving our veteran family engagement or 
community-veteran-engagement board and our veteran family 
advisory council in the discussions.
    Mr. Cunningham. Okay. I appreciate all of your efforts and 
I want to thank you again for everything you all do for our 
veterans and thank you again for appearing today to answer 
questions.
    I yield back.
    Ms. Lee. Thank you. I now recognize Mr. Kilmer for 5 
minutes.
    Mr. Kilmer. Thank you, Madam Chair, and I would like to 
thank you and Chairman Takano for allowing me to sit in.
    This is a big deal for the region I represent. Nine days 
ago we celebrated Veterans Day. I am honored to represent more 
military veterans than any Democrat in Congress. I think we are 
a much stronger region as a consequence of the men and women 
who serve and who choose to make my region their home. The work 
we do to make sure we have the backs of those who serve is the 
most important work we do and I want to thank each of you who 
are testifying today for your work in that regard.
    Why am I here? Well, we saw when the DOD did the rollout of 
their electronic health record in my region, a bit of a bumpy 
rollout and I appreciate the work that the DOD has done since 
then, along with its industry partners to try to right those 
issues, to identify some lessons learned in hopes that the 
rollout elsewhere is more smooth.
    I think we owe it to our vets to make sure that we do not 
have a repeat performance of what we saw within the DOD system. 
I do not think there is any reason to repeat those mistakes and 
I guess that is what I wanted to hear more from you is what is 
the VA doing, specifically, to make sure it is ready for the 
rollout this spring and what lessons were learned from the DOD 
experience and how are they being applied within the VA?
    In particular, I am hoping you can speak to how do we make 
sure that the DOD lessons learned are not repeated? I know I am 
conscious that it is a different contractor, and I want to make 
sure that even though it is a different contractor, we are 
still learning the lessons we learned from the last 
experiences.
    Mr. Byrne. I can tell you that we do have a very close 
relationship with DOD and we are incredibly conscious of those 
lessons learned. I think Mr. Windom might be able to be a 
little bit more specific on the history of that relationship 
and the lessons, in particular, that we have learned.
    We did have the luxury of visiting Madigan 2 month or so 
ago and we now see where they are and they did share several of 
those lessons with us.
    Mr. Windom.
    Mr. Windom. Thank you, sir.
    Sir, we appreciate your concern and we very much are in a 
similar posture. One thing I want to applaud DOD is being 
willing to share their lessons learned, their challenges, and I 
can tell you it just did not start with us incorporating those 
yesterday. We started incorporating those lessons learned 
before contract award.
    Within the framework of the terms and conditions of our 
contract are things like help desk support. You may have seen 
some of the gaudy statistics regarding trouble tickets. We made 
sure we put in a robust help desk support mechanism because we 
want end-users' questions answered the first time the right 
way. That eliminates frustration.
    I can tell you field participation, another major lessons 
learned, and I will let Dr. Kroupa--making sure the field 
understands what is coming, making sure they are well-trained, 
well-educated in what is to come so they are not--they do not 
reject what is about to transpire.
    You have heard me emphasize time and time again, this is 
about end-user adoption, infrastructure readiness. A state-of-
the-market, state-of-the-art electronic health record does not 
run better on an old infrastructure. Congress has been 
incredibly supportive, financially, in providing us the 
requisite sources of funding to upgrade our infrastructure well 
in advance of the deployment of EHR. You heard that in the 
deputy secretary's comments regarding log-in times. Just the 
upgrades of the infrastructure have improved log-in times 
thousands of percentage from minutes--30 to 40 minutes to 15 to 
30 seconds.
    There are a myriad of other areas. I want to give my 
compatriots here an opportunity, because from a clinical and 
then John Short, from a technical perspective, they really, I 
think, can give you the rest of the story.
    Dr. Kroupa.
    Dr. Kroupa. I think the main lesson we took from the DOD is 
that we made sure that we included frontline clinicians in the 
design and build of the record. We spent a lot of time with the 
clinical councils, meeting on a recurring basis to make 
decisions. We included DOD on those councils so they could hear 
directly from their compatriots about how it worked in their 
system and could make decisions together. We also brought in 
industry, best-practice associates from other healthcare 
systems to help us make those decisions.
    John.
    Mr. Short. I will just add a couple of items. As an 
