[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
GETTING IT RIGHT: CHALLENGES WITH
THE GO-LIVE OF ELECTRONIC
HEALTH RECORD MODERNIZATION
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HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY
MODERNIZATION
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, MARCH 5, 2020
__________
Serial No. 116-60
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
51-636 WASHINGTON : 2023
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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
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THURSDAY, MARCH 5, 2020
Page
OPENING STATEMENTS
Honorable Susie Lee, Chairwoman.................................. 1
Honorable Jim Banks, Ranking Member.............................. 3
Honorable Mark Takano, Chairman, Full Committee.................. 4
WITNESSES
Dr. Melissa Glynn, Assistant Secretary for Enterprise
Integration, Office of Enterprise Integration, Department of
Veterans Affairs............................................... 6
Accompanied by:
Dr. Richard Stone, Executive in Charge, Veterans Health
Administration, Department of Veterans Affairs
Dr. Robert J. Fischer, Director, Mann-Grandstaff VA Medical
Center, Department of Veterans Affairs
Mr. John Windom, Executive Director, Office of Electronic
Health Record Modernization, Department of Veterans
Affairs
Mr. David Case, Deputy Inspector General, Office of Inspector
General, Department of Veterans Affairs........................ 7
Mr. Travis Dalton, President, Cerner Government Services......... 9
APPENDIX
Prepared Statements Of Witnesses
Dr. Melissa Glynn Prepared Statement............................. 29
Mr. David Case Prepared Statement................................ 31
Mr. Travis Dalton Prepared Statement............................. 39
GETTING IT RIGHT: CHALLENGES WITH
THE GO-LIVE OF ELECTRONIC
HEALTH RECORD MODERNIZATION
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THURSDAY, MARCH 5, 2020
U.S. House of Representatives
Subcommittee on Technology Modernization
Committee on Veterans' Affairs
Washington, D.C.
The subcommittee met, pursuant to notice, at 9:05 a.m., in
room 210, House Visitors Center, Hon. Susie Lee [chairwoman of
the subcommittee] presiding.
Present: Representatives Lee, Cunningham, Banks, and
Watkins.
Also present: Representatives Takano and McMorris Rodgers.
OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN
Mrs. Lee. Good morning. 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 hearing, should they be able to attend.
Without objection, so ordered.
Today, the subcommittee continues its oversight of the
Department of Veterans Affairs' implementation of the
Electronic Health Record Modernization program. Less than 4
months ago, we held a hearing on the very same topic with much
of the same panel here today. The focus of that hearing on
November 20th was to assess preparations for the planned March
28th, 2020 go-live in Spokane, Washington. Each of the panel
members testified that she or he had the authority and the
willingness to hit the pause button, if so required, which, as
we will discuss today, is what happened; however, that is not
the entire story.
While I have always maintained that getting it right is
much more important than meeting a deadline, it is equally
important that the VA remain transparent about its progress and
problems.
As this subcommittee reviewed what happened between
November 20th and February 10th when the Secretary told me the
project was delayed, it has become clear that there were issues
with the direction that the VA was headed. As early as
December, facility staff who participated in testing were
expressing concerns about the State of the product development.
The concerns were compounded at superuser training in mid-
January when staff were confronted with a system that was not
what they expected in a frustrating training process. Yet,
despite being briefed by the VA on January 17th, the
subcommittee was not made aware of these issues. That is hardly
the transparency that we have been asking for.
I know that these concerns were communicated to the program
office in real time. Further, these concerns were communicated
to the VA leadership at least starting on February 4th. My
question is, why was Congress left out of the loop? Did the VA
think the issues identified by staff were not serious or could
be solved in 2 months or less? Did the VA and Cerner not
communicate about development issues? Did the VA think it is
not relevant for Congress to know about conditions on the
ground were not promising for a March go-live after all? I
would like to have some answers to those questions.
Recently, subcommittee staff traveled to Spokane and spoke
with numerous VA staff who participated in the testing and
superuser training about their concerns and experience; their
candor was refreshing and welcome. Clearly, they are
hardworking VA staff who are committed to participate in this
implementation outside of their primary responsibilities,
because they do want to get it right and they want to improve
the care for veterans. They get the accolades for standing up
and saying it was not working. I am glad that the VA management
listened to their own workforce and appropriately responded by
pausing implementation.
There are several issues I want to get to the bottom of
today. The overarching issue I see is a lack of communication
between the VA and its staff, the VA and Cerner, the VA and
external stakeholders, including veterans, and obviously with
Congress. In addition, there are lingering concerns about
staffing, infrastructure and readiness, which according to
testimony of the Office of Inspector General remain serious
issues to resolve.
There are questions about why VA did not realize earlier
that its commitment to a stripped-down first capability set
would be problematic. Were the right people involved in that
decision in the first place? Were key stakeholders left out?
What was communicated about the potential pitfalls of training
on a system that did not have the functions and workflows that
staff actually needed to learn? Was this a commercial practice
that VA did not understand the ramifications of adopting?
This was a lesson learned from Department of Defense (DOD)
that did not seem to be learned by the VA. Clearly, it was not
a practice that worked for the VA staff.
VA has said that it does not want to initiate
communications with veterans too early, but what is too early?
Based on feedback from veterans and Veterans Service
Organizations (VSOs), they need information and would like to
have more of it. Outreach is just starting to happen, which in
my view would have been much too late had the VA intended to go
live in March. What is the plan now for external communication
given the go-live is planned for July?
VA is now pushing to add new capabilities to the first set;
what are the ramifications of this? The subcommittee has
requested an updated time line for months, and I am again
requesting it and hope to receive it soon. We also need a
revised cost analysis, especially in light of the VA's budget
request for Electronic Health Record Modernization (EHRM). The
budget request raises many concerns, because it is no longer
based on an accurate picture of the program.
I hope that we get answers to these many questions and I am
certain that I will have many more by the end of this hearing.
It is my expectation moving forward that we will be getting
more timely, accurate, and transparent information about the
state of this program, and I hope the VA's intention is to
start delivering that today.
I would now like to recognize my colleague Ranking Member
Banks for 5 minutes to deliver opening remarks. Thank you.
OPENING STATEMENT OF JIM BANKS, RANKING MEMBER
Mr. Banks. Thank you, Madam Chair.
I first want to thank our witnesses for joining us today.
The presence of so many senior VA leaders reflects the gravity
of the matter before us, as well as a recognition of the
committee's role as a serious, constructive partner in
electronic health record modernization.
I especially want to thank Dr. Fischer for joining us again
from Spokane. Sir, above all else, this conversation is about
your employees and the veterans that they serve.
I want to reemphasize something that I have said in
previous hearings. In my opinion, this subcommittee's purpose
is to bring status reports on the Electronic Health Record
(EHR) modernization into public view. Since the go-live delay
was announced, there have been numerous high-level
conversations and briefings behind closed doors; however, the
public deserves to know what is happening. Delaying the initial
Spokane go-live was undoubtedly a difficult decision to make; I
believe it was correct, but I am sure it came with some
consideration of public relations backlash.
I laid out the facts as I saw them in our hearing in
November. Configuration and design decisions for the Cerner EHR
still had to be made. Dozens of systems' interfaces remained to
be built. Authorities to connect to the network were still due
from DOD. All of these things remain true to some extent today
and they are precursors to completing testing and training.
Perhaps most importantly, the Spokane employees must be able to
train on something representative of the actual production
system, not merely a mock-up training system.
In November, I was cautiously optimistic that a March 28th
go-live was still achievable, but a rough, rushed go-live was
clearly not in anyone's interest. I was relieved to learn of
Secretary Wilkie's decision to take additional time rather than
follow the path of least resistance, but highest risk.
It is important to be mindful of the incentives and
disincentives that Congress creates for the agencies that we
oversee. It seems unlikely this will be the last time during
the project that VA leaders will have to weigh the right thing
to do against reputational and political consequence.
I want to have a forward-looking conversation about how VA
will use the additional time to prepare for a successful go-
live. If several weeks represented the difference between a
rough go-live and a relatively smooth go-live, I expect VA to
use the additional 4 months to achieve excellence. The key
issues are the quality of training on the Cerner EHR and the
completeness of the system.
While I understand VA's rationale for splitting the Spokane
go-live into an initial capabilities set and a final
capabilities set, I think it has created a host of practical
problems, and many of those problems only became clear as the
March 2020 deadline approached. I am encouraged that the
Department has revisited some of these decisions and opted to
pull forward some capabilities into the initial go-live.
However, I want to be sure that no stone has been left unturned
and anything remaining in the final capabilities set is well
justified.
I also hope that we can minimize the need for VA employees
to navigate back and forth between VISTA and Cerner to retrieve
information and provide patient care. It seems the only thing
worse than a clunky EHR is two EHRs operating side by side. VA
seems to have heeded our concerns about gaps in the Cerner
patient portal's capabilities during the initial Spokane go-
live, especially concerning prescription refills. I want to
understand exactly how this problem is going to be solved.
Finally, I want to focus on our oversight responsibility to
monitor resource utilization and spending. I have never been
satisfied with VA's explanations of the frequent changes in the
10-year EHRM cost estimate. In the past, numbers have moved
around inexplicably. Now we have a budget proposal for a $400
million increase over the most recent Fiscal Year 2021 estimate
that seems was supported only by generalities.
The most significant driver of the cost estimate is the
implementation schedule and the VA has promised Congress a new
schedule by March 10th. I find that timing unfortunate. Much
has changed since the existing implementation wave schedule was
developed nearly 3 years ago.
I am also eager to see a new schedule and, if it is
credible, I will enthusiastically support it. I hope it will
move joint DOD/VA health care facilities forward into earlier
implementation waves. I firmly believe the James Lovell Federal
Healthcare Center in North Chicago could benefit more than any
other facility from a unified Cerner EHR. I had hoped to be
discussing the new schedule here today, but I remain
optimistic.
I look forward to exploring these issues with you all today
and with our witnesses.
With that, Madam Chair, I yield back.
Ms. Lee. Thank you.
I would now like to recognize the chairman of the full
committee, Mr. Takano.
OPENING STATEMENT OF MARK TAKANO, CHAIRMAN, FULL COMMITTEE
Mr. Takano. Thank you, Chairwoman Lee, for calling this
hearing along with Ranking Member Banks, and for both of your
commitment to continuing oversight of this important VA
program.
The stakes are high. We are spending a lot of money on this
integration; we have seen other integrations fail. I arrived to
Congress in 2013 with the announcement of the failure of
previous efforts and it boggled my mind that this could happen.
I want to associate myself both with the concerns expressed in
Ms. Lee's comments, as well as the ranking member's. We have
always maintained on this committee that getting this project
right is more important than meeting an artificial deadline.
That being said, we also just can not keep pushing deadlines
back and watch the costs mount, because we are already
projecting a huge cost.
You know, IT is one of those things, IT modernization is
one of those things that policymakers, you know, struggle with
in a big way. We often as lay people do not have full grasp of
those details and trying to get a firm accountability for the
sake of the public and the precious tax resources, this is a
difficult thing. That is why we established this subcommittee,
as per Dr. Roe's initial concern in the previous Congress, and
I wanted to continue this oversight.
It is paramount--I will say again--it is paramount that the
new EHR system work for staff and that it is safe for veterans.
A month ago, I was told by Secretary Wilkie that everything was
on track with the electronic health record modernization
rollout, with no anticipated issues. Then just a week later we
were told that the go-live was going to be postponed until
July. VA has a responsibility to operate with transparency and
accountability and that starts with informing this committee. I
cannot emphasize that enough. We want VA to communicate with
us, we want to build that trust; we also want to hold you
accountable for making sure you are moving things along.
I am concerned with VA's internal communication that may
have been lacking. Veterans Health Administration (VHA) and the
Officer of Electronic Health Record Modernization (OEHRM) must
be in continuous communication and the concerns of local
facilities must be taken seriously by VA's central office. I
want to know that that communication is happening internally
within the VA. We also need to ensure stable leadership is in
place to make this $16 billion project a success. VA has
recently--there has been recent changes at the top. The VA
Deputy Secretary is the accountable official for the Electronic
Health Record Modernization program under law, that is as per
law, yet that position is now vacant and a successor has not
been nominated, and even an acting Deputy Secretary has not
been named. We need to know who is in charge and who is
authorized under law to really manage this program.
I look forward from hearing from our witnesses today and
moving this important program forward. I yield back, Madam
Chair.
Ms. Lee. Thank you, Mr. Chairman.
I will now introduce the witnesses we have before the
subcommittee today. Dr. Melissa Glynn, the Assistant Secretary
for Enterprise Integration, and we have been told by Secretary
Wilkie that she is responsible to him for the EHRM program. Dr.
Glynn is accompanied by Dr. Richard Stone, Executive in Charge,
Veterans Health Administration; Dr. Robert Fischer, Director,
Mann-Grandstaff VA Medical Center; and Mr. John Windom,
Executive Director of the Office of Electronic Health Record
Modernization.
Also at the witness table are Mr. David Case, Deputy
Inspector General, Department of Veterans Affairs, Office of
Inspector General; and Mr. Travis Dalton, President of Cerner
Government Services.
