[Senate Hearing 116-]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2020
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TUESDAY, FEBRUARY 5, 2019
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:30 a.m. in room SD-124, Dirksen
Senate Office Building, Hon. John Boozman (chairman) presiding.
Present: Senators Boozman, Schatz, Collins, Capito, Daines,
Tester, Udall and Baldwin.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. JAMES BYRNE, GENERAL COUNSEL
PERFORMING THE DUTIES OF DEPUTY SECRETARY
ACCOMPANIED BY:
JOHN WINDOM, EXECUTIVE DIRECTOR, OFFICE OF ELECTRONIC
HEALTH RECORD MODERNIZATION
DR. LAURA KROUPA, CHIEF MEDICAL OFFICER (ACTING),
OFFICE OF ELECTRONIC HEALTH RECORD
MODERNIZATION
JOHN SHORT, CHIEF TECHNOLOGY INTEGRATION OFFICER,
OFFICE OF ELECTRONIC HEALTH RECORD
MODERNIZATION
opening statement of senator john boozman
Senator Boozman. The committee will come to order. You guys
can have a seat. Good morning, and thank you for coming today
to discuss the Department of Veterans Affairs Electronic Health
Record Modernization Effort.
I would like to begin by recognizing today's panel: the
Honorable James Byrne; VA's General Counsel, Performing the
Duties of the Deputy Secretary. Thank you for being here. He is
accompanied by leadership in VA's Office of Electronic Record
Modernization, including Mr. John Windom, Executive Director,
Dr. Laura Kroupa, Acting Chief Medical Officer, and Mr. John
Short, Technology Integration Officer. So thank you all for
being here, and we do appreciate your service to the--for our
veterans.
For years, the Department of Defense and VA struggled to
share health information to service members transitioned to
civilian life. Even within VA, there were more than 130
different version of VISTA, the legacy electronic medical
record. Last May, VA kicked off a 10-year, $16 billion effort
to modernize VA's health IT system. This includes a $10 billion
contract with Cerner by adopting the same (EHR) Electronic
Health Record platform as DoD. VA argued that the patient data
would be seamlessly shared between DoD, VA, and community
providers, improving efficiency and transparency.
Many of us on this committee have long advocated for a
single, joint medical record that will follow a service member
throughout their career in the military and into their time as
a veteran. We are hopeful that this collaboration between VA,
DoD, and Cerner can deliver on this vision.
Since last May, VA has undertaken efforts to address
lessons learned from past EHR modernization initiatives. VA
conducted detailed workflow analysis, technology assessments,
change of management workshops, and outreach to key
stakeholders. However, challenges remain, including
interoperability with both legacy and community health systems,
simultaneous implementation with other initiatives, and
spending at a lower than expected rate. Perhaps the most
important challenge facing VA is the need for its workforce to
embrace what will be a wholesale change in the way they do
business on a daily basis. We look forward to discussing these
and other issues this morning. And also, this is our first
meeting, I believe, without Chad Schulken, who did a tremendous
job on the minority staff. You know, the nice thing about these
committees is that the staff and members work together so very
well. We hear a lot about the rancor, but he did a tremendous
job, and I know he will do a great job wherever he is at, but
he will be missed.
And now, I will turn to our Ranking Member, Senator Schatz
from Hawaii for his opening statement.
opening statement of senator brian schatz
Senator Schatz. Thank you, Mr. Chairman and thank you for
holding today's hearing on the VA's effort to modernize its
electronic health record system. This is particularly important
as we prepare to consider the Department's fiscal year 2020
budget and fiscal year 2021 advance request.
A new electronic health record has the potential to be
transformational. This is an opportunity to improve patient
care with seamless health data sharing between DoD and VA as
well as community providers, and that is why in last year's
appropriations bill, we provided more than a billion dollars so
that the Department can get this system going. That includes
more than $400 million, specifically to improve IT
infrastructure. Now, we all know this process has not been easy
for VA and that there were some initial challenges with rolling
out the contract and the system. There were contracting delays
and issues with aligning the project management and deployment
with Department of Defense, but the VA has taken some important
steps to address these problems. Last September, the VA and DoD
issued a joint commitment which makes clear that they will work
together to coordinate project and data management and develop
and organizational structure that will deliver a single,
seamlessly integrated, and interoperable EHR. That is the goal.