example, DOD, at first when they rolled out they did just-in-
time infrastructure. Just-in-time infrastructure for most 
people's experience is just-in-delayed infrastructure, and so, 
they learned to go to 3 to 6 months ahead of schedule. We 
mirrored that, most of the infrastructure already in place for 
the go live sites. We are already working in wave one, wave 
two, and wave three sites already, putting that infrastructure 
in place. So many elements like that.
    Another example was making sure we are going to go live 
over the weekend, to have the IT contracts in place where you 
can call those vendors in on the weekend to make sure that is 
available. So, that is another lesson learned. DOD is 
constantly providing those to us and we are using those.
    Mr. Kilmer. Thank you.
    Thank you, Madam Chair.
    Mr. Windom. Sir, may I add just one thing, because I think 
it is important. The Wave Travis deployment that DOD just 
executed--phenomenal.
    So, the experiences at Fairchild, they have taken onboard 
their own lessons learned and they have been willing to 
continue to share those. We have watched them return to 
efficiency levels within 6 weeks that far exceeded 
expectations. I just wanted to make sure that was known, that 
they have not rested on their laurels either, and we continue 
to learn and share.
    Mr. Kilmer. Thank you.
    Thank you, Madam Chair. I yield back.
    Ms. Lee. Okay. I now recognize Mr. Larson for 5 minutes.
    Mr. Larson. Madam Chair, thanks for indulging us from 
Washington State and we are obviously very interested in this 
program and we appreciate you allowing us to ask questions and 
waiting for us to get from other markups. There is actually 
other things going on in the Hill today, so it is really great.
    I am sorry that I am late and maybe--this question, but the 
rollout in Washington State and especially in Puget Sound has 
been delayed and with regards to that delay, is there anything 
that you need--I guess this is for Mr. Tadych--I cannot see 
that far without my glasses. I lost my glasses--oh, there you. 
How you doing? Sorry for being so informal today.
    Is there anything else you need to ensure that the rollout 
happens on time or actually, now in the fall, as opposed to any 
delays?
    Mr. Tadych. We have had very good support throughout from 
both, OEHRM and VHA through this process. The discussions 
around the different capability blocks was a very collaborative 
approach and based on concerns we raised, the leadership at 
both, VHA and OEHRM, were willing to delay our implementation 
until those different blocks could be--different capabilities 
could be delivered to us.
    Mr. Larson. Are you anticipating learning anything in 
Spokane that you would pick up and put down in the fall?
    Mr. Tadych. Absolutely.
    Mr. Larson. Do you have an idea of what those are?
    Mr. Tadych. I am sure there will be many bumps in how they 
implement with primary care and other areas that will be very 
valuable to our implementation process.
    Mr. Larson. Thank you. How about in terms of the 
capabilities that you are rolling out in Spokane, any of those 
that you anticipate that are not in Puget Sound that you would 
pick up and put down in the Puget Sound?
    Mr. Tadych. I think with the capabilities, one of the 
lessons learned will probably be around some of the how 
patients flow, workflows that we need to address more than 
anything. Those capabilities should be well in place by the 
time that Puget Sound goes live.
    We will also have to look at how the capability block two 
workflows work at that point as we get ready to go.
    Mr. Larson. I noted that Bellingham and we have a vet 
center are on the list at some point. Do you know what the 
timeline is for those?
    Mr. Tadych. I do not know about the vet center.
    Mr. Larson. Okay. Does anybody know about the vet centers? 
How are they?
    Dr. Kroupa. The vet centers do not actually write into the 
electronic health record; they are records are separate. They 
will have the ability to see, but they are not going to be 
actually entering information into the electronic health 
record.
    Mr. Larson. Okay. All right.
    Dr. Kroupa. Those are kept separate on purpose.
    Mr. Larson. What purpose is that?
    Dr. Kroupa. So that veterans can go to the vet centers and 
have confidential information that is not revealed anywhere 
else.
    Mr. Larson. Then, finally--and, again, I apologize if this 
has been asked--but perhaps, for Mr. Windom, what efforts has 
the VA taken to familiarize, you know, older veterans with the 
changes with the new system?
    Mr. Windom. Sir, I think that one thing we recognize is 
that communications to the veterans that will be called to use 
upon the system is imperative. One of the struggles with comms 
is not to get there too soon. So, we intend to really saturate 
the area, in a matter of a couple of months or 6 weeks out to 
make sure people are well-versed on what is about to occur.
    Mr. Tadych and both, Dr. Fischer and Dr. Kroupa, have 