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.
Dr. Glynn, you are now recognized for 5 minutes.
STATEMENT OF MELISSA GLYNN
Ms. Glynn. Thank you. Good morning, Madam Chair Lee,
Ranking Member Banks, and to your staffs. On behalf of my
colleagues here with me today, we appreciate the opportunity to
address you on this critical matter and, as you have noted,
having a complement of leadership, because we do take this
implementation extraordinarily seriously.
Before I begin, I would like to thank this committee and
specifically the subcommittee for the support of this
groundbreaking program. We appreciate the investment of your
time and that of your staff, who visited Spokane last week to
get their firsthand look of the deployment and to work with our
teams out there.
We share a commitment to getting this right and, while we
have revised a go-live date at the Mann-Grandstaff Medical
Center, we believe we are poised for success, and that path to
success factors the complexity of our system, its unique
requirements, and our unprecedented collaboration with the
Department of Defense.
We have made tremendous progress thus far. We completed
critical infrastructure updates at the Initial Operating
Capability (IOC) sites; these are already resulting in improved
performance. We have successfully migrated terabytes of data.
We will launch a new Joint Health Information Exchange with
DOD. This will allow all legacy and modernized VA in DOD sites,
as well as our private sector partners working with those
departments and our departments, to share health data
regardless of location. We are currently testing the new
Centralized Scheduling Solution in Columbus, Ohio, which will
align with the Cerner platform. We will deploy the system
across the entire VA before we deploy the full EHR solution.
As Assistant Secretary for Enterprise Integration, OEI, my
office supports the Secretary through leading governance to
support management in execution of our major initiatives,
especially focused on this program. OEI is responsible for
coordinating the internal requirements of all of VA's offices
to ensure the EHRM is successfully deployed.
I will say this, as my former experience, I have been an
audit partner at a Big Four firm and I have sat with the
responsibility to boards of directors overseeing go-lives as
well. I have had that exact experience, perhaps not of this
scale and the size and complexity of this program, but it is
nothing new.
The subcommittee has cautioned us, as mentioned, not to
rush to deploy a product that may jeopardize our ability to
deliver quality care veterans deserve and we agree. We agree
with your guidance and put in place a governance model which
prioritizes patient safety, balances risk, enhances user
adoption, and leverages lessons learned from DOD in their
initial deployment.
Last month, our clinicians in the field identified and
communicated critical requirements and capabilities that must
be available prior to user training. This was testament to the
cultural changes that we have put in place at VA that our field
staff can raise concerns all the way to the top of the
organization without fear. Secretary Wilkie made the decision
to postpone our go-live date so we can bring the EHR system
build closer to 100 percent complete before launching the next
phase, which includes the investment of thousands of hours of
staff training. We have greater confidence given our new go-
live date allows us to add capabilities to block one that will
enhance user adoption and improve the veteran experience.
In short, we are responsibly adapting Cerner's commercial
approach for EHR deployment to meet the unique needs of VA and
our health care system. Our governance model worked exactly as
it was supposed to by identifying those concerns and raising
the issue to the top levels of the organization.
We have provided Congress with an updated time line,
additional information on the project, and, as noted, the full
deployment schedule will be provided next week and we look
forward to walking through that with you. Our goal is to be
transparent and give perspective on the milestones ahead, the
scope and complexity of the task underway. I will note, serving
in a similar capacity with MISSION Act chairing the Enterprise
Project Management Office, we scheduled monthly briefings with
staffs and look forward to a similar type of engagement
strategy, so that we can have much more constant engagement on
the status of the program and the activities underway.
To be clear, no other health care organization in the world
is attempting something of this scale and complexity, and we
share your commitment to getting this absolutely right for our
veterans. Thank you for your continued support of our mission.
We are happy to respond to any questions you may have this
morning.
[The Prepared Statement Of Melissa Glynn Appears In The
Appendix]
Ms. Lee. Thank you, Dr. Glynn.
Mr. Case, you are now recognized for 5 minutes.
STATEMENT OF DAVID CASE
Mr. Case. Thank you. Chair Lee, Ranking Member Banks, and
members of the subcommittee, thank you for the opportunity to
discuss the Office of Inspector General's oversight of VA's
Electronic Health Record Modernization program. The Office of
Inspector General (OIG) recognizes VA's commitment to this
complex effort and appreciates the time VA staff have given OIG
personnel as we work to help VA achieve its goals.
We have seen dedicated VA employees working so veterans can
receive timely, high quality health care, and we heard their
concerns. They recognize the many challenges ahead in
responsibly managing risks. The OIG encourages VA to ensure its
mitigation strategies are properly tested, trained for, and
communicated to stakeholders. The OIG applauds VA's decision to
delay deployment given the state of readiness. Patient care is
put at risk when a system is rolled out with gaps in important
capabilities and what we perceive as currently inadequate
mitigation strategies.
Our office is conducting early, continual oversight of EHRM
because of its cost and scale, and its impact on VA, millions
of veterans and their caregivers. I want to discuss the
findings from two upcoming OIG reports about EHR preparation at
the Mann-Grandstaff VA Medical Center.
Our audit and health care teams focused on Mann-Grandstaff
because the work there is critical for ensuring future
successes. Both reports are in draft form and currently under
review at VA, consistent with OIG practices. Our teams will
integrate VA's feedback and plans for implementing our
recommendations prior to publication. While we do not normally
discuss not-yet-published reports, due to this hearing's timing
and VA having the draft reports, I will generally describe our
findings.
Our first report finds that patient care could be put at
risk when the EHR is deployed, particularly given missing key
capabilities. Based on DOD's transition to Cerner, Mann-
Grandstaff leaders estimated a 30 percent productivity drop for
18 months after go-live, but we found the facility's related
mitigation plans flawed. There appeared to be inadequate
personnel to handle the transition, due in part to a 2019
hiring pause, and challenges to providing timely access to
community care because of complex manual scheduling work.
By July 2019, VA found not all EHR capabilities would be
ready for the March 2020 go-live. Therefore, Mann-Grandstaff
would initially deploy limited functions which require
mitigation. While VA just delayed the Mann-Grandstaff's go-live
event to continue development, the OIG health care team found
VA's mitigation strategies did not resolve significant risk to
patient safety. This is the case with the lack of an online
prescription refill system, veterans' most popular way to get
refills.
The second upcoming OIG report finds VA's deployment
schedule was unrealistic to facilitate meeting VA's goals for
upgrading facility infrastructure before rollout.
In June 2019, OEHRM leaders told this subcommittee of their
goal to have upgraded physical infrastructure, such as cabling
and cooling systems, and IT infrastructure, such as network
components and end-user devices like laptops, completed 6
months before going live. This was a key lesson learned from
DOD's experience: this work should have been done before
October 2019.
During their October 2019 site visit, our audit team found
all 24 priority telecommunication rooms and the data centers
still needed upgrades. VA confirmed last month that some
contracts for critical upgrades still had not been awarded.
Moreover, some end-user devices had not been received in
October, let alone configured for use. This January, the team
found the facility had not received about half the medical
devices needed for go-live.
Infrastructure upgrades were primarily delayed for four
reasons. First, VA lacked early, comprehensive site assessments
to determine a realist go-live date. They did not assess the
facility's physical infrastructure needs until May 2019, about
a year after setting the March 2020 go-live. Second, OEHRM and
VHA had difficulty agreeing on required standards. Third, VA
lacked some controls to monitor infrastructure readiness. Last,
VA lacked staff to oversee the work.
In conclusion, the OIG will continue to monitor this
massive effort by reviewing Puget Sound VA Health Care System's
infrastructure readiness, examining VA's employees' related
training, and working with the DOD OIG to review the extent to
which the new system will achieve interoperability among
departments and community health care providers.
Chair Lee, this concludes my statement. I would be happy to
answer any questions you or other members of the subcommittee
may have.
[The Prepared Statement Of David Case Appears In The
Appendix]
Ms. Lee. Thank you, Mr. Case.
Mr. Dalton, you are now recognized for 5 minutes.
STATEMENT OF TRAVIS DALTON
Mr. Dalton. Thank you, Chairwoman Lee, Ranking Member
Banks, and distinguished members of the committee. My name is
Travis Dalton, President of Cerner Government Services. Thank
you for the opportunity to be here and for your continued
engagement and support of the Department of Veterans Affairs
Electronic Health Record Modernization program.
Cerner is honored to be a part of a shared mission to
ensure a lifetime of seamless care for our veterans,
servicemembers, and their families.
Transformation at scale is hard, it carries risks, and we
do not take the challenges lightly. We must deploy to over
1,700 sites, train over 300,000 VA employees, collaborate with
the DOD to make decisions, and interoperate with community
providers. Those challenges also represent opportunities.
Under VA's leadership, we have made significant strides on
our journey to transform care. We have incorporated commercial
practices, lessons learned from the DOD, and VA provider-led
feedback to ensure user adoption and readiness to meet
veterans' needs. We are pleased with the progress.
VA has come together to establish standardized workflows
and designs based on the work of 18 clinical councils,
comprised of thousands of providers across the VA, and eight
national workshops. This enterprise standardization is a
monumental achievement.
We launched Veterans Health Information Systems and
Technology Architecture (VITAL), a training series to empower
superusers with the technical and change management skills
needed to support the EHR implementation and ongoing success.
We have migrated 23.5 million veterans' health records into
the VA environment. This is the first time that historical VA
and DOD health data are in the same system.
In the coming months, we will implement a new Joint Health
Information Exchange that will allow interoperable information
sharing across VA, DOD, and community providers connected to
the network. Progress is being made.
We are supportive of the revised go-live schedule and the
decision to take additional time for testing and end-user
training. We heard the advice from this committee to take the
time to get it right and listen to the provider community. The
additional time will allow us the opportunity to ensure a
successful go-live at Mann-Grandstaff.
This program is truly transformational. By moving from 130
disparate systems to one open, modern, integrated system, we
will have the right data at the right place and time to drive
outcomes. We also have access to advanced analytics that will
give us the opportunity to better diagnose, treat, and prevent
chronic diseases; environmental exposures; suicide prevention
and PTSD; and opioid and substance abuse.
Health care's highest calling is caring for the men and
women who sacrificed in service to our country. Every day we
are energized by the passion and the commitment we see in
pursuit of this common purpose. On behalf of Cerner and our
partners, we are humbled and proud to be a part of this effort.
Thank you and I look forward to our discussion today.
[The Prepared Statement Of Travis Dalton Appears In The
Appendix]
Ms. Lee. Thank you, Mr. Dalton. I will now recognize myself
for 5 minutes for questions.
Before I get into the questions, I am going to ask some
questions looking back, but really, ultimately, the purpose of
that is so we can identify issues and correct those issues
moving forward.
On February 10th, Secretary Wilkie notified Congress that
the VA would be delaying the planned March 28th go-live. We
heard some differing reasons as to why, so I would sort of like
to get to the bottom of that before we move on.
Dr. Glynn, what was the specific root cause of the delay?
Ms. Glynn. Yes. Overall, I will just lay out a little bit
of the time line and address your question as to the cause of
the delay. We had a plan governance event always planned for
February 10th to review the status of the integrated validation
testing, the second round of that, IV-2, so that time line
correspond with that testing event finishing, and always
anticipated having a review--whether we were going live with
the next set of activities, which really was dedicated user
training.
As mentioned in my opening statement, that is thousands of
hours of clinician training, front-line training that takes
away from Dr. Fischer's team's time and ability to focus on
their day-to-day activities. That is why we had a high priority
on that time line.
The review of IV-2 results identified that we had concerns
moving forward and we had an opportunity to engage, the
Secretary directly engaged Dr. Fischer as part of our process.
He moved forward with identifying the feedback he had hear from
his staff and that was the cause for the postpone of the
training, frankly, as planned in our oversight time line.
Ms. Lee. Thank you. I have heard several reasons. I head
that the delay was not due to build issues and that the
capabilities were 80 percent there. We have heard concerns
about community care referral and beneficiary travel, and that
the delay was due to a set of five capabilities that were never
intended to be part of Capability Set 1, but now will be.
During our budget hearing last week Dr. Stone was emphatic that
the cause of delay was development, noting, quote, ``There are
73 interfaces, 19 are completed as of today, and that is why we
are delayed; this is development.''
Dr. Stone, was the delay due to these capabilities not
being included in the first capability set?
Dr. Stone. Yes.
Ms. Lee. Dr. Fischer, what is your assessment of the
reasons for the delay?
Dr. Fischer. From our perspective, ma'am, it was related to
gaps in training. Our staff are involved in national/local
councils, they had an expectation about what they would see in
the training build, and they simply did not see it. They
provided that feedback and I sent that up my chain.
Ms. Lee. I just want to make clear, like in October was
when they pushed the modules out for development that would be
used for the training. Then they continued to develop those
modules, but the modules that were going to be used for the
user training were stalled at October. When your staff was
going to be trained on that, they were basically an incomplete
system; is that a correct assessment?
Dr. Fischer. That was their perception, ma'am, yes.
Ms. Lee. OK. Honestly, looking back, at that point in time
is when we should have been notified that there was an issue.
