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


                   GETTING IT RIGHT: CHALLENGES WITH
                       THE GO-LIVE OF ELECTRONIC
                      HEALTH RECORD MODERNIZATION

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

                                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
       
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                    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

                              ----------                              


                        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

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


                    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.
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    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.
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    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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]