already commented on the fact that they are having town halls, 
they are meeting with the VSOs. I meet quarterly with the VSOs. 
I have already asked them to help me best understand how to 
engage the veterans.
    We appeal to you. If you have ideas, we would love to sit 
down with you and listen to those, because I can assure you in 
no way, shape or form do we think we have cornered the market 
on how to communicate. We welcome your thoughts on enhancing 
our communication profile, and so we look forward to a 
following discussion on that. We look forward to continue to 
share our ideas.
    Mr. Larson. Yes. I just finished six more veterans town 
halls in my district and they all went very well, in part, 
because Mr. Tadych was there helping us out. One of the things 
that happens at these town halls is--case work; these are more 
policy-oriented and we talk about changes in the VA, and we end 
up getting sometimes surprised by those questions because maybe 
our offices have not been briefed or maybe we missed something.
    I would just really encourage full outreach to 
congressional offices so we know who to send these folks to 
when we get the calls, as well as, so that we have some basic 
information on the implementation to help me out.
    Thanks. I yield back.
    Ms. Lee. Thank you. I now recognize Ranking Member Banks 
for 5 minutes.
    Mr. Banks. Thank you, Madam Chair.
    Deputy Secretary Byrne, I have a series of questions about 
VA's My HealtheVet patient portal and the Cerner HealtheLife 
patient portal. Please feel free to direct any of these 
questions to members of your team if appropriate.
    When Cerner goes live in Spokane, what health records will 
a veteran be able to access in the Cerner patient portal and 
what records will he or she need to use My HealtheVet to 
access?
    Mr. Byrne. Thank you for that question. I think Dr. Kroupa 
might be best to answer that.
    Dr. Kroupa. Certainly. In Spokane at the go live, the 
veterans will be able to access through the Cerner portal, 
their Spokane records. If they want to look back at a previous 
secure message or something from another VA, they will access 
My HealtheVet.
    Mr. Banks. Okay. Doctor, which types of appointments will 
veterans be able to schedule using the Cerner portal and which 
appointments will they need to use the My HealtheVet to view or 
make?
    Dr. Kroupa. I believe that they will be able to make 
appointments in Spokane in the Cerner portal, but I can take 
that for the record to be sure on that one.
    Mr. Banks. Fair enough.
    Which patient portal and which other systems will veterans 
of Spokane need to use to schedule a Community Care 
appointment?
    Dr. Kroupa. Well, I do not know that they currently use a 
portal to do all of their Community Care appointments now, so I 
will have to take that for the record unless, John, if you 
know?
    Mr. Banks. Okay. Mr. Short, you are making a lot of 
progress with VA.gov in expanding the online self-service tools 
for veterans. Has anyone figured out how to integrate all of 
that with the Cerner HealtheLife patient portal?
    Mr. Short. Currently, sir, there is work being done on 
development to be able to allow them to use those tools. It is 
in the development phase right now. We will provide additional 
information for the record, if you would like.
    Mr. Banks. Okay. Secretary Byrne, OEHRM has the lead 
responsibility for the Cerner implementation, but it is by no 
means alone in this effort. How much funding has been 
transferred or allocated from the veterans electronic health 
record account to other VA offices to support the work?
    Mr. Byrne. I think Mr. Windom might have some specifics on 
that.
    Mr. Windom. I will have to take that for the record, sir, 
for exact accounting, but what I will say is this, is that as 
we discussed in previous hearings, it made sense to leverage 
the contracting of vehicles that existed within OIT. We have 
allocated moneys to use their vehicles with strict 
accountability between the two organizations being maintained, 
but that made sense to get infrastructure off the ground sooner 
rather than later.
    In addition, as we expressed at various hearings, we had a 
debt to VHA for allowing us to use their clinicians to support 
our requirements, development efforts, clinical workshops, 
efforts. We have, actually, written guidance in place to how 
we, if you will, reimburse VHA and other organizations for 
their efforts. We will gladly share that, sir.
    Mr. Banks. I appreciate Mr. Windom taking that back for the 
record and providing us with a complete list.
    My next question is for Dr. Kroupa and Dr. Fischer. Please 
tell me about the training system, meaning the version of the 
Cerner EHR that will soon be available to Spokane personnel to 
train on. How similar is it to the Cerner EHR that will go live 
next year?
    Dr. Kroupa.
    Dr. Kroupa. The training environment is being imaged now. 
It is being based on the decisions that we made at the 