Dr. Fischer. Ma'am, I think that there were expectations in
complete build and the training environment that were
predicted, but we only saw the training build when it was time
to train our superusers. Sometimes the expectations do not
match what we thought the deliverables would be. I do not
ascribe that to any particular agency or directorship, it is
just the nature of this complex process.
Ms. Lee. Mr. Windom, when was the determination made what
capabilities would be included in Capability Set 1 and
Capability Set 2?
Mr. Windom. Ma'am, I think it is important to characterize
what a completed build is. A completed build--and I will use a
mathematical equation--equals the core EHR being delivered by
Cerner, plus the interfaces--for the build one, it is 73
interfaces--plus the workarounds or alternate workflows that
are needed for a clinician to perform its duties or her duties.
That completed build set is an important characteristic.
As part of our testing activities, the completed build was
being--the core EHR was being developed based on introductory
of workflows--the interfaces, as you know, are still ongoing
and being worked--and the workarounds associated with that are
being developed as well. What ultimately was derived from the
activities as planned at the IV-2 event was that the totality
of those solution sets were needed for the end users to
properly train or to establish a foundation of training for
them to be comfortable that they were ready to implement.
Things revealed themselves as intended and at the IV-2
event it revealed that we needed to have closer to a completed
build, which meant more interfaces being ready, which meant
more clarification on workarounds being ready and, hence, we
went to the Secretary with the request to delay the go-live. I
think things worked, I just wanted to make that clarity for
you.
Ms. Lee. No, that is fine----
Mr. Windom. Okay.
Ms. Lee.--but can you answer the question of what date was
the determination between the capability sets made?
Mr. Windom. Ma'am, we had our first capability review--
again, our capability set is a byproduct of what the clinicians
need at Mann-Grandstaff to perform their services in support of
our veterans.
Ms. Lee. Can you just answer the question----
Mr. Windom. Well, ma'am----
Ms. Lee.--what was the date? My time is expiring.
Mr. Windom. Well, there is no specific date, because it was
an evolving process. It started in July 2019 and has evolved to
this present point in time.
Ms. Lee. All right. I just request that you provide the
subcommittee with a full list and final breakdown of what is in
each of those capability sets.
Mr. Windom. Yes, not a problem, ma'am.
Ms. Lee. Thank you.
Mr. Windom. Thank you.
Ms. Lee. My time has expired. I now recognize Ranking
Member Banks.
Mr. Banks. Thank you, Madam Chair.
Dr. Glynn, you have taken over some of former Deputy
Secretary Byrne's oversight and decisionmaking responsibilities
for EHRM, help me understand exactly what those are. For
example, leading up to the delay decision there were two rounds
of integration validation testing, three other kinds of
testing, and superuser training. What reports did Mr. Byrne get
from these events and what decisions did he sign off on?
Ms. Glynn. Yes, sir. As Deputy, Mr. Byrne was an important
member of our leadership team, overseeing many of our
initiatives; however, the Secretary has always made this
program a priority since its inception, he was the one who
signed the Cerner contract originally. The Secretary was and
remains the chair of our governance process. Mr. Byrne was
involved in that governance process while Deputy, but case in
point, we reached the planned milestone last month, the
Secretary made the call to postpone the training and revise go-
live.
To your question specifically, we had a governance process
in place, the Deputy served as a member of that team, chairing
our executive steering committee, the Secretary was always the
chair. We have always had briefings, program management reviews
with the Secretary present and we continue to do so. In fact,
we will be doing just that later this week.
Mr. Banks. Which of those reports that I mentioned will now
go to you and which decisions will you be responsible for
specifically?
Ms. Glynn. My responsibility is to help coordinate and to
facilitate making decisions on behalf of the executive steering
committee, moving those decisions forward for the Secretary to
be able to make those decisions.
Dr. Glynn and Dr. Stone, the EHR appropriation has
specified for 3 years now that, quote, ``The funds provided in
this account shall only be available to the Office of the
Deputy Secretary to be administered by that office.'' What has
that meant in practice? In other words, what leadership or
supervision was the Deputy Secretary providing and how has it
benefited this project?
Ms. Glynn. I will start off by saying the Deputy had
responsibility for review of the contract terms, the oversight
of signing off on the task orders, and the obligation of funds.
Dr. Stone. I would concur with what Dr. Glynn has said. All
of those decisions are now flowing to the Secretary for sign-
off and that is probably the major change. Dr. Glynn's role as
assuming the role of integrator, compiler, forcing function of
bringing people together to make sure that we resolve problems,
has now emerged more fully since the departure of the Deputy
Secretary from a financial standpoint. There is also a
reconciliation of who is responsible for which expense. For
instance, VHA as the health care system is responsible for
cabling in our buildings, for creating the heating and cooling
systems; in the switch closets, Office of Information and
Technology (OI&T) has responsibilities; and de-conflicting
those pieces of financial responsibility are essential to the
role that Dr. Glynn now assumes.
Mr. Banks. Okay. Let us shift gears a little bit.
Mr. Dalton, the main issues that Secretary Wilkie cited
when calling for the delay were the incomplete EHR build and
the quality of training. What aspects of the EHR configuration
and workflow remains incomplete and when will they be complete?
Mr. Dalton. Thank you, sir, for the question. I would like
to just make a quick comment. You know, we are using a proven
commercial practice here. The process we are using is we are
doing unit system and integration testing, so we are doing
levels of testing on an incremental basis. We have got some
structured processes, we have gate reviews, we have checklists
that we are using, and we have an ongoing, systematic
evaluation of the risk. Our goal is that we have--as we go,
these processes are fluid, they are never perfect, you know
more now than we knew at the beginning--so our goal is to have
processes and checklists and informed decisionmaking and a
constant evaluation of risks over time, which I think is what
we have seen as this process has played out.
I think that there are a couple, you know, key sets in
Capability Set 2 specifically to your question, sir. Imaging is
one of those, some cardiology elements, and then also some
pieces related to referral management, but 90 percent-plus of
the clinical capability will be in Capability Set 1 when we go
live in Mann-Grandstaff, sir.
Mr. Banks. All right. Just a quick follow up, Mr. Dalton.
Are you confident that your trainers fully understood VA's
specific workflows and processes, and did they shadow the VA
employees beforehand to become familiar?
Mr. Dalton. If I may, just a little context. In terms of
the training, I agree with Dr. Fischer's assessment. I would
just like to say that I am not sure it is specifically a
training issue, I think it was a content and expectation issue
related to what they expected to see. We were training to
workflows, which I think is important, but I am not sure all
the content was there that they would have expected, and we
agree with their assessment.
We are using primarily Cerner trainers, we have got some
contract trainers, and I think we have got some work to do
there in terms of the quality that we are bringing and also in
the following of the VA workflow, sir.
Mr. Banks. Okay, thank you. My time has expired.
Ms. Lee. Thank you.
I now recognize Mr. Watkins for 5 minutes.
Mr. Watkins. Thank you, Madam Chair.
Mr. Dalton, as a veteran who receives care in the VA and
somebody who grew up in the medical community, I have an
appreciation for the challenges that you face. Will you give us
a sense of the progress that has already occurred to date?
Mr. Dalton. Yes, sir. First of all, thank you for the
question. I think, you know, it is easy to get focused on what
is not going well and I think it is an important discussion
that we are having here today, but I also appreciate your
question because I do not want to forget the why and also the
progress that is being made.
We are moving to a single longitudinal record for the DOD
and the VA. I think you will see increased efficiency and you
will see safety as well, so you will embedded rules and alerts.
In many cases you have providers out there today that are
having to use five systems to complete standard workflows;
going forward, they will be using one system with integrated
data, which is ours.
Economies of scale, so you have the opportunity to reduce
operating costs over time and save taxpayer dollars. We have
seen that in the commercial markets in a material way. And then
innovation and advanced analytics, using the data we have been
able to migrate in order to solve and work on problems related
to toxic exposure, opioid abuse, and suicide prevention.
There are accomplishments along the way, sir. I mentioned
that enterprise design that the VA has worked on. You know, I
have worked with 24 large health systems, that is a major
accomplishment bringing together your enterprise in that way to
come together on standard workflows.
Then I think we talked a little bit too about improved
decisionmaking, we see a lot of progress. We have seen a lot of
coordination between DOD and VA as well in their working
relationship and decisions getting made.
Then finally, if I may, sir----
Mr. Watkins. Yes.
Mr. Dalton.--I think the interoperability issue and
question is one that I would like to bring up is that we--first
of all, Cerner's position is it is your data, it is the
patient's data, and I want to be crystal clear on that. That we
support open standards, patient rights, Office of National
Coordinator for Health Information Technology (ONC) rules, and
other rulemaking associated with providing that data.
The Joint DOD/VA Health Information Exchange (HIE) go-live
cannot be understated how important that is. It really sets the
stage for a national interoperable network of data with
community providers, which is something we have talked about
collectively for years and have not accomplished. We are on the
precipice of accomplishing that and the VA is leading the way
with that, and I really think that is an important step for the
Nation in going forward, sir.
Mr. Watkins. I understand, and understand the challenges,
but it seems to me that--it does seem to me that the work that
the VA has--the work accomplished has positioned the VA to be a
leader in the health care space and enhanced delivery of health
care to our veterans. Would you agree?
Mr. Dalton. Yes, sir, I would.
Mr. Watkins. All right. Mr. Windom or Mr. Dalton, how many
system interfaces have been tested to any degree and how many
from end to end?
Mr. Windom. Sir, right now, of the 73 that are identified
as what are Capability Set 1, 20 we can say are done end to
end, with a large group of interfaces to the tune of about 42
more being available this month, the month of March.
Mr. Watkins. Who is the Director of Infrastructure
Readiness in your office and who was performing this
responsibility before that position was filled?
Mr. Windom. Sir, my Technology Integration Officer, Chief
Technology Integration Officer, Mr. John Short, who I believe
is sitting somewhere behind me, fills that void--or fills that
role. In addition, he is the same one leading the joint
interface elements between DOD, VA, and Cerner. I think that
synergy supports our objectives.
Mr. Watkins. Dr. Fischer, how do you expect Cerner's
training to be different going forward, and what do you and
your employees need to see in order to ensure confidence going
into the July go-live?
Dr. Fischer. Sir, I believe Cerner represents a very agile
corporation. Based on feedback, both the National Councils and
our local subject matter experts will thoroughly review the
training program before it is executed, and I think that is
from lessons learned recently and I am very enthusiastic that
training will be of high quality next time around.
Mr. Watkins. Mr. Case, in your testimony you laid out what
is still incomplete in the Spokane Medical Center's
infrastructure upgrades. Some of these statistics are dramatic,
like 92 percent of the server rooms still need cable upgrades,
80 percent have poor cable management. Do your office and VA
have a different definition of what infrastructure upgrades are
critical versus desirable?
Mr. Case. I do not think we do. I think, if you are looking
at IT infrastructure, we basically took what they said they
needed and we just counted. If you are looking at laptops and
other IT infrastructure that should have been there in October,
6 months ahead of time, 30 percent were missing. There is
medical devices that have to be connected to the system. When
we looked at that last in February, only 50 percent were there.
When you look at the physical infrastructure, we once again
adopt whatever position it is that VA is taking in terms of our
scrutiny. The term is grandfathered-in 5E cables, as I recall,
for the 6A cabling, and so we do not expect them to put the 6A
cabling in on those where they have 5E, but they need to
upgrade other rooms. When we last looked, they had taken steps
to bring a lot of their telecommunications rooms into
standardization, which we looked, I want to say, a week or so
or 2 weeks ago.
Once again, we are trying to measure them against a
standard they accepted and which comes from the DOD lessons
learned, which is 6 months prior we should have a system ready
and upgraded as appropriate. We understand DOD's more
successful rollout in their recent rollout, one of the reasons
for that was they strictly adhered to that 6-month standard.
Mr. Watkins. Understood, thank you.
I am out of time, Madam Chair. I yield.
Ms. Lee. Thank you. I now recognize myself for 5 minutes.
Mr. Dalton, was the VA clear in what was required within
Capability Set 1 and the go-live in Spokane? It is just a yes
or no.
Mr. Dalton. Yes.
Ms. Lee. Did this time line give Cerner sufficient
development time before training and go-live in Spokane?
Mr. Dalton. Following a commercial approach, yes.
Ms. Lee. Was Cerner on track to deliver all of Capability
Set 1 on time for the March 28th go-live?
Mr. Dalton. From a clinical configuration, yes; from an
interface perspective, I can't say definitively.
Ms. Lee. You can not say----
Mr. Dalton. I do not know. We were working it day to day--
--
Ms. Lee. Okay.
Mr. Dalton.--that was a big number, it was more than we
thought when we started, it was--it is daily in process, ma'am.
Ms. Lee. Probably not?
Mr. Dalton. Probably not.
Ms. Lee. Yes. Dr. Stone, were there capabilities that
Cerner was expected to deliver within Capability Set 1 that
they failed to deliver?