But a commitment is only as strong as the willingness of
each party to follow through and so I look forward to hearing
from our witnesses about exactly how both Departments are
planning to deliver on their promise to service members and
veterans. As VA obligates and spends the funding that Congress
provided for EHR, the Department needs to remain transparent
about the status, the funding, and continue to provide regular
updates, and that is especially important at the early stages.
This information will help us as appropriators better meet the
VA's needs and serve our veterans. And it gives us the
confidence that you are making thoughtful decisions that will
prevent cost overruns and schedule delays and other avoidable
pitfalls.
Finally, Mr. Chairman, I want to express my frustration and
disappointment with how the VA has engaged Congress on its
proposed access standards for the new Veterans Community Care
Program created under the Mission Act.
Members of the majority and minority, authorizers, and
appropriators have made repeated requests for information to
hear from VA about what information the Department relied on to
inform its decisionmaking and the potential budgetary
implications of expanding eligibility for veterans to seek care
in the community.
The VA can and should ensure access for all veterans by
relying on community providers, that is especially important
for veterans who live in rural and remote areas, but it cannot
come at the expense of VA's internal healthcare system.
But we do not have any analysis or projections about how
the proposed access standards will effect utilization rates,
and as a result, how it will affect the cost of VA's Community
Care Program. And as a result, how it will interact with core
VA services. Now I know that is not why we are here today, but
we have a responsibility to the American people and to the
Veterans Administration to ensure the VA's leadership is making
decisions that are consistent with Congress' intent.
I will have more to say on this as the VA files its
proposed rule in the Federal register. And look forward to
hearing from Secretary Wilkie directly when he comes before the
subcommittee to present the Department's advance budget
request.
Thank you, Mr. Chairman.
Senator Boozman. Mr. Byrne.
summary statement of hon. james byrne
Mr. Byrne. Good morning. Chairman Boozman, Ranking Member
Schatz, distinguished members of the subcommittee. Thank you
for the opportunity to testify about the Department of Veterans
Affairs Initiative to transform veterans' care through
modernizing VA's electronic health records system, EHR. And
thank you for your unwavering support of veterans, their
families, caregivers, and survivors.
Mr. Chairman, please let me start with some recent good
news from VA. First, you may have seen the Dartmouth report
from the Annals of Internal Medicine that found, ``VA
healthcare is as good or better than any care our American
people receive in any part of the country.''
Second, the partnership for public service, a nonprofit
think tank that values the work of our Federal agencies
reported that for the first time, VA is now one of the best
places to work in the Federal Government. Moving from 17th
place to 6th place.
Last, a new study from the Journal of American Medical
Association, JAMA, recently found that, ``Access to care within
VA facilities appears to have improved between 2014 and 2017
and appears to have surpassed access in the private sector for
three of the four specialties evaluated.'' I believe these
reports reflect the quality of how all of our employees and the
hard work they do on behalf of veterans and taxpayers every
day.
Today, I am excited to be here to discuss the opportunities
presented by our modernization of VA's electronic health record
system. Does it mean that the implementation of our new EHR
system will be simple, easy, or without hurdles? It is, in
fact, a complex, difficult, time-consuming job. We appreciate
the congressional funding of this critical modernization effort
and welcome the committee's oversight as we negotiate this
critical task.
But as we move forward, I would like to remind all of my VA
colleagues of some important facts: First, EHR modernization
was not forced on us. This transformation is something that we,
at VA, decided had to be done, because it makes sense and is
best for veterans. Second, we must always keep our eyes on what
those in the military refer to as the commander's intent. For
VA and the end state of our EHRM efforts. VA exists to make
life better for veterans. That is what transforming our EHR
system and adopting the same system at DoD is all about.
Meeting the challenging and evolving needs of veterans,
improving their lives and their care, and making the system
easier and more efficient for them.
We need to constantly remind ourselves that when we
complete this difficult, complex transformation, there will be
tangible, measurable benefits for veterans, including but not
limited to, patient data residing in a single site with records
updated instantly at the time of care. Seamless transitions as
service members become veterans and equally seamless access to
quality care when veterans move between DoD, VA, and community
care providers.