workshops, so it is going to be very--have a high level of 
fidelity to the production account and so, it should--it is a 
VA-specific build. It is not the Cerner major product or the 
DOD product. It is being imaged, based on our design decisions.
    Mr. Banks. Okay.
    Mr. Windom. Yes, I would add, sir, that in advance of our 
build, what we did was set up what we call a ``flight 
simulator,'' which is a training environment that incorporated 
the DOD build so that people could start getting oriented on 
the Cerner Millennium solution. We put that in place and have 
allowed clinicians access to that, if you will, as a preface to 
the training they will receive on their actual build.
    Mr. Banks. Okay. Thank you very much. I yield back.
    Ms. Lee. Thank you. I now recognize myself.
    As the subcommittee understands that patient information 
will be flagged as either VA or DOD, depending on where the 
treatment occurred and where the data originated, Mr. Short, is 
that a correct assessment?
    Mr. Short. Yes, ma'am, that is correct.
    Ms. Lee. A provider in either department can access a 
patient's full record and full medical history, regardless of 
whose flag is on the data, either through Millennium or use in 
the JLV; is that correct?
    Mr. Short. For the purposes of patient care, yes, ma'am.
    Ms. Lee. We have heard that a patient who has been treated 
at both, the VA and DOD would have to request their records 
separately from the two departments due to restrictions caused 
by data ownership policies; is that accurate?
    Mr. Short. I believe that is accurate, ma'am. I will take 
the full question for the record to validate that for you.
    Ms. Lee. This is concerning to me, because the goal of 
Congress in establishing the EHRM programs was to establish one 
single record that follows servicemembers as they enlist in the 
military, perform their service, transition, and then for the 
rest of their lives.
    Secretary Byrnes, if a portion of the veteran's health 
record is held by DOD and another is held by VOA, is that truly 
a single, unified record?
    Mr. Byrne. As I understand it, it is all in an enclave 
right now. It was ingested from DOD and we have had some 
records that we have had ingested from the Department of 
Veterans Affairs.
    For the ability of the record to go to a Department of 
Defense healthcare provider and then back into the enclave and 
then back into a VA facility for care and back in again, that 
is the interoperability component of the enclave that I 
understand we should have the capability of doing. Granted, 
that is challenging, that is a capability that I believe we 
intend to have if we do not have it already.
    Now, Mr. Short is that----
    Mr. Short. That is correct, sir.
    Madam Lee, the question, I believe, was if a veteran asked 
for their entire record from the DOD to VA, could one part of 
the DOD or VA pull the whole record? We will have to take that 
one for the record.
    Dr. Kroupa. Yes, there is a lot of law and regulation 
around what each agency can release, and so I think that is 
where there is been a lot of discussion about how to adjudicate 
that and who has providence over different parts of the record.
    Ms. Lee. Yes, I mean, I just--you know, to me, if a patient 
needs to go to both, the VA and DOD, to get their complete 
record, we are not establishing--we are not meeting the goal of 
the system. It sounds like there are some----
    Dr. Kroupa. I can tell you that we have had discussions 
with Dr. Evans about what might be some possible ways to try 
and improve that. Because, of course, those laws and 
regulations were never written at a time when we had the same 
instance of an electronic health record. We are going into a 
new era here.
    Ms. Lee. Okay. To the extent that there needs to be a 
change in laws and regulations, obviously, we would like to 
understand exactly what needs to happen so we can be of 
assistance and expedite that.
    Secretary Byrne, are there policies in place or in 
involvement regarding this joint ownership or is this something 
that we are at a standstill because of these laws and regs?
    Mr. Byrne. I would like to toss that to Mr. Windom, if I 
can, ma'am.
    Mr. Windom. Madam Chair, this is at the forefront of data 
syndication discussions. I can tell you this consumes Dr. Neil 
Evans, who is the FEHRM chair. He is squarely leading this 
effort.
    I want to make sure you walk away with the understanding 
that the patient still owns his data, the access to his or her 
data. The access to that data is still controlled by the 
patient. The roles of care are being worked out of who will 
have access and whether there is any legislation relief that we 
need.
    We owe you a follow up discussion, but that is a follow up 
discussion that I would really want Dr. Neil Evans, with us in 
a support role, to come and brief you on, because I think he is 
squarely at the forefront of working with DOD.
    Ms. Lee. Is Dr. Evans the person who is responsible to 