Dr. Stone. The basic problem--and I know you would like a
yes or no, but I am going to give a nuanced answer--the basic
problem is we accepted Capability Set 1 as a minimum viable
product, but expected every piece of it to be present. When we
emerged from the second set of testing, we could not assure
that our workarounds and mitigation strategies that were
necessary--and there are in excess of 65 of them that are
necessary in Capability Set 1--could be tested and trialed and,
therefore, we had to concur with our clinical lead on the
ground and our leadership, as well as our other communities,
which included our financial community, our pharmacy community,
and our community care purchasing group, who all felt they
could not assess their readiness to go live because they could
not see their mitigation strategies. Therefore the answer was,
no, the system was not ready.
Ms. Lee. So but you--I guess my question is, you would--
then the answer would be that Cerner delivered what they were
expected to deliver, but just the capabilities, the
workarounds, and the mitigations were----
Dr. Stone. We could not--we could not----
Ms. Lee.--too much?
Dr. Stone. Madam Chair, we could not see the processes that
the users expected to see and designed in the work groups, and
clearly the interfaces that allowed us to mitigate--and let me
just concentrate on pharmacy, there are four key mitigation
strategies that tie us into our automated pharmacy refill,
which occurs 11,000 times a month at the Spokane site, none of
that could be seen and validated. Therefore, the ability to
pull people off of their regular job and begin intensive
training, which was about 20,000 hours of needed training, did
not make sense at all. Therefore, as Mr. Windom had predicted,
we would reach a February 10th decision date, when we looked at
each other on that February 10th date, it was absolutely clear
that we needed to carry to the Secretary a recommendation to
not go live.
Ms. Lee. Okay. Mr. Dalton, how do you respond to this?
Was--how do you respond to that? Was the VA clear on what it
needed for the go-live in Spokane?
Mr. Dalton. I think so. I think we collectively worked on
the capability sets, it was not a unilateral decision. We had a
process where we had functional experts, we worked closely with
the VA, we worked with the councils, we weighed in with our
professional opinion.
I do not feel that anything was levied upon us, I think we
collectively decided on those capability sets, ma'am.
Ms. Lee. Dr. Stone, was the VHA involved in those decisions
on what was in the capability sets?
Dr. Stone. Yes. Last fall--and I can not remember the exact
dates--when discussions began to occur whether the full
capability set would be ready, what we now call Capability Set
2, and whether we could take a minimum viable product, we all
agreed that there was huge value to an initial go-live at a
lower-complexity facility like Mann-Grandstaff, and we still
remain committed to that. There is huge value. There is also
tremendous enthusiasm on the ground, as your staff recognized,
from those clinicians and those workers and employees that are
participating in this to get this live, to learn our lessons.
One of the lessons that I learned when I was in the
commercial space and was assigned to the DOD fielding was we
failed to really listen to those efforts and lessons learned
and, therefore, we attempted to go live in DOD and then ended
up with a 23-month delay in order to do the operational
readiness testing that we have now demanded. I think we have an
incredibly agile vendor here with huge amounts of commercial
experience, but is still learning the lessons of working in
government space where we look forward to the agility that they
bring to us that will allow us to really test this system end
to end as we would do in any other system that we would bring
on board.
Ms. Lee. Dr. Glynn, so as leaders of this project--and Dr.
Stone--like just give me a top line, how are you examining this
and, you know, what steps are you taking to make sure--I mean,
clearly, I think the big issue was you had a capability set
that had a lot of mitigation steps in it, which, honestly, I am
totally fine with examining the capability sets to avoid that,
because, honestly, from a management point of view, once you
put these mitigation steps in place, that becomes the standard.
You know, you want user success and user acceptance. If you are
going to have multiple training modules where you are going
back and updating it, you are going to see dissatisfaction from
the end users, because they are not going to want to have to go
through training and then develop a step, then get rid of that
step and go through another training. I am totally on board
with this. I just want to know, what are you doing from a
management point of view to make sure that this process does
not repeat itself again?
Ms. Glynn. Yes, ma'am. Overall, what we have put in place
recognizes the complexity of all the work that is going on, as
highlighted by my colleagues, and by Mr. Case and Mr. Dalton.
We have--three times a week we have a joint operations center
in place inside the VA, which features representation across
the agency. There is over 300 individuals either participating
in person or by phone, including the folks in Spokane and
Seattle, and we are tracking everything from where is the
status of the interfaces, are there any stops that we can
overcome between our colleagues in IT and Mr. Windom's office
and OEHRM, working with VHA; understanding and updating the
testing, the planning for all the mitigating actions.
We found this--we stood this up to support the launch of
the MISSION Act, we found it to be a very effective program,
because we get everybody in the room who can hear the same
thing at the same time. And, frankly, from my experience at the
VA, that is one of our biggest challenges, because it is a
large organization, especially when we are fielding--or sitting
in D.C. and we are fielding a system in Washington State. We
need to have everybody hearing the same message, being able to
be heard and have their concerns heard at the same time, and
tracking the progress. So that everyone understands when we
say--you know, one of the terms we sort of jokingly say and ask
Mr. Windom the question of were the interfaces ready, we call
them done-done, because we want to make sure that everyone has
the same understanding of what does complete mean.
Mr. Case highlighted, you know, concerns and findings that
the Inspector General (IG) had a point in time, the program has
been very dynamic. We have been tracking infrastructure
readiness, the completion of the infrastructure, and all of the
setups and readiness at Mann-Grandstaff, you know, for many
months now, and we are very pleased to say that anything that
had been found in that audit has been cleared and has been in
place for some time at this point.
We are tracking, from a management perspective, there is a
lot of work that goes into--these are just not three times a
week we have meetings, there is a critical working group behind
that with representation across VA to make sure that we are
ready, tracking, and available to understand where the risks
are and being able to mitigate those. That flows up to our
executive steering committee, which we all sit on, and then
flows up to the Secretary's program management reviews.
Ms. Lee. I think she answered the question, clearly.
I would now like to recognize Mrs. McMorris Rodgers.
Mrs. McMorris Rodgers. Thank you, Madam Chair and Ranking
Member and the committee, for your commitment to this project.
I want to thank Dr. Fischer for traveling to represent Mann-
Grandstaff. Dr. Fischer, thank you for your leadership, your
advocacy for the interest of veterans in Eastern Washington. I
have heard a lot of positive about your leadership and
appreciate you taking on this project.
Dr. Stone, I want to thank you for appearing here today and
your commitment at this critical time in the electronic health
records modernization.
I want to pick up on some issues of staffing that I asked
about at a previous hearing. I want to make sure that your
commitment to, quote, ``flood Mann-Grandstaff with resources to
cushion the Cerner rollout'' is being carried out.
First, how many travel nurses do you have onsite now and
how many are you hoping to get?
Dr. Fischer. Ma'am, we have 24 traveling nurses onsite, but
since we have had a delay in go-live they will likely be
packing up here pretty soon and we will bring them back out in
June. That is the current plan and so that whole cycle will be
repeated.
Mrs. McMorris Rodgers. Thank you. How many physicians have
you added, either from the clinical resource hub or reassigned
from other medical centers, and how many do you hope to add?
Dr. Fischer. I do not have that breakdown today, but I am
happy to forward that to you. We have hired over 50 of our 108
mitigation personnel and we anticipate to be 90-percent healthy
in mitigation staffing with this delay in go-live, an added
benefit of slowing this train down a bit.
Mrs. McMorris Rodgers. I just heard--I was going to ask
about the additional permanent staff, that goal was 108 and you
just said it was----
Dr. Fischer. That is correct, ma'am.
Mrs. McMorris Rodgers. You are at 50.
Dr. Fischer. We are at 50, 54.
Mrs. McMorris Rodgers. Fifty four.
Dr. Fischer. Several have had an offer, we are just waiting
to on-board them, but I am told by June by our H.R. department,
we will be at about 90-percent strength by the time we go live.
Mrs. McMorris Rodgers. Okay. The additional permanent staff
that you need you believe will be in place by July 2020?
Dr. Fischer. We anticipate 90 percent. Some of the
physician positions are extremely difficult to recruit under
any circumstances. I am optimistic, as I was the last time I
sat here, but we will likely not reach 100 percent. We never
really anticipated we would reach all of those recruitments,
but over 90 percent, from my perspective, is healthy.
Mrs. McMorris Rodgers. Okay. Given the delay of the initial
rollout from March to July, are we going to be able to keep all
these employees, some of whom are temporary, for when they are
needed most?
Dr. Fischer. The answer would be yes, because they are
permanent hires. Our hope is that once we reach steady State we
might find an excess, in which case we will allow them to
attrit. In the short to medium term, as long as we need them,
the permanent hires are permanent and we would attrit them when
they were ready to move or if they underwent an adverse action;
hopefully, that would not be the case.
Mrs. McMorris Rodgers. Okay. Thank you.
Mr. Case cited in his testimony a backlog of 21,155
requests for community care at the medical center----
Dr. Fischer. Yes, I am happy to----
Mrs. McMorris Rodgers.--perhaps this does not surprise me.
I understand one of Secretary Wilkie's reasons for delaying the
Cerner go-live was that the functionality to process community
care is not ready for prime time yet.
With the additional time and staff you have and will have,
how are you going to walk through this backlog and make
community care available to the veterans who want it?
Dr. Fischer. Just for clarification, ma'am, the backlog is
now, I think, down around 17,000. That is not to say that the
care has not been rendered, we simply have not administratively
closed those consults. Through a combination of overtime and
compensation time, as well as leveraging those travel nurses, I
am told by the end of April we will have completely resolved
that backlog.
Furthermore, I have asked our Veterans Integrated Services
Network (VISN) for additional personnel in order to support the
Office of Community Care, so that we do not reach that
crossroads again.
I would say that in the last 2 years I have increased the
personnel in the Office of Community Care by 48 percent, this
next bump will represent a substantial increase as well, but
the reality is we are purchasing more care and it takes more
staff to support that care.
Mrs. McMorris Rodgers. Okay. Mr. Case, would you respond to
just where you believe we are?
Mr. Case. On various issues, I would say yes. Community
care, which you described, they have been scheduling overtime
to deal with the backlog. My understanding is, in the process,
in reducing the backlog, they are going to train people to
adapt to the new scheduling of community care. That may be more
complicated, but it is also going to require--there is going to
be more demand, is the anticipation of a mitigation.
Mrs. McMorris Rodgers. Okay. Mr. Fischer, would you also
address where we are with, you know, the issue of only having
31 percent of computers and 51 percent of new medical devices
not being received yet?
Dr. Fischer. My understanding is that all the computers
have been distributed to my staff. Biomedical devices are
continuing to be distributed as well. I would defer to Mr.
Windom on the technical aspects of where precisely we are with
biomedical devices. I have a new computer, it is in my bag, and
so do does every single staff member have a new and improved
computer with greater RAM, so we are good to go with respect to
our computers, ma'am.
Mrs. McMorris Rodgers. Okay. My time has expired. I do have
further questions that I will submit for the record. I
appreciate all of your attention to getting this right and
getting it done as soon as possible. Thanks.
Dr. Fischer. Thank you, ma'am.
Ms. Lee. Thank you.
Dr. Glynn, on 2020 I sent a request for several documents
related to this project; as of yet, we have yet to receive any
of them. Can I get your assurance today that I can get those
documents by next week?
Ms. Glynn. I believe you can get them sooner than next
week. I am not sure if we brought them with you, but we do have
those prepared----
Ms. Lee. Oh, great.
Ms. Glynn.--and available. So----
Ms. Lee. Thank you.
Ms. Glynn.--I know I was working on making sure those were
prepared.
Ms. Lee. Mr. Windom, what is now--what is the revised time
line in terms of training, et cetera?
Mr. Windom. Ma'am, we look forward to delivering that to
you on March 10th. I do not have it memorized, but it reflects
a new anticipated go-live timeframe of July 2020 with a
critical path element of the completed build, which I keep
harping on this, because it is important, the completed build
is the core EHR, plus the interfaces, plus the workarounds or
alternate workflows.
Ma'am, we can deliver that schedule to you as well next
week as part of our March 10th deliverable.
Ms. Lee. Great.
Mr. Case, does Dr. Fischer's statements on staffing match
OIG's observations?
Mr. Case. Yes. They asked for 108 or anticipate 108, last
time we checked they were at 51. They are making progress, the
question is can they continue to make progress, and we do not
doubt their commitment to that and their efforts in that
regard.
Ms. Lee. When was that?
Mr. Case. I believe the last time we looked was about 2
weeks ago they were at 50. I think that is an accurate number
as of then, but they may have increased it some since then.
Ms. Lee. Mr. Dalton, what things have to happen between now
and your new July go-live date?
Mr. Dalton. There are several activities. We will be doing
our build completion, we will be working on the additional
items we are bringing forward as part of Capability Set 1. We
will be doing additional testing, there will be training
activities. We will be meeting with our counterparts here on a
cadence and from a governance and project management
perspective, but really it is--and we will be adding some
additional rigor and discipline to the process via operational
readiness assessment and some other event activities as well.
Ms. Lee. Dr. Glynn, I wanted to--and this might be Dr.
Fischer--in terms of the training necessary to roll this out in
July, how many thousands of hours did you say?
Ms. Glynn. I think we estimated somewhere around 20,000
hours.
Ms. Lee. Twenty thousand hours?
Ms. Glynn. Yes.