Much greater ease in sharing health information that will
result in care delivered in a more timely and safe manner.
Scheduling of appointments, reimbursement of community
providers, and critically, research of healthcare issues of
special importance to veterans will all be easier and more
efficient.
And finally, care provided by one member of a veteran's
care team will be transparent to all members of the team and to
the veteran, especially important in treating patients at risk
of suicide or opioid abuse. Our goal is to deliver an EHR
system that is easy to understand, simple to administer, and
meets veterans' needs. And now is the time to modernize. It is
the right thing to do for veterans. This is our Commander's
intent and how we see the end state of our EHRM efforts. As we
strive for that end state, we at VA are committed to
transparency and close coordination with DoD and all aspects of
modernizing our EHR system and from learning all we can from
their previous work with Cerner.
We are ensuring our new EHR system is in alignment with
commercial best practices, and we have every confidence that it
does. We are determined to engage clinicians in the field who
interact with veterans and their families each day to ensure we
have their immediate, real time feedback on what works best to
best serve veterans.
Mr. Chairman, as I have traveled the VA medical centers
across the country, I have encountered a sense of excitement
about EHRM. On many occasions, I have had hospital directors,
administrators, and clinicians ask me how their facility could
be moved up on the schedule for fielding the new EHR system.
Those who work most closely with veterans in providing care
know that our current system is simply insufficient and
recognize the vast potential the new EHR system represents:
improvements in timeliness and quality of care, efficiencies in
presentation of data, and prescription and administration of
pharmaceuticals, and reducing risk for patients, treatment of
chronic conditions, reduction in suicides, and in many other
areas of care and treatment. They want it now, because they
know it will help veterans.
Mr. Chairman, in closing, thank you and all the members of
the subcommittee once again for your support of veterans and
VA. You have provided the funds for us to make this leap
forward in care that will help veterans, their families, and
caregivers. We recognize the importance of what we are about,
the need for transparent and careful use of appropriated funds,
and the need to move forward quickly but carefully as we make
strides not only for our nation's veterans but in areas that
surely pay dividends for better care of Americans in the
future. We are all committed to strengthening the VA system.
EHRM will help us do that and strengthen the ties that bind
veterans to their VA.
Thank you, sir, and we look forward to your questions.
[The statement follows:]
Prepared Statement of Hon. James Byrne
Good morning Chairman Boozman, Ranking Member Schatz, and
distinguished Members of the Subcommittee. Thank you for the
opportunity to testify today in support of the Department of Veterans
Affairs (VA) initiative to modernize its electronic health record (EHR)
through the acquisition and deployment of the Cerner Millennium EHR
solution. I am accompanied today by Mr. John Windom, Executive Director
of the Office of Electronic Health Record Modernization (OEHRM), Dr.
Laura Kroupa, Acting Chief Medical Officer of OEHRM and Mr. John Short,
Technology and Integration Officer of OEHRM.
I want to begin by thanking Congress, and specifically this
Subcommittee, for your continued support and shared commitment for the
program's success. Because of your continued support, VA has been able
to stay on track for implementation, enabling us to continue our
mission of improving healthcare delivery to our Nation's Veterans and
those who care for them while being a good steward of taxpayer dollars.
background
On May 17, 2018, VA awarded an Indefinite Delivery/Indefinite
Quantity (ID/IQ) EHR contract to Cerner. Given the complexity of the
environment, VA has awarded this ID/IQ to provide maximum flexibility
and the necessary structure to control cost. Through this acquisition,
VA will adopt the same EHR solution as the Department of Defense (DoD).
The solution allows patient data to reside in a single hosting site
using a single common system to enable the sharing of health
information, improve care delivery and coordination, and provide
clinicians with data and tools that support patient safety. VA believes
that implementing a single EHR will allow for seamless care for our
Nation's Servicemembers and Veterans.
program milestones
Since contract award, VA has accomplished several key events
outlined below.