setting the policies and finalizing them? Who is responsible?
    Mr. Windom. What I would offer, ma'am, in his role as the 
FEHRM lead, he is the responsible element that is brokering the 
relationship and the understanding between DOD and VA, such 
that we have a single conduit. I think VA and DOD are prepared 
to for his lead, but I do not want to speak for the Dep. Sec., 
but he has been empowered and he has been acting as the FEHRM 
director for months in advance of this point.
    We are comfortable with the movement in this arena. I don't 
want to overspeak the situation. I think we owe you greater 
granularity on how we are going to get there, but we appreciate 
your offer of legislative support because no one contemplated 
this single enclave, this single hosting site and we may need 
your involvement in support of delivering.
    Ms. Lee. Okay. As soon as those policies are ready, we 
would love to have a copy of them----
    Mr. Windom. Yes, ma'am.
    Ms. Lee.--or a further discussion on what needs to be done.
    Mr. Windom. We understand. Thank you, ma'am.
    Ms. Lee. Just--I am not going to recognize Ranking Member 
Banks for 5 minutes.
    I am going to close out with one more question about 
staffing, Dr. Fischer. Did you have a hiring plan in place 
before Mann-Grandstaff was selected to go first?
    Dr. Fischer. Not for augmentation of staff, ma'am, no. That 
occurred approximately 1 month after the Cerner contract was 
signed.
    Ms. Lee. Okay. And just a question: You have 108 FTEs that 
you are going to hire. Where are you on that?
    Dr. Fischer. We have hired over 40 of the 108 and there are 
several recruitments that are in various phases of having those 
folks on the campus and fully starting work.
    Ms. Lee. When do you want to--like, what is the goal date 
to have these 108 in place? Is it January? Is it March? Is it 
December?
    Dr. Fischer. As soon as possible. We are aggressively 
pursuing those hires.
    You know, this is kind of a living document. When we looked 
at the model and staffing requirements in June 2018, as time 
progresses and we learned more about the initial capability set 
and the other information, we have morphed some of those 
positions. It is a living document.
    We just identified the last 20 and we are pursuing those 
recruitments. I do not think it is a static requirement and I 
do not think it should be, because we are all learning as time 
progresses.
    Ms. Lee. Yes, I guess my question is, you have a March 28th 
rollout. You know that you need to provide training for all of 
the staffing. Are you planning on a month of training? Are you 
planning on 2 months? Like, obviously, you need to have the 
staff in place to train to implement the program.
    Dr. Fischer. Well, end-user training, in addition to a few 
hours of computer-based training, is 1 week in length. I think 
we will find time to get new employees trained up in Cerner 
before they start work.
    Ms. Lee. How long did it take you to get those 40 of the 
108 onboard from initiation to in your building?
    Dr. Fischer. Well, I think it depends--oh how long does it 
takes to recruit----
    Ms. Lee. How long from when you decided you needed the 
people to--you advertised, you interviewed, till they are in 
your building? I am just sort of curious.
    Are you on track to fill those 108?
    Dr. Fischer. Ma'am, I can give you an estimate. I would 
prefer to give you something that is more reliable. I do not 
perceive a significant delay between identification of a 
position and recruitment and presence oncampus, providing care 
and/or support, but it certainly depends on what I am hiring.
    If you ask me how long it takes to hire an oncologist, it 
might take forever based on our market. If you ask me how long 
it takes to hire an administrative assistant, we can do that 
pretty quickly.
    It is hard to come up with a generalized answer. But there 
are no significant obstacles that I am aware of when we have 
identified a recruitment action to getting someone onboard.
    Ms. Lee. Okay. Thank you.
    Well, thank you all for being here for providing this 
informative update and answering our questions. We look forward 
to continuing to have the conversation, particularly with 
respect to the data migration and data--I know it is not 
ownership--data stewardship areas, because, ultimately, again, 
this is all about having one seamless record for veterans from 
enlistment to active-duty to becoming--transition, and then for 
the rest of their lives.
    If we are going to have this management issue back and 
forth, we are really not achieving the underlying goal of this 
whole project. I am wishing you all the best of luck and we 
will continue to work together and we look forward to hearing 
about your success, come March 28th. Thank you.
    All members will have 5 legislative days to revise and 
extend their remarks and include extraneous material. This 
hearing is now adjourned.
    [Whereupon, at 2:56 p.m., the subcommittee was adjourned.]