Ms. Lee. When do you anticipate--I mean, the training that
has been done, is it sort of a start-over at this point?
Ms. Glynn. For the user training, yes. That will commence
in full, as Mr. Windom said, once that completed build is
available.
Ms. Lee. Dr. Fischer, do you feel that the new time lines
properly address the issue that your personnel had with the
original time line? I mean, are you confident that we can--that
this 4-month delay is a sufficient amount of time?
Dr. Fischer. At this moment, I am. I think my staff had a
large sigh of relief when we were able to slow this forward
progress in order to dot some of the I's and cross the T's, as
both Cerner and VA learned about initial implementations in a
large Federal health care system. There is just not a ton of
experience with initial implementations in an agency our size,
so we both have to be willing to learn and we are learning.
Ms. Lee. Great.
Dr. Stone, is the VHA satisfied with this new time line?
Dr. Stone. With your forbearance, a bit of nuanced answer.
That answer is yes, but there are gates that must be met. As
Mr. Windom has said, we are expecting large numbers of
interfaces to come on line in March, we are expecting the
finish of the build in April and May of both the processes,
what is the VA-Cerner Millennium product, as well as the
interfaces, and then we need about 6 weeks of training and
about 2 weeks for an end-to-end operational assessment. At each
one of those there is a gate that my answer could change. Am I
optimistic? Absolutely, because I have got great partners here,
and the people you see at the table are all committed to
getting to the same place, but there are gates that must be met
in order to sustain that optimism.
Ms. Lee. Mr. Windom, when do you expect the training domain
to be pulled?
Mr. Windom. Ma'am, at this juncture, we believe that April
6th or thereabouts. Again, I can give you the granularity you
are looking for included when we anticipate the completed
build, we anticipate the interface. What I do not want to do is
speak on the record about specific dates when I can give you
the absolute document next week.
In addition, we believe that that completed build, as a
lesson learned for this training environment, is that the
completed build is mandated before we start the superuser and
the end user training. Again, you will see that all laid out
and you will see that our timeline supports the optimism of a
July go-live timeframe.
Ms. Lee. Thank you.
I now recognize Ranking Member Banks.
Mr. Banks. Thank you, Madam Chair.
Dr. Stone, I want to make sure I understand which Cerner
capabilities have been pulled forward to be available in July
and which ones were judged nonessential for the initial go-
live. I will start with the most important one, the
prescription reordering capability in the patient portal.
Please explain how this will work now, what alternatives you
explored, and what the veteran's experience will be in Spokane
and Seattle.
Dr. Stone. This is an automated process in what we call our
CMOP program, our Consolidated Mail Order Pharmacy. In order
for us to mitigate what is not complete, we will need a
telephone bank of trained pharmacists and pharmacy techs that
literally will receive these telephonically; that is the
workaround mitigation. That will also require the interface of
audio care, which is what we use to request, as well as
ScriptPro and Omnicell, in order to be fully functional.
Now, Omnicell is what allows us to really tag in supplies
that are delivered, as well as our utilization rates. ScriptPro
is also a prescription refill automation system, which is part
of the mitigation strategy. All of those interfaces need to be
completed, some of them are in Capability Set 2, some in 1, but
the key piece is we must be able to have a manual phone bank
that we then publicize to our veterans that they can call in
for their refills, and then we will manually enter that as a
workaround.
The joy of this delay is we may be able to avoid all of
that by pulling forward the connections into what we are now
defining as Capability Set 1.1. We have been very hesitant to
move the complete goalposts of Capability Set 2 and 1 for the
reasons that we have discussed already. We do not really want
to move the goalposts, but pharmacy refill is absolutely a
potential major risk, as Mr. Case has identified, and we have
been working hard to mitigate that.
I think I have answered your question.
Mr. Banks. I think so. Same question, though, please
explain the video visit capability. This is a really important
one to move forward.
Dr. Stone. I think it is. I do not think technically--I
would probably defer to John Windom on the technical pieces of
this or his support and John Short, but mitigation in a
critically short, vulnerable area like Spokane where we have
trouble hiring providers, the use of video telemedicine is
something we do across the Nation. In fact, we are the world's
leader in provision of telemedicine services, more than 2.6
million visits last year across the Nation. We are prepared to
provide that, but the interface is necessary, and I would
refer, if you are amenable to that, to Mr. Windom to actually
try to answer it.
John, I do not know if----
Mr. Banks. I have a lot more to ask and a very little----
Mr. Windom. Yes, sir, we can come in and brief your staff,
sir, on all the 1.1 elements in whatever granularity you would
like moving forward.
Mr. Banks. Okay. Dr. Stone, what about Auto Prescription
Remit and Beneficiary Travel Kiosk capabilities?
Dr. Stone. Yes, those are huge valuable pieces. We cannot
exist without the ability to do beneficiary travel and so those
kiosks must be linked.
Mr. Banks. How about Vitals Link Integration? I understand
this one pertains to medical devices.
Dr. Stone. Yes, I cannot speak to the technology of that.
Mr. Banks. All right. Dr. Stone, what solution have you
come up with to improve the processing of community care
referrals and authorizations? The problem seems to be limited
integration between Cerner and Health Share Referral Manager,
and an awkward workflow involving HSRM and the joint legacy
viewer.
Dr. Stone. I think that is a piece of it, I think the other
piece of it is just sheer volume. Since MISSION Act went into
effect, the 6 months before MISSION Act we referred nationwide
2.7 million veterans to community care, the next 6 months we
referred 3.8 million, and part of the backlog that Dr. Fischer
is experiencing is just sheer growth in community care. About
35 percent of our visits are now community care at a cost of
about 27 percent of our actual budget.
We are working to resolve that nationwide with our clinical
resource hubs and the interfaces that are necessary, but I
would defer to OEHRM on the actual technical pieces and
capability of those software systems.
Mr. Banks. All right. What have you decided to do to pull
forward with the Care Aware Multimedia functionality? This is a
very important Cerner imaging capability for cardiology,
radiology, and others, and I understand the difficulty has been
getting an authority to connect from DOD, so that VA can
upgrade to a newer version of CAM.
Dr. Stone. That is an essential workaround that requires
multiple screen looks from our providers and going into our
joint legacy viewer until that capability comes online in IV-
2--I am sorry, in Capability Set 2.
Mr. Banks. Okay. Mr. Dalton, what will the impact of this
be? Are you satisfied if VA employees will have to use VISTA or
Joint Legacy Viewer (JLV) to look at medical imaging?
Mr. Dalton. It is a standard commercial process. Many times
we actually interface to existing Picture Archiving and
Communication (PAC) systems and they utilize those. This is not
entirely different than what we might do commercially, sir. Am
I satisfied? No. CAM-7 needs to be there, they need to be able
to view images in a greater way. Do I think that it is
appropriate for it to be in Capability Set 2? I believe so,
sir, based on our commercial experience.
Mr. Banks. Yes, this seems really important.
Mr. Dalton. It is.
Mr. Banks. Mr. Windom, before the delay, the decision to
split the Spokane implementation in Capability Set 1 and
Capability Set 2 created 68 alternative workflows. Most of
these are work processes that rely on Cerner as well as VISTA,
and some of them are manual. How many alternative workflows are
you going to use the delay to eliminate?
Mr. Windom. Sir, I will have to get back with you on that.
I do not even want to speculate. I know the number goes down
with the introduction of 1.1 capabilities that are being
brought forward. I guess I would offer, you know, we view
workarounds as this negativity, there is workarounds in
Computerized Patient Record System (CPRS), there are hundreds,
if not thousands of workarounds. What we are doing as part of
our efforts are creating an integrated system where you do not
have to go in and out of the system. You will see that number
going down over time, sir, but we can get to you on exact
numbers, but that is being dwindled and it is part of our
transition activities, with more even being eliminated as part
of Capability Set 2.
Mr. Banks. All right. I know we have to go vote, I will
just finish with this last question about the patient portal
from our November hearing. Which parts of the medical record,
which prescription refills, and which types of appointments
will veterans be able to view or request using the Cerner
portal, Mr. Windom?
Mr. Windom. Sir, I will have to get back to you on that, I
do not have the specifics. What I would offer to you is that
interim solution is the Cerner portal with a migration to a
hybrid portal as we move into Capability Set 2. We have no
desire to reduce the capabilities that we deliver to our
veterans or reduce the veteran experience.
Again, that is what is good about the flexibility and the
partnership with Cerner is that we are evolving to even a
better State and that is going to come with the Capability Set
2.
Mr. Banks. Okay. With that, I will yield back. Thank you
very much.
Ms. Lee. Thank you. Before we wrap up, I just want to focus
a little bit on the infrastructure.
Mr. Case, in your written testimony you indicated that as
of February 25th, 2020 contracts had yet to be awarded for
critical infrastructure upgrades, can you elaborate on which
upgrades you are talking about?
Mr. Case. Yes. From our perspective, and we take the
perspective from the VA, one of the issues is the cooling of
the telecom rooms, and that is something that there is a
temporary solution to and then ultimately moving to a permanent
solution. Our understanding is the contract for the fan systems
that will be the temporary solution has yet to be awarded as of
today. Now, that does not mean it can not get in place and be
done, but once again we continue to try to hold VA to the 6-
month time line, recognizing that that is an important lesson
learned from DOD, that is the critical one.
Ms. Lee. What is the potential risk to patient safety or
system stability caused by the lack of this infrastructure?
Mr. Case. The issue is, they may be up and running, it goes
to equipment longevity--if I have said that right--and then,
you know--so, ultimately, if there is an effect on the
equipment, it can affect functionality, we hope that is not the
case. There is a plan in place to have a temporary solution. We
point it out, because let us put that temporary solution in
place in time and that is the reason we point that out.
Ms. Lee. All right. Well, we have to run off to vote, so we
are going to wrap this up. We look forward to reading the full
OIG report when that comes out. We expect we will probably have
some additional questions given the information you gave us,
but I want to thank you all first and foremost for your
commitment and your service to veterans and our country and for
taking on what is an incredibly complex project. I hope that we
continue to have the transparency that we need to provide the
proper oversight of this project, you know.
I especially appreciate that the VA listened to personnel
who were on the front line who had concerns about safety and so
thank you for taking that step. I know we had talked previously
about making sure we get this right instead of meeting a
deadline. That being said, you know, I want to make sure we
have 4 months for this July date, what are our plans to meet
that and to make that a realistic deadline. I am very concerned
about the infrastructure issues, especially with cooling. It to
me is just--I just feel like we are shooting ourselves in the
foot on that one. I hope that we can see some progress made
with that, especially given how expensive this project is. I
would hate to see us get it up and running and then see, you
know, the shelf life diminished or, furthermore, a complete
system breakdown, which would jeopardize patient safety, so
hopefully we can get that on track.
We have 4 months to build, to test, to train. We have the
infrastructure issue. We look forward to seeing the plans that
you are providing today and hope that this will be the
beginning of an honest and transparent dialog back and forth.
You know, honestly, God speed, we hope that you guys get this
right. You know, you are right, this is an incredibly important
project not just for the VA, but for health care across this
country. We will continue to have some hearings on this as we
progress and I thank you all for being here today.
With that, all members will have 5 legislative days to
revise and extend their remarks and include extraneous
material, and the hearing is now adjourned.
[Whereupon, at 11:29 a.m., the subcommittee was adjourned.]
=======================================================================
A P P E N D I X
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Prepared Statement of Witnesses
----------
Prepared Statement of Melissa Glynn
Good afternoon Madam Chair, 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) Electronic
Health Record Modernization (EHRM) initiative and deployment of the
Cerner Millennium Electronic Health Record (EHR) solution. I am
accompanied today by Dr. Richard Stone, Executive in Charge of the
Veterans Health Administration (VHA), Mr. John Windom, Executive
Director of the Office of Electronic Health Record Modernization, and
Dr. Robert Fischer, Director of Mann-Grandstaff VA Medical Center
(VAMC).
I would like to begin by introducing myself and my role within VA.
The Office of Enterprise Integration helps guide VA operations, inform
decisionmaking, and integrate initiatives within the Department and
with other agencies. In my role, I support the Secretary on major
transformational initiatives, including our supply chain modernization,
financial management business transformation, the VA Maintaining
Internal Systems and Strengthening Integrated Outside Networks Act and
EHRM deployment. In this capacity, I work closely with leadership in
our Office of EHRM and VHA to support implementation activities at the
enterprise level. Additionally, my office is the lead for coordination
activities with the Department of Defense (DoD) which is vital to this
joint endeavor. Our internal coordination with DoD will ensure seamless
delivery of quality health care to Servicemembers, Veterans, and
qualified beneficiaries.
In November 2019, VA appeared before this subcommittee to provide
testimony and an update on the process of the implementation of the EHR
system. We met critical milestones including site assessments,
infrastructure upgrades, the migration of 78 billion health records,
development of an enterprise interface, and the completion of 8
national user workshops. These workshops spanned nearly 1,500 sessions
and over 50,000 cumulative work hours by more than 1,000 frontline
clinicians and end users from across the enterprise. We established
national councils comprised of VA and DoD clinicians, technologists,
and industry leaders to collaborate as we build a single, standardized
system.