Task Orders
As mentioned earlier, VA awarded the Cerner contract on May 17,
2018. VA also awarded the first three Task Orders (TO), which are
project management, Initial Operating Capabilities (IOC) site
assessments, and data hosting. In September of 2018, VA awarded three
TOs for Data Migration and Enterprise Interface Development, Functional
Baseline Design and Development and IOC Deployment. By leveraging the
ID/IQ contract structure, VA can award TOs as needs arise and negotiate
firm-fixed- prices on an individual TO basis, allowing VA to moderate
work and modify deployment strategies efficiently. Below are additional
details regarding the TOs:
--Task Order 1- EHRM Project Management, Planning Strategy, and Pre-
IOC Under this task order, Cerner will provide project
management, planning, strategy, and pre-IOC build support. More
specifically, the scope of services included in this task order
are project management; enterprise management; functional
management; technical management; enterprise design and build
activities; and pre-IOC infrastructure build and testing.
--Task Order 2- EHRM Site Assessments--Veterans Integrated Service
Network (VISN) 20 Under this task order, Cerner will conduct
facility assessments, to prepare for the commercial EHR
implementation, for the following VISN 20 IOC sites: Mann-
Grandstaff VA Medical Center (VAMC) (Spokane WA), Seattle VAMC,
and American Lake VAMC (Tacoma, WA). Cerner will also provide
VA with a comprehensive current-state assessment to inform
site-specific implementation activities and task order-specific
pricing adjustments.
--Task Order 3- EHRM Hosting Under this task order, Cerner will be
funded to deliver a comprehensive EHRM hosting solution and
start associated services to include hosting for EHRM
applications, application services, and supporting EHRM data.
--Task Order 4- Data Migration and Enterprise Interface Development
Cerner will provide data migration planning refinement,
analysis, development, testing, and execution. Cerner will
support enterprise interface planning refinement, design,
development, testing, and deployment. Cerner will provide
commercially available registry selected by VA for IOC as well
as details and updates on the progress of IOC data migration
and enterprise interface development.
--Task Order 5- Functional Baseline Design and Development Cerner
will provide project management, workflow, training, change
management, and EHRM stakeholder communication.
--Task Order 6- IOC Deployment Cerner will provide: project
management; IOC planning and deployment; test and evaluation;
pre-deployment training; go-live readiness assessment,
deployment, and release; go-live event; post-production health
check and deployment completion; post-deployment support; and
continued deployment decision support.
Current State Review
In July 2018, VA and Cerner conducted a Current State Review at
VA's IOC sites to gain an understanding of the sites' specific as-is
state, and how it aligns with the Cerner commercial standards to
implement the proposed to-be state. The team conducted organizational
reviews around people, process, and technology. They observed and
captured current state workflows; identified areas that will affect
value achievement and present risk to the project; identified benefits
from software being deployed; and identified any scope items that need
to be addressed.
VA reviewed final reports analyzing the Current State Review in
October 2018 and discovered there are infrastructure readiness areas
that are in better condition than initially forecasted and areas that
require slightly more investment due to aging infrastructure. However,
there were no unexpected major needs or significant deviations from the
current projected spend plan.
Model Validation Event
In September 2018, VA held its Model Validation Event, where VA's
EHR Councils met with Cerner to begin the National and local workflow
development process for VA's new EHR solution. There was a series of
working sessions designed to examine Cerner's commercial recommended
workflows and evaluate the current workflows used at VAMCs. This allows
VA to configure the workflows to best meet the needs of our Veterans,
while also implementing commercial best practices.
Cerner Baseline Review
VA is committed to align its workflows closely with commercial best
practices; therefore, VA commissioned Cerner to complete a baseline
assessment of how closely DoD's MHS GENESIS aligns with these
practices. In September 2018, Cerner presented the results of the
assessment. VA learned DoD has high adoption of recommendations and
system configuration, which are generally in alignment with commercial
best practices.
oehrm organizational structure and strategic alignment with dod
On June 25, 2018, VA established OEHRM to ensure VA successfully
prepares for, deploys, and maintains the new EHR solution and the
health IT tools dependent upon it. OEHRM reports directly to VA Deputy
Secretary and works in close coordination with VA Veterans Health
Administration and Office of Information Technology. Mr. Windom
currently serves as the program's executive director and has supported
the effort at a leadership-level since its inception. Prior to joining
VA, Mr. Windom was a Program Manager for the Program Executive Office
of the Defense Healthcare Management Systems (DHMS).