?

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


                         A  P  P  E  N  D  I  X

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


                     Prepared Statement of Witness

                              ----------                              


                   Prepared Statement of James Byrne

    Madam Chair Lee, Ranking Member Banks, and distinguished Members of 
the Subcommittee. Thank you for the opportunity to testify today in 
support of the Department of Veterans Affairs (VA) initiative to 
modernize its electronic health record (EHR) through the acquisition 
and deployment of the Cerner Millennium (Cerner) EHR solution. I am 
accompanied today by Dr. Steve Lieberman, Acting Principal Deputy 
Undersecretary for Health, Veteran health Administration (VHA); Mr. 
John Windom, Executive Director, Office of Electronic Health Record 
Modernization (OEHRM); Dr. Laura Kroupa, Chief Medical, OEHRM; Mr. John 
Short, Chief Technology and Integration Officer; Mr. Michael Tadych, 
Director, Puget Sound Veteran Administration Medical Center (Seattle); 
and Dr. Robert Fischer, Director, Mann-Grandstaff Veteran 
Administration Medical Center (Spokane).
    I want to begin by thanking Congress, and specifically this 
Subcommittee, for your continued support and shared commitment to the 
success of the Electronic Health Record Modernization (EHRM) program. 
Because of your unwavering support, VA is able to continue its mission 
of improving health care delivery to our Nation's Veterans and those 
who care for them while being a responsible steward of taxpayer 
dollars.

Background

    On May 17, 2018, VA awarded an Indefinite Delivery/Indefinite 
Quantity (ID/IQ) EHR contract to Cerner. Given the complexity of this 
endeavor, VA awarded this ID/IQ to provide maximum flexibility and the 
necessary structure to control cost. Through this acquisition, VA will 
adopt the same EHR solution as the Department of Defense (DoD). The 
solution allows patient data to reside in a single hosting site, using 
a single common system and enables the sharing of health information; 
improves care delivery and coordination; and provides clinicians with 
data and tools support patient safety. VA believes that implementing 
this single EHR solution will allow for seamless care for our Nation's 
Servicemembers and Veterans. Since the last EHRM update on June 12, VA 
has accomplished several key milestones.

Task Orders

    VA has cumulatively awarded 20 Task Orders (TO). VA leverages the 
ID/IQ contract structure awarding firm-fixed-price TOs as requirements 
are validated. This strategy affords VA the flexibility to moderate 
work and modify implementation and deployment plans efficiently. Since 
June 12, VA has awarded and begun execution on 12 new TOs to include:

      TO 9 - Registry and Report Development for IOC: 
development, testing, and execution in support of registries and 
reports required for EHRM IOC. More specifically, these tasks include 
project management, registry development, report development, training, 
and development of measures.

      TO 10 - Additional Data Migration Development for IOC: 
additional data migration development, testing, and execution in 
support of data migrations required for EHRM IOC. These tasks include 
project management and IOC site-specific data migration/ingestion 
development.

      TO 11 - Cerner Standalone Scheduling Pilot Site Surveys: 
conduct Cerner Scheduling Solution (CSS) site survey (SS) activities 
for the Chalmers P. Wylie Veterans Outpatient Clinic and the Ohio 
Veterans Affairs Medical Center and both sites' associated facilities. 
These deliverables include the Technical Kickoff, Pilot Plan Tailoring, 
Pilot Site Technical SS, Pilot Functional SS, and Milestone Decision 
Review.

      TO 12 - Current State Review (CSR) Waves 1 - 3: conduct 
technical and functional CSR activities for sites in Preliminary Waves 
1 - 3. These activities will include the Technical Kickoff, Wave Plan 
Tailoring, Wave Technical CSR, and Wave Functional CSR.

      TO 13 - Cerner Scheduling Solution (CSS) Project 
Management, Planning, and Strategy: provide project management and 
planning support services for the VA CSS solution. These services 
include CSS Project Management, CSS Enterprise Management Support, CSS 
Functional Management Support, and CSS Technical Management Support.

      TO 14 - Revenue Cycle Workflow Strategy Support Services 
for IOC: provide resources to support system and process design to 
accommodate the unique needs of the Veterans Benefits Administration, 
the Office of Community Care, the Consolidated Patient Account Centers, 
and the Veterans Health Administration.

      TO 16 - EHRM Wave 1 Deployment: conduct Wave 1 deployment 
activities for the following VISN 20 Sites and associated facilities: 
Jonathan M. Wainwright Memorial VA Medical Center (VAMC) and White City 
VAMC.

      TO 17 - Data Syndication Development and Execution for 
IOC: provide additional data syndication development, testing, 
execution, and sustainment required for EHRM IOC.

      TO 18 - Revenue Cycle Development for IOC: test and 
deploy additional revenue cycle functionality in support of VA revenue 
cycle requirements for IOC.

      TO 19 - Encoder and Clinical Documentation Improvement 
(CDI) Services for IOC: develop, test, and deploy encoding and CDI 
functionality in support of VA EHRM revenue cycle requirements for IOC.

      TO 20 - Revenue Cycle Managed Services for IOC: develop, 
test, and execute managed services in support of VA revenue cycle 
requirements for IOC.