We received valuable insight from DoD, which has brought lessons
learned and context to the EHR configuration, and by industry advisors
who shared commercial best practices. Through these workshops, we
reached consensus on more than 1,300 design decisions, and over
approximately 900 workflows were standardized to best meet the needs of
our Veterans.
These efforts have moved us beyond mere partnership to support true
coordination with DoD. We established a joint Federal Electronic Health
Record Modernization Office, and in Spring 2020, we are poised to
deliver a Joint Health Information Exchange with DoD. This will benefit
all legacy and modernized VA and DoD health care sites, as well as
community providers who exchange records with both Departments. I am
proud of our progress, and we are continuing to work toward a
successful EHR deployment.
EHRM Deployment
VA pioneered the first EHR in the 1980's, which paved the way for
widespread EHR adoption throughout the U.S. health care system. To
achieve greater interoperability with DoD, in May 2018, VA awarded
Cerner Corporation a contract to replace the Department's legacy
patient record system with the commercial-off-the-shelf solution
adopted by DoD. A single, interoperable solution across VA and DoD will
enable the secure transfer of Active Duty Servicemembers' health data
as they transition to Veteran status. This 10-year modernization effort
will create a lifetime of seamless care for Servicemembers and
Veterans.
VA's health care platform is composed of a highly complex clinical
and technical environment, delivering Veterans specialty care not
typically supported by commercial EHRs with unique requirements that
must be configured and properly integrated to ensure continuity of
care. No other health care organization in the world is attempting
something of this scale and complexity, and we are committed to getting
this absolutely right for our Veterans.
We selected the Mann-Grandstaff VA Medical Center, in Spokane,
Washington, as our Initial Operating Capability (IOC) site and
established a very aggressive and optimistic deployment timeline that
also prioritizes patient safety, balances risk, enhances user adoption,
and leverages lessons learned from DoD's deployment. During the IOC
deployment, we are working to identify efficiencies to optimize the
schedule, hone governance, refine configuration, and standardize
processes for future locations.
Our immediate focus for our IOC site is readiness of the system to
support training. After we completed the second Integration Validation
Testing (IV2) in early February 2020, we identified that additional
efforts are needed to configure the system to meet VA's unique
requirements for community care, beneficiary travel, and others--for
which there are not similar requirements elsewhere in modern health
care. We were able to identify these issues because leadership and
clinicians at the Mann-Grandstaff VA Medical Center raised concerns
using feedback mechanisms built into our deployment plan. This led to a
decision on whether to sustain the user training schedule or continue
development to move the system build closer to 100 percent complete
before conducting training. The training event, which was scheduled to
begin the week of February 10th, would have marked the start of ongoing
education for professional staff--clinicians, providers, and VA staff--
who will use the new EHR.
The governance process I established to support leadership
oversight provided a check point to validate the beginning of this end
user training and the overall implementation timeline with the
completion of IV2. Thus, reaffirming the timeline for our go-live date
was anticipated to occur at this point. As the IOC timeline has been
expected to occur over many months, a re-planned go-live date will
still occur during the IOC period.
It is important to note that we are not adjusting our 18-month
timeline for IOC at Mann-Grandstaff VAMC. We are still operating within
the designated time period for IOC and continuing to build capabilities
into the system so that our clinicians and users can train on a more
complete EHR interface.
Congress and other stakeholders have cautioned VA not to rush and
deploy a product that would fall short of the quality patient care
Veterans expect and deserve. We could not agree more that getting it
right is more important than meeting an aggressive schedule, and we
decided to postpone our go-live date at Mann-Grandstaff VAMC. Detecting
course correction opportunities prior to go-live is at the core of our
approach to deploying an EHR solution. This approach ensures patient
safety, security, and a functional system for all VA health care
professionals.
Current Status
A large-scale EHR deployment follows an iterative model in which
new capabilities are added as the system is deployed. Though we
initially planned to commence user training when the system was 75-80
percent complete, our clinicians in the field identified some critical
requirements that must be completed prior to go-live at Mann-Grandstaff
VAMC.
If not addressed, these critical requirements would pose
significant risk to preserving continuity of care to our Veterans, thus
VA will take all precautions to manage this risk to an acceptable level
for our clinicians and users, and even more importantly, our Veterans.
Therefore, we decided to continue development to move the system closer
to 100-percent complete before conducting user training.
We are currently working to have the system closer to 100 percent
and expect to validate this milestone in the spring. Once we validate
functionality of the system, we will commence user training with the
goal of establishing a new go-live phase in July 2020.
Ultimately, our EHR transformation success revolves around user
adoption. By adjusting our training schedule, we will be adding
additional capabilities originally scheduled to be incorporated after
our go-live date. These capabilities are intended to enhance user
adoption, improve productivity and efficiency for our field staff, and
enhance the Veteran experience.
It is also important to recognize that we are not doing this alone.
Our VA deployment schedule leverages lessons learned as we deliver a
single, longitudinal health record at VA and military health
facilities.
EHRM Budget
With the support of Congress and the President, we have a Fiscal
Year (FY) 2021 budget request of $2.6 billion for EHRM, which is $1.2
billion above Fiscal Year 2020. This budget request provides necessary
resources for full deployment of VA's new EHR solution at the remaining
sites in Veterans Integrated Service Network (VISN) 20 and VISN 22.
Additionally, it funds the concurrent deployment of waves comprised of
sites in VISNs 7 and 21. This budget will also allow us to continue
implementation efforts and nationwide deployment of the simultaneous
Centralized Scheduling Solution.
We are currently testing the Centralized Scheduling Solution at the
Chalmers P. Wylie Ambulatory Care Center, in Columbus, Ohio, and
through our governance process, we will validate commencement of user
training and our implementation schedule. Our intent is to implement
this new, resource-based scheduling solution across the enterprise on
an accelerated timeline and enhance scheduling accuracy. This
initiative will bring the benefit of a modern, resourced-based
scheduling system to VA and to our Nation's Veterans before the full
EHR solution is implemented. By providing this capability sooner, VA
will improve timely access to care for Veterans, increase provider
productivity, and enable the adoption of the full EHR solution.
Because we are still operating within our designated IOC 18-month
schedule, we do not anticipate a change in funding requirements at this
time. Should our deployment schedule change such that it impacts our
current or proposed budget, we are committed to providing Congress with
timely notification.
Closing
I would like to once again thank Congress and specifically, this
Subcommittee, for your continued support and shared commitment to our
success. Because of your support, we are able to continue our mission
of improving health care delivery to our Nation's Veterans and those
who care for them while being a good steward of taxpayer dollars. We
are committed to providing the high-quality care and benefits that our
Nation's Veterans deserve, and we will continue to keep Congress
informed of milestones as they occur.
Madam Chair, Ranking Member Banks, and Members of the Subcommittee,
thank you for the opportunity to testify before the Subcommittee today
to discuss our deployment of the Cerner EHR solution. I would be happy
to respond to any questions that you may have.
__________
Prepared Statement of David Case
Madam Chair, Ranking Member Banks, and members of the Subcommittee,
thank you for the opportunity to discuss the Office of Inspector
General's (OIG's) oversight of the Department of Veterans Affairs'
electronic health record modernization (EHRM) program. The OIG
recognizes the significant level of effort and commitment required by
VA to manage and facilitate this massive and complex system
implementation, including the tremendous work already conducted by VA
staff to date. The OIG's initial oversight efforts of the EHRM program
have been primarily focused on the planning, preparation, and other
activities related to the initial deployment location--the Mann-
Grandstaff VA Medical Center (Mann-Grandstaff VAMC) in Spokane,
Washington, and its affiliated facilities.\1\ The lessons learned by
OIG audit and healthcare teams about VA's preparation and other aspects
of implementation related to infrastructure, access to care, and EHRM
risk mitigations at this first site will help assess what works and
where there are deficiencies that must be addressed as additional
facilities go live. Our findings focus on decisions and actions leading
up to the initial site deployment and, when the related reports are
released, are meant to serve as a roadmap for aspects of future VA
implementation efforts. Failure to redress identified issues puts VA at
risk for cascading failures, breakdowns, and delays when deploying the
new electronic health record (EHR) system nationwide in the years to
come.
---------------------------------------------------------------------------
\1\ On February 11, 2020, the Executive Director of the Office of
Electronic Health Record Modernization (OEHRM) confirmed to OIG staff
that the go-live date at Mann-Grandstaff VAMC was delayed. Because the
new deployment date is unknown, the go-live date referred to in this
statement is the prior VA target of March 28, 2020. Mann-Grandstaff
VAMC, part of Veteran Integrated Service Network (VISN) 20, has a
medical center and four community clinics located in Ponderay and Coeur
d'Alene, Idaho; Libby, Montana; and Wenatchee, Washington.
---------------------------------------------------------------------------
There are two forthcoming reports with the OIG's findings about the
deployment of the new EHR system at the Mann-Grandstaff VAMC.
Currently, both are in draft and, consistent with our practices, are
being reviewed by the Department. These reviews allow VA offices to
comment on OIG findings and recommendations, as well as to provide
responsive action plans to implement the recommendations. After
receiving VA's responses, OIG staff will integrate that feedback into
the final reports and publish them. While it is not the OIG's practice
to testify regarding not-yet-published reports, due to the timing of
this hearing and VA being in receipt of the reports, the findings will
be generally discussed today.
The first OIG report discusses the potential impact of the
transition to the new EHR system on patient access to care and the
initially available capabilities. The issues go beyond technical
concerns, however. For example, the OIG healthcare team found that the
Mann-Grandstaff VAMC lacks adequate staffing to navigate the additional
strains of the transition and had not received formal, written guidance
on minimizing obstacles to patients' access to care. The OIG also found
that the risk mitigations facility leaders would employ during the go-
live period with incomplete capabilities present a significant risk to
patient safety. The second OIG report focuses on the progress and gaps
in VA's efforts to update the Mann-Grandstaff VAMC's physical and
information technology (IT) infrastructure. The OIG audit team found
critical physical and IT infrastructure upgrades have not been
completed at the Mann-Grandstaff VAMC in line with VA's own timelines.
On February 10, 2020, a VA spokesperson announced that the new EHR's
deployment scheduled for March 28, 2020, would be postponed
indefinitely because at 6 weeks prior to go-live, it was only 75-80
percent ready.
BACKGROUND
The OIG's mission is to conduct effective oversight of VA programs
and operations to help make certain that veterans receive access to
quality health care and benefits in a timely manner, as well as ensure
VA funds are appropriately spent. The OIG is conducting early oversight
of EHRM because of the tremendous cost and scale of the effort and
because prior modernization efforts by VA have been unable to achieve
seamless interoperability with the Department of Defense (DoD). Since
2000, the OIG has identified VA's information management as a ``major
management challenge'' because VA has a history of not always properly
planning, overseeing, and implementing updates to its critical IT
investments.\2\
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\2\ Department of Veterans Affairs, ``Inspector General's VA
Management and Performance Challenges,'' Fiscal Year (FY) 2019 Agency
Financial Report, sec. III, (2019). The OIG is required to report
annually on VA's major management challenges.
---------------------------------------------------------------------------
The VA's legacy EHR system, VistA, has served the department for
more than 40 years but lacks needed interoperability and is too costly
to maintain. While VA has taken steps to modernize VistA, these
attempts have not resulted in a single, interoperable EHR system with
DoD. Moreover, the Government Accountability Office (GAO) previously
reported that these prior efforts have cost VA over a billion
dollars.\3\ VA determined that using a common EHR system with DoD will
drive better clinical outcomes by giving healthcare providers a more
comprehensive picture of the veteran's medical history and enhance
collaboration with VA's community healthcare partners.
---------------------------------------------------------------------------
\3\ Government Accountability Office, ``VA Health IT Modernization:
Historical Perspective on Prior Contracts and Update on Plans for New
Initiative,'' July 25, 2019.
---------------------------------------------------------------------------
On June 1, 2017, then VA Secretary David Shulkin signed a
``determination and findings'' document declaring VA would acquire the
new EHR system from Cerner Corporation using an exception to the
Federal Acquisition Regulation requirement for full and open
competition. Cerner developed the core platform of DoD's new EHR
system, Military Health System (MHS) GENESIS.
The determination and findings provided several rationales for why
the acquisition of the new EHR system was in the public's interest. The
reasons included the ability for VA to gain efficiencies from DoD
lessons learned, accelerated delivery of a modern EHR to support
improved health care, and the facilitation of a more consistent patient
experience between VA and DoD. In May 2018, VA awarded Cerner an almost
$10 billion contract to replace VistA.
In addition to the Cerner contract, VA estimated also needing $6.1
billion for program management and infrastructure-related costs during
the new EHR's 10-year-deployment. Of the $6.1 billion, about $4.3
billion is for infrastructure-related costs, such as IT infrastructure
and interfaces. The infrastructure cost estimates do not cover,
however, some physical infrastructure upgrades, such as cabling,
ventilation, air conditioning, and physical security, to be funded by
the Veterans Health Administration's (VHA's) nonrecurring maintenance
budget. While the OIG is not aware of any VA estimate for these costs
at the current time, VHA has requested facility assessments be
completed at all sites by March 31, 2020. Once those are done, VA may
have a better idea of gaps between the current and necessary future
State of facilities nationwide and be able to develop informed cost
estimates. The remaining $1.8 billion is for program management.