To ensure appropriate VA and DoD coordination, we emphasize
transparency within and across VA through integrated governance and
open decisionmaking. The OEHRM governance structure has been
established and is operational, consisting of technical and functional
boards that will work to mitigate any potential risks to the EHRM
program. The structure and process of the boards are designed to
facilitate efficient and effective decisionmaking and the adjudication
of risks to facilitate rapid implementation of recommended changes.
At an inter-agency level, the Departments are committed to
instituting an optimal organizational design that prioritizes
accountability and effectiveness, while continuing to advance unity,
synergy, and efficiencies between VA and DoD. The Departments have
instituted an inter-agency working group to review use-cases and
collaborate on best practices for business, functional, and IT
workflows, with an emphasis on ensuring that interoperability
objectives are achieved between the two agencies. VA's and DoD's
leadership meet regularly to verify the working group's strategy and
course correct when necessary. By learning from DoD, VA will be able to
address challenges proactively and reduce potential risks at VA's IOC
sites. As challenges arise throughout the deployment, VA will mitigate
adverse effects to Veterans' healthcare.
implementation planning and strategy
It will take OEHRM several years to fully implement VA's new EHR
solution and the program will continue to evolve as technological
advances are made. The new EHR solution will be designed to accommodate
various aspects of healthcare delivery that are unique to Veterans and
VA, while bringing industry best practices to improve VA care for
Veterans and their families. Most medical centers should not expect
immediate major changes to their EHR systems.
VA's approach involves deploying the EHR solution at IOC sites to
identify challenges and correct them. With this IOC site approach, VA
will hone governance, identify efficient strategies, and reduce risk to
the portfolio by solidifying workflows and detecting course correction
opportunities prior to the deployment at additional sites. As
mentioned, VA and Cerner have conducted Current-State Reviews for VA's
IOC sites. These site assessments include a current-state technical and
clinical operations review and the validation of the facility
capabilities list. VA started the go-live clock for the IOC sites, as
planned, on October 1, 2018.
Further, VA is continuing to work proactively with DoD and experts
from the private sector to reduce potential risks during the deployment
of VA's new EHR by leveraging DoD's lessons learned from its IOC sites.
Several examples of efficiencies that VA is leveraging are: revised
contract language to improve trouble ticket resolution based on DoD
challenges; optimal VA EHRM governance structure; fully resourced PMO
with highly qualified clinical and technical oversight expertise;
effective change management strategy; and using Cerner Corporation as a
developer and integrator consistent with commercial best practices.
During the multi-year transition effort, VA will continue to use
Veterans Information System and Technology Architecture (VistA) and
related clinical systems until all legacy VA EHR modules are replaced
by the Cerner solution. For the purposes of ensuring uninterrupted
healthcare delivery, existing systems will run concurrently with the
deployment of Cerner's platform while we transition each facility.
During the transition, VA will ensure a seamless transition of care. A
continued investment in legacy VA EHR systems will ensure patient
safety, security, and a working functional system for all VA healthcare
professionals.
change management and workflow councils
Because the program's success will rely heavily on effective user-
adoption, VA is deploying a comprehensive change management strategy to
support the transformation to VA's new EHR solution. The strategy
includes providing the necessary training to end-users: VAMC
leadership, managers, supervisors, and clinicians. In addition, there
will be on-going communications regarding deployment schedule and
anticipated changes to end-user's day-to-day activities and processes.
VA will also work with affected stakeholders to identify and resolve
any outstanding employee resistance and any additional reinforcement
that is needed.
VA has established 18 EHR Councils (EHRC) to support the
development of national standardized clinical and business workflows
for VA's new EHR solution. The councils represent each of the
functional areas of the EHR solution, including behavioral health,
pharmacy, ambulatory, dentistry, and business operations. VA
understands that to meet the program's goals we must engage frontline
staff and clinicians. Therefore, the composition of the EHRCs will
continue to be about 60 percent clinicians from the field who provide
care for Veterans, and 40 percent from VA Central Office. As VA
implements its new EHR solution across the enterprise, certain council
membership will evolve to align with contemporaneous implementation
locations. While deploying in a particular VISN, the needs of Veterans