      TO 21 - EHRM Wave 2 Deployment: conduct Wave 2 deployment 
activities for the following VISN 20 Sites and associated facilities: 
Portland VAMC, Vancouver VAMC, Roseburg VAMC.

Current State Review

    In July 2018, VA and Cerner conducted a Current State Review at 
VA's IOC sites to gain an understanding of the sites' specific as-is 
State, and how it aligns with the Cerner commercial standards to 
implement the proposed to-be State. The team conducted organizational 
reviews around people, processes, and technology. They observed and 
captured current State workflows; identified areas that will affect 
value achievement and present risk to the project; identified benefits 
from software being deployed; and identified any scope items that need 
to be addressed.
    VA reviewed final reports analyzing the CSR in October 2018 and 
discovered there are infrastructure readiness areas that require 
slightly more investment due to aging infrastructure and areas that 
will not require as much investment as initially predicted. To date, 
improved network and system performance by increasing network bandwidth 
and upgrading aging infrastructure resulting in reduced login times at 
IOC sites from 30-45 minutes to 15 seconds. VA conducted an analysis of 
industry and DoD/DHA health IT infrastructure to develop EHRM 
Requirements and Specifications which will optimize usage of the new 
EHR solution. As a result of these standards, enhancements were made to 
the local area network (LAN) and wide area network (WAN) at IOC sites, 
to minimize potential latency with data transfer from IOC sites to the 
Cerner Data Center. VA procured approximately 21,700 desktops and 
laptops of which over 50 percent are configured and in use by end 
users.

Organizational Structure and Strategic Alignment with DoD

    On June 25, 2018, VA established OEHRM to ensure that we 
successfully prepare for, deploy, and maintain the new EHR solution and 
the health information technology (IT) tools dependent upon it. OEHRM 
reports directly to VA Deputy Secretary and works in close coordination 
with the Veterans Health Administration and Office of Information 
Technology.
    To ensure appropriate VA and DoD coordination, we emphasize 
transparency within and across VA through integrated governance and 
open decisionmaking. The OEHRM governance structure has been 
established and is operational, consisting of technical and functional 
boards that will work to mitigate any potential risks to the EHRM 
program. The structure and process of the boards are designed to 
facilitate efficient and effective decisionmaking and the adjudication 
of risks to facilitate rapid implementation of recommended changes. As 
a result, since the June 12 hearing, the two Departments have supported 
closure of 20 out of 27 critical VA/DoD joint decisions.
    At an inter-agency level, the Departments are committed to 
instituting an optimal organizational design that prioritizes 
accountability and effectiveness, while continuing to advance unity, 
synergy, and efficiencies between VA and DoD. The Departments have 
instituted an inter-agency working group, facilitated by the 
Interagency Program Office/the Federal Health Record Modernization 
(FEHRM) Office, to review use-cases and collaborate on best practices 
for business, functional, and IT workflows, with an emphasis on 
ensuring that interoperability objectives are achieved between the two 
agencies. VA's and DoD's leadership meet regularly to verify the 
working group's strategy and course correct when necessary. By learning 
from DoD, VA will be able to address challenges proactively and reduce 
potential risks at VA's IOC sites. As challenges arise throughout the 
deployment, VA will mitigate adverse effects to Veterans' health care.

FEHRM

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

Implementation Planning and Strategy

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

National Workshops

    In September 2018, VA held its Model Validation Event, where VA's 
EHR Council met with Cerner to begin the national and local workflow 
development process for VA's new EHR solution. There was a series of 
working sessions designed to examine Cerner's commercial recommended 
workflows and evaluate the current workflows used at VAMCs. Because of 
Model Validation, VA planned eight national workshops to educate 
diverse clinical end-users and validate workflows to ensure VA's new 
EHR solution meets the Department's needs.
    VA completed the eight national workshops that spanned nearly 1,500 
sessions and over 50,000 cumulative work hours by over 1,000 frontline 
clinicians and end users from across the enterprise. VA was supported 
by DoD, who brought lessons learned and context to the DoD's EHR 
configuration, and by industry advisors who shared commercial best 
practices. Through these workshops consensus was reached on over 1,300 
design decisions and over 850 workflows were standardized to best meet 
the needs of our Veterans. VA also held seven of eight local workshops 
to validate national design decisions and configure to meet local site 
requirements. This educated local sites in how their facilities would 
use the new EHR solution to deliver quality health care to their 
Veteran population.