In Fiscal Year 2020 alone, the OEHRM was appropriated $1.5 billion
in program funding. Of this amount, approximately $328 million is
estimated for infrastructure costs, such as IT infrastructure end-user
device upgrades. VHA and OEHRM officials told OIG staff that funding
for some of the physical infrastructure upgrades to facilities will
come from VHA's nonrecurring maintenance budget, which is in addition
to the $328 million. These infrastructure upgrades have the potential
to represent a significant cost to VA, as these upgrades at the Mann-
Grandstaff VAMC alone are estimated by VA to cost about $23.2 million.
Developing the New EHR
OEHRM and Cerner worked with various VA offices to develop the
required clinical, technical, and structural readiness deployment
requirements for the new EHR. VA established 18 clinical councils
composed of subject matter experts from VA, VHA, Cerner, and DoD. These
experts reviewed MHS GENESIS's functions and determined which ones
needed to be further developed to meet VHA's clinical and
administrative requirements.
At eight national and eight local workshops, clinical councils
configured the new EHR. Within a workshop session, each council
compared VHA's standards with the commercial Cerner software. If the
council identified gaps, the council worked with Cerner to design a
specific workflow that best met VA needs. A workflow describes business
or clinical steps from beginning to end, including key tasks and the
roles of the individuals who perform the tasks.\4\ Cerner groups
related workflows into a capability. For example, the separate
functions of medication refills and renewals are part of the outpatient
pharmacy capability, whereas inpatient pharmacy functions would be
considered a different capability. Capabilities are further organized
under a series of ``solutions,'' such as the pharmacy solution that
contains all inpatient and outpatient pharmacy functions.
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\4\ A specific workflow might describe the entire process from the
time a patient comes to the outpatient pharmacy window in need of a
prescription refill to the successful completion of the task. A
different workflow might describe, from start to finish, the steps
required by both patient and provider to renew a prescription.
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As Mann-Grandstaff VAMC approaches going live, Cerner will train
clinical and administrative staff on how to use the new EHR. The two-
part integration and validation testing, based on actual patient
scenarios, was intended to ensure the new EHR will function correctly.
The testing also serves as a rehearsal for going live and provides
information for readiness assessments.
Governance
There are two entities responsible for making the EHRM effort a
success. The first is VA's OEHRM, which was established in June 2018.
The OEHRM is responsible for ensuring VA properly prepares for,
deploys, and maintains the new EHR. This office is also responsible for
coordinating with DoD on numerous issues, including applying DoD's
lessons learned during its system implementation. While executive
leaders from the OEHRM report directly to the VA Deputy Secretary, the
office collaborates with VHA and the Office of Information and
Technology (OIT).\5\ All three VA entities are supposed to work
together to upgrade the infrastructure needed to deploy the new EHR
system. For example, the OEHRM developed the technical requirements for
the new system, while OIT and VHA shared the responsibility to define
the requirements for proper IT and physical infrastructure. OIT also
aligns projects and plans to support IT infrastructure upgrades and
uses local staff for surge support during the transition from VistA to
Cerner's system. VHA is responsible for decisions related to medical
devices and facility upgrades, and maintenance of the physical
infrastructure. The OEHRM has a director of infrastructure readiness
who provides oversight of the infrastructure upgrades related to EHRM,
but this position was vacant until August 2019.
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\5\ On February 21, 2020, VA Secretary Robert Wilkie signed a memo
designating the Office of Enterprise Integration as the integrator of
the EHRM project, reporting progress and challenges directly to him.
The memo did note that the Office of Deputy Secretary will retain
responsibility for fiscal oversight as required by the Further
Consolidated Appropriations Act, 2020, Public Law 116-94.
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On March 1, 2019, DoD and VA jointly established the Federal
Electronic Health Record Modernization (FEHRM) Program Office. This
office replaced the Interagency Program Office as the single
decisionmaking authority for all future EHRM efforts for VA and DoD. As
of December 2019, many details of this Office were still being
determined, but Section 715 of the conference report to the National
Defense Authorization Act for Fiscal Year 2020 states that the Offices'
Director and Deputy Director will serve 4-year terms with DoD and VA
alternating as the selecting agencies for both positions.
Deployment Schedule
VA's deployment schedule includes three Initial Operating
Capability (IOC) sites followed by 47 additional cycles, which OEHRM
calls ``waves,'' for the remaining sites VA-wide through Fiscal Year
2027. The three IOC sites are Mann-Grandstaff VAMC and two sites in the
Puget Sound Health Care System in Washington--the Seattle VAMC and
American Lake VAMC in Tacoma along with their associated facilities.
For the IOC sites to be effective learning grounds, infrastructure
upgrades should be in place six months before the go-live date so that
weaknesses can be identified and addressed. This is a clear takeaway
from the DoD experience. OEHRM leaders have testified to this
Subcommittee their commitment to making timely infrastructure upgrades
six months before going live as a standard.\6\
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\6\ In November 2018, the OEHRM's Chief Technology Integration
Officer told this Subcommittee that the office planned to have
technology readiness done six months before going live. On June 12,
2019, the OEHRM's Executive Director confirmed to the Subcommittee VA's
plan for infrastructure to be ready six months prior to the go-live
date. Later in the hearing, OEHRM's Chief Technology Integration
Officer admitted that not all infrastructure would be completed by the
go-live date. In November 2019, in an interview with OIG staff, the
OEHRM's Executive Director confirmed that VA's objective to have
infrastructure completed six months before the system is deployed at
the IOC sites is ``critical'' to mitigating setbacks that occurred at
DoD's sites. Additionally, OEHRM's integrated infrastructure plan,
dated November 2018, stated infrastructure upgrades are ``expected to
be complete no later than six months prior to the go live event.''
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Go-Live Date & EHR Capabilities
The day that a site turns on the new EHR system at the IOC site for
personnel to use is being referred to as the go-live date. However,
going live does not mean that the full system with all functionalities
will be up and running. As early as July 2019, OEHRM determined that
not all EHR functions would be available for the planned March 2020 go-
live date. In response, OEHRM leaders made the decision to deploy EHR
functions in separate blocks at different times. These separate blocks
are called ``capability sets.'' Capability Set 1 was scheduled to be
deployed in March 2020, with Capability Set 2 scheduled for deployment
approximately 6 months later. The new EHR has more than 300
capabilities in total, and while the majority are included in Set 1,
there are some significant functions missing. For example, cardiology
and some aspects of telehealth are in Set 2. As discussed later in this
testimony, the absence of an online patient portal in Set 1 for
medication refill requests is a significant concern.
Once Mann-Grandstaff VAMC goes live with the new EHR system, care
providers and administrators will use it for clinical and
administrative work, while relying on the Joint Longitudinal Viewer
(JLV) to view records not contained in the new EHR. These include
records from VA medical centers not yet using the new EHR.\7\
Similarly, all VA staff who do not have the new EHR will be required to
view facilities' patient information through JLV. Facility staff will
be required to switch back and forth between the new EHR and JLV to
correctly capture all clinical and administrative information.
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\7\ The JLV is a web application that provides an integrated, read-
only view of EHR data from VA, DoD, and some community partners through
the Veterans Health Information Exchange, a program that allows
participating community providers to securely share health information.
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When IOC sites go live, providers will need to adjust to using the
new EHR for tasks associated with taking care of patients. They also
will have to view consult referrals, active inpatient orders, and
active outpatient laboratory and imaging orders in JLV, and then
manually reenter the information into the new EHR to ensure action. For
example, if a clinician ordered an x-ray in VistA for a patient, and
that x-ray has not been acted upon by the go-live date, the clinician
must find the order in JLV and manually reenter it into the new EHR so
that the study is documented, scheduled, and completed.
In July and August 2019, OEHRM presented the capabilities in Set 1
and Set 2 to leaders at the Mann-Grandstaff VAMC and the VA Puget Sound
Health Care System, the initial operating locations originally
scheduled for spring 2020 deployment. Due to the absence of some
required functions in Set 1, VA Puget Sound Health Care System leaders
decided to delay their IOC rollout until the completion of Set 2 out of
concern for the clinically sophisticated nature of their healthcare
system. Mann-Grandstaff VAMC leaders decided to continue with the March
2020 go-live date and began developing mitigation strategies for the
clinical and administrative function gaps between the deployments of
Set 1 and Set 2.
The first report in this testimony discusses VA's work to mitigate
risks during the new EHR's transition that will impact the facility's
ability to provide timely care.
REVIEW OF ACCESS TO CARE AND CAPABILITIES DURING THE TRANSITION TO VA'S
NEW EHR
The OIG focused this review on the initially available capabilities
and the potential impact of the EHR transition on access to care at the
Mann-Grandstaff VAMC.
Facility Management of Access to Care Risks
The OIG found that Mann-Grandstaff VAMC leaders consulted with DoD
staff who transitioned to the Cerner system in 2017 and experienced a
30-percent decrease in productivity for 18 months following the
transition. This reduction will generate access-to-care risks that
require mitigation strategies. Thus, facility leaders used a 30-percent
decrement in productivity over a 12-to-24-month period as a measure
when generating a mitigation plan. The Mann-Grandstaff VAMC's
mitigations include adding facility staff, enhancing clinical space,
changing clinic processes, and increasing the use of community care.
Facility leaders told OIG staff that VHA's Office of Healthcare
Transformation (OHT) gave strong support to help prepare for decreased
access to care. However, the OIG's review of OEHRM activities during
the last two years did not reveal evidence of final operational
guidance to the Mann-Grandstaff VAMC on the matter. Absent that
evidence of written guidance, facility leaders utilized a self-designed
mitigation plan.
In June 2018, facility leaders told the VISN Director that a
projected staffing shortage might prevent Mann-Grandstaff VAMC from
meeting the access to care challenges of the new EHR implementation.
Thus, in September 2018, facility leaders requested hiring 102
employees (over time this request increased to 108). In April 2019,
despite Mann-Grandstaff VAMC leaders' concerns regarding staffing
levels for the new EHR implementation, VISN 20 conducted an analysis of
fiscal resources, which led facility leaders to initiate a hiring
pause, with an aim to meet the VISN's goal to decrease overall staffing
by 88 positions.\8\ The hiring pause continued until October 2019. As
of February 5, 2020, 48.5 of 108 new staff had been onboarded.
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\8\ A VISN leader reported that in the 2018 fiscal year,
substantial hiring by Mann-Grandstaff VAMC led to a budget deficit.
Facility leaders acknowledged to the OIG that budget planning errors
for the 2019 Fiscal Year led to a projected deficit, which exceeded $20
million for personnel. These events complicated planning for adequate
staff hires during the EHR transition.
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The OIG identified that Mann-Grandstaff VAMC leaders addressed
recent in-house access to care challenges within primary care, but a
significant backlog of 21,155 community care consults remained as of
January 9, 2020. The OIG found that while facility staff have been
working additional hours since December 2019 to reduce the open
community care consult backlog, that same staff will face other
obstacles when going live due to the increased manual work needed to
schedule community care owing to Set 1's limited capabilities. VHA and
the facility are also aware that community care access will be
challenged by increasing demand and limited supply in the Spokane area.
Capability Limitations
OEHRM and Cerner determined in July 2019 that not all anticipated
capabilities of the new EHR would be available for the initially
proposed go-live date. Mann-Grandstaff VAMC leaders worked with OHT and
OEHRM to generate mitigations for the incomplete capabilities in Set 1
at the go-live date.
By August 2019, both OHT and facility staff developed processes to
track mitigation efforts. The facility mitigation tracker has 84
strategies for minimizing the impact of the missing capabilities
classified as moderate and high risk. Since then, facility risks and
mitigations have been regularly updated and tracked with progress
updates reported to the wider group of project stakeholders.
Facility leaders and staff told the OIG healthcare team of concerns
related to the deployment of capability sets including
Not knowing what capabilities would be available at the
IOC;
Changing capabilities to meet the go-live timeline,
instead of changing the go-live timeline to meet the completion of
capabilities;
Challenges in developing training due to incomplete
information regarding which capabilities would be available at the IOC;
Limitations in Set 1 that present as ``significant
handicaps at day zero;''
Requiring staff to access two systems (JLV and the new
EHR) while providing patient care;
Feeling compelled to go-live in March 2020, without the
full capability being ready; and
Inability to accurately predict patient safety risks
because of incomplete information about which capabilities would be
available at the IOC.
For example, online prescription refills, the most popular
mechanism for refilling prescriptions at the Mann-Grandstaff VAMC, was
identified as a capability that would be absent at the go-live date.
Examples of mitigation plans include the need for
Care in the community staff to navigate between the new
EHR, JLV, and other third-party software to determine patient
eligibility, and track consult approval and status;
Primary care teams to manually enter all non-VA patient
medications to ensure a complete record of active medications in the
new EHR; and
Patients who previously ordered refills of medications
through the MyHealtheVet portal to use alternative means for refill
requests.\9\
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\9\ MyHealtheVet is an online personal health portal in which
patients can schedule appointments, view medical records, refill
prescriptions and send secure messages to their providers.