Change Management and Workflow Councils

    Because the program's success will rely heavily on effective user-
adoption, VA is deploying a comprehensive change management strategy to 
support the transformation to VA's new EHR solution. The strategy 
includes providing the necessary training to end-users: VAMC 
leadership, managers, supervisors, and clinicians. In addition, there 
will be on-going communications regarding deployment schedule and 
anticipated changes to end-user's day-to-day activities and processes. 
VA will also continue to work with affected stakeholders to identify 
and resolve any outstanding employee resistance and any additional 
reinforcement that is needed.
    VA has established 18 EHR Councils (EHRCs) to support the 
development of national standardized clinical and business workflows 
for VA's new EHR solution. The Councils represent each of the 
functional areas of the EHR solution, including behavioral health, 
pharmacy, ambulatory, dentistry, and business operations. VA 
understands that to meet the program's goals we must engage frontline 
staff and clinicians. Therefore, the composition of the EHRCs will 
continue to be about 60 percent clinicians from the field who provide 
care for Veterans, and 40 percent from VA Central Office. As VA 
implements its new EHR solution across the enterprise, certain Council 
memberships will evolve to align with contemporaneous implementation 
locations. While deploying in a particular VISN, the needs of Veterans 
and clinicians in that particular VISN will be incorporated into 
national workflows.
    Further, in response to lessons learned from DoD and commercial EHR 
deployments, VA designed the VA Innovative Technology Advancement Lab 
(VITAL) to provide advanced, hands-on education for VA informatics and 
analytics leaders as a lesson learned from DoD. The VITAL program 
consists of four, three-day, in-person sessions and a capstone project. 
The capstone project allows for participants to solve real-world 
problems, so they gain confidence and competence to take full advantage 
of the advanced capability in the new EHR solution. These participants 
are an important component of the super user community as they can 
support their peers during training, Go-Live, and sustainment 
activities. Initially 76 trainees were divided across four cohorts to 
participate from across 40 point-of-care clinical and support functions 
from VISN 20 sites.

Centralized Scheduling Solution

    VA accelerated the timeline to implement a resource-based 
scheduling solution across the enterprise in advance of the delivery of 
the full EHR solution. VA currently manages clinical scheduling using 
the Veterans Health Information Systems and Technology Architecture 
(VistA). According to a VA study VistA scheduling does not provide VA 
with the requisite functionality, usability, and overarching business 
benefits. Additionally, the outdated user interface and cumbersome 
manual processes create inefficiencies and prevent schedulers from 
viewing the medical provider's complete picture of available 
appointments.
    As a result, in 2018, VA piloted the Medical Appointment Scheduling 
System (MASS), a commercial resource-based, scheduling solution in 
Columbus, Ohio, to replace the clinic-based VistA scheduling system. 
This pilot site demonstrated that a resource-based solution improved 
timely access for Veterans, increased provider productivity, and 
enhanced scheduling accuracy. Further, the resource-based solution:

      Increased visibility of available appointments,

      Allowed providers a comprehensive view of their entire 
day, and

      Enabled staff to efficiently manage resources needed for 
appointments.

    Because a resource-based solution supports delivering better health 
care for Veterans, VA will implement the Centralized Scheduling 
Solution (CSS) to bring these benefits to all Veterans.
    VA's EHR modernization contract contains the licenses to implement 
CSS across the enterprise to fulfill interoperability objectives. Like 
MASS, CSS is a resource-based scheduling solution and will be 
implemented in a number of VA facilities in advance of full EHR 
modernization capabilities. The Chalmers P. Wylie Ambulatory Care 
Center, in Columbus, Ohio, will serve as the pilot site for CSS, with 
Go-Live scheduled for April 2020. The Louis Stokes VA Medical Center in 
Cleveland, Ohio, will serve as the next and larger pilot site for CSS. 
VA will leverage the architecture and lessons learned from the MASS 
solution by collaborating with key stakeholders from the MASS 
implementation to ensure these lessons learned are incorporated in VA's 
new scheduling initiative.
    VA established a dedicated pillar, or division, within OEHRM to 
provide oversight of CSS integration, deployment, and change management 
activities. Further, the pillar will collaborate with partners such as 
the Veterans Health Administration, Office of Information and 
Technology, and the Veterans Benefits Administration to successfully 
implement the CSS solution. Accelerating CSS implementation will enable 
VA to provide a resource-based scheduling solution across the 
enterprise sooner, and also replace VistA Scheduling Enhancements 
(VSE), which is the current temporary bridge for scheduling needs.

Funding

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

Conclusion

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