The OIG reviewed facility refill requests during calendar year 2019
and found the MyHealtheVet portal was the most frequently used method
for patients to request prescription refills.\10\ Facility leaders and
staff told the OIG of safety concerns related to losing the
MyHealtheVet electronic refill portal and that mitigation strategies
seemed insufficient to meet patient needs. This mitigation plan
requires patient involvement, and as of January 15, 2020, facility
leaders had not yet communicated with patients about the new electronic
prescription refill process.
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\10\ My HealtheVet, Get to Know Rx Refill Options, https://
www.myhealth.va.gov/mhv-portal-web/ss20180423-prescription-refill-
options-for-veterans. (The website was accessed on January 17, 2020.)
VA medical facilities provide patients with several methods to refill
VA prescribed medications: online through the MyHealtheVet portal, by
phone through the automated telephone refill line, in person at a VA
pharmacy, and by mail through the VA mail order pharmacy.
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The OIG determined that the work-arounds needed to address the
removal of the online prescription refill service create additional
barriers for patients to refill medications. The barriers created by
these processes present a patient safety risk and the mitigation
strategies are insufficient to significantly reduce those risks should
a decision to go live at a future date involve only Set 1. The OIG was
unable to determine all patient safety risks associated with the new
EHR, but the work-around for the electronic prescription refill process
alone presents significant concerns as it may impact a patient's
ability to fill a life-sustaining medication.
DEFICIENCIES IN INFRASTRUCTURE READINESS FOR DEPLOYING VA'S NEW
ELECTRONIC HEALTH RECORD SYSTEM
In order to deliver patient care using the new EHR, significant
infrastructure upgrades are needed to VA's physical and IT
infrastructure. The OIG conducted an audit to determine whether VA's
infrastructure readiness activities are on schedule at the Mann-
Grandstaff VAMC and associated facilities. The audit team examined
physical and IT infrastructure to determine VA's readiness to proceed
with system implementation and to identify infrastructure challenges
that could impact the overall system deployment schedule.
Physical infrastructure refers to the underlying foundation that
supports the system, such as electrical; cabling; and heating,
ventilation, and air-conditioning. IT infrastructure includes network
components such as wide and local area networks, end-user devices
(e.g., desktop and laptop computers, and monitors), and medical
devices.
VA has recognized the need to apply lessons learned from DoD to
avoid deployment setbacks, and as discussed earlier, OEHRM leaders
testified before this Subcommittee in June 2019 that having the
infrastructure in place six months before system deployment to sites
was a program goal, meaning that infrastructure upgrades should have
been completed by the end of September 2019.
The OIG found critical physical infrastructure upgrades had not
been completed at the Mann-Grandstaff VAMC as of the audit team's site
visit in October 2019--less than the six-months prior to the go-live
date. The lack of important upgrades jeopardizes VA's ability to
properly deploy the new EHR system and increases risks of delays to the
overall schedule.
Physical Infrastructure Was Not Upgraded Timely, with Many Upgrades
Pending Completion After Going Live
The audit team found some infrastructure upgrades intended to
mitigate diminished system performance are not projected to be
completed until months after going live. For example, modifications to
telecommunications rooms were not estimated to be completed until up to
four months after March 2020. Furthermore, the audit team followed up
with VA and confirmed that as of February 25, 2020, contracts had yet
to be awarded for some critical physical infrastructure upgrades. Until
modifications are complete, many aspects of the physical infrastructure
existing in the telecommunications rooms (such as cabling) and data
center do not meet national industry standards or VA's internal
requirements.
On the week of October 7, 2019, less than six months prior to go-
live, the audit team found that all 24 telecommunications rooms and the
data center at the Mann-Grandstaff VAMC and associated facilities still
needed work completed in order to meet industry and VA standards. Table
1 illustrates the findings from these telecommunications rooms'
inspections.
Table 1. Summary of Telecommunications Room Deficiencies Identified at
the Mann-Grandstaff VA Medical Center and Two Associated Facilities
(October 7-11, 2019)
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
The Mann-Grandstaff VAMC's data center will house Cerner's servers
and act as the main computer room. The audit team identified issues
with data center infrastructure, including substandard cabling and
improper management, inadequate fire sprinkler systems clearance, and
the potential for leaks from the facility's cafeteria located above the
data center.
Finally, properly controlling operating temperature in
telecommunications rooms helps ensure equipment longevity. An OEHRM
official stated that increased temperature in the telecommunications
rooms when going live was his biggest concern. Installation of
additional equipment will increase the rooms' temperatures, requiring
more cooling. The interim solution to prevent increased temperatures
was to place temporary exhaust fans in rooms, replacing them later with
a permanent cooling system. The audit team also found the potential for
additional costs by using the temporary exhaust fans only to replace
them later with a permanent cooling system.
Critical IT Infrastructure Was Not Upgraded Six Months Before Going
Live and Medical Devices May Not Be Able to Connect to the New System
The audit team also identified deficiencies with the preparedness
of IT infrastructure and found the medical center and its associated
facilities did not have critical IT infrastructure upgrades completed
six months before the March 2020 go live date. For example, as of the
week of the audit team's site visit in October 2019, about 31 percent
of the needed end-user computing devices had yet to be received. And,
as recently as early January 2020, VA had yet to receive about 51
percent of the medical devices needed for going live as well as an
approval from DoD to connect the medical devices to the new system.
The Infrastructure Upgrade Schedule Was Likely Unrealistic for the
March 2020 Go-Live Date and Could Contribute to Further System
Deployment Delays
Infrastructure upgrades were not completed at the Mann-Grandstaff
VAMC in a timely manner to properly prepare for the new EHR deployment
primarily because VA lacked
Comprehensive site assessments to determine a realistic
go-live date,
Requisite specifications for infrastructure and
appropriate monitoring mechanisms, and
Adequate staffing.
The OIG concludes in its upcoming report that VA committed to an
aggressive, but likely unrealistic, deployment date of March 2020
without having the necessary information on the facility's
infrastructure. Specifically, on June 26, 2018, VA announced the
medical center's go-live date of March 2020; however, it was not until
nearly a year later in May 2019 that an assessment was performed
identifying physical infrastructure needs. Also concerning is that
OEHRM first made infrastructure requirements for physical
infrastructure available to VHA at a technical design session in April
2019, just 5 months before the necessary infrastructure was supposed to
be ready for the go-live event.
In June 2019, OEHRM leaders told Congress that infrastructure
upgrades would not be complete before going live and indicated the
infrastructure upgrades were not necessary to support the March 2020
go-live event. In addition, as of November 1, 2019, the infrastructure
requirements specifications document was still not approved by VHA.
While OEHRM, VHA, and OIT share the responsibility for infrastructure
readiness upgrades, disagreements on specific standards contributed to
delays.
Similarly, for IT infrastructure, the Current State Reviews were
completed in July 2018, which first identified the need for end-user
device upgrades to support the new system.\11\ This gave VA about 14
months (until September 2019) to achieve its goal for the completion of
IT infrastructure upgrades. This was about eight fewer months than the
approximately 22 months the OEHRM Infrastructure Readiness Planner
estimated that it takes from the time the need for a device is
identified to delivery to an end user. Also, VA did not begin procuring
end-user devices until April 2019, leaving only about five months for
delivery to the Mann-Grandstaff VAMC and for the actions needed for
end-user readiness such as configuring. Finally, it is evident that VA
needed more time than allotted to complete actions necessary for
receiving approval from DoD for the authority to have medical devices
connect to the new system.
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\11\ Among other reasons, the Current State Reviews were conducted
by Cerner to assess gaps in the facility's IT infrastructure and
provide VA leaders with finding and recommendations. The Current State
Reviews did identify the need for significant IT infrastructure
upgrades, such as new computers, monitors, printers, scanners, and bar
code readers.
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Despite OEHRM's Executive Director confirming to OIG staff in
November 2019 the criticality of infrastructure upgrades being
completed six months prior to the go-live date, it is evident that
OEHRM and VHA personnel knew that physical and IT infrastructure
upgrades could not be completed within this timeframe. Therefore, the
infrastructure schedule that was developed was unrealistic.
Management Controls Were Lacking and Key Staffing Positions Were Vacant
VA lacked some management controls needed to effectively monitor
infrastructure readiness at the Mann-Grandstaff VAMC. For example, the
OEHRM internal tracking tool was not put into use until June 2019, only
3 months before VA's goal to have infrastructure upgrades complete. As
of November 2019, an OEHRM employee reported that no comprehensive tool
existed at the national program level to monitor upgrades to critical
patient care medical devices. Although OEHRM was conducting internal
briefings that included infrastructure readiness, the lack of a
comprehensive, effective tracking mechanism increases the risk that
milestones will not be achieved.
The OIG team found VA lacked staff to oversee the program's
infrastructure readiness. As of November 2019, four of six staff
positions on the infrastructure readiness team were still unfilled, and
the infrastructure readiness director position was vacant until filled
in August 2019, or about two months before VA's goal of having
infrastructure upgrades complete six months prior to the go-live date.
Without this dedicated position being filled early in the
infrastructure planning process, VA would be less likely to spot
potential issues stemming from deficient infrastructure.
Because the second IOC site will not deploy the new EHR until
November 2020, the first three waves of site deployment, scheduled to
go live in August, October, and November 2020, have also been postponed
until 2021. By not having infrastructure ready for the deployment of
the new EHR, VA could experience issues like those encountered by DoD
and have less time to respond to and correct infrastructure-related
deficiencies before deploying the system at future sites. In turn, this
could delay advancing VA's goal of improving patient care through the
modernization initiative.
Inadequate Safeguarding of Critical Physical Infrastructure at the
Mann-Grandstaff VAMC Increases Risks to System Security
The OIG staff also found, while not directly affecting system
deployment, some security vulnerabilities at the Mann-Grandstaff VAMC.
Neither Cerner nor VA identified these vulnerabilities because their
assessments do not call for identification of physical security
concerns. A Mann-Grandstaff VAMC employee recognized that damage to
physical infrastructure due to unauthorized access could result in
campus-wide loss of connectivity and patient care downtime for an
extended period.
CONCLUSION
This Subcommittee and VA have made it a priority to improve VA's IT
systems. The OIG's work highlighted in this statement reveals there are
still considerable challenges, particularly regarding plans to ensure
continued access to timely health care for veterans and incomplete
critical physical and IT infrastructure upgrades at the Mann-Grandstaff
VAMC and associated facilities. The OIG is committed to providing
practical recommendations that flow from our oversight work to help VA
deploy the new EHR efficiently and in a manner that improves veterans'
experiences. The OIG will continue to monitor aspects of VA's EHRM
effort to help realize the improvements sought by Congress and our
Nation.
Madam Chair, this concludes my statement. I would be happy to
answer any questions you or other members of the Subcommittee may have.
__________
Prepared Statement of Travis Dalton
Thank you Chairwoman Lee, Ranking Member Banks, and distinguished
members of the committee. My name is Travis Dalton, President of Cerner
Government Services.
Thank you for the opportunity to be here, and for your continued
engagement and support of the Department of Veterans Affairs' (VA)
Electronic Health Record Modernization (EHRM) program.
Cerner is honored to be part of a shared mission to ensure a
lifetime of seamless care for our Veterans, Service members and their
families.
Transformation at scale is hard. It carries risks and we don't take
the challenges lightly. We must deploy to over 1,700 sites, train over
300,000 VA employees, collaborate with DoD to make decisions and
interoperate with community providers. Those challenges also represent
opportunities.
Under VA's leadership, we have made significant strides on our
journey to transform care. We have incorporated commercial practices,
lessons learned from DoD, and VA provider-led feedback to ensure user
adoption and readiness to meet Veteran needs. We are pleased with our
progress.
VA has come together to establish standardized workflows
and designs based on the work of 18 clinical councils, comprised of
thousands of providers across VA, and 8 National workshops. This
enterprise standardization is a monumental achievement.
We launched VITAL, a training series to empower super
users with the technical and change management skills needed to support
the EHR implementation and ongoing success.
We have migrated 23.5M Veterans health records into the
VA environment. This is the first time that historical VA and DoD
health data are in the same system.
In the coming months, we will implement a new joint Health
Information Exchange (HIE) that will allow interoperable information
sharing across VA, DoD and community providers connected to the
network. Incredible progress is being made.
We are supportive of the revised go-live schedule and the decision
to take additional time for testing and end-user training. We heard the
advice from this committee to take the time to get it right and
listened to the provider community. The additional time will allow us
the opportunity to ensure a successful go-live at Mann-Grandstaff.
This program is truly transformational. By moving from 130
disparate systems to one open, modern, integrated system, we will have
the right data, at the right place and time to drive outcomes. We also
have access to advanced analytics that will give us the opportunity to
better diagnose, treat and prevent chronic diseases; environmental
exposures; suicide and PTSD; and opioid abuse.
Healthcare's highest calling is caring for the men and women who
sacrificed in service to our country. Every day we are energized by the
passion and commitment in pursuit of this common purpose. On behalf of
Cerner, we are humbled and proud to be a part of this effort.
Thank you and I look forward to our discussion today.
[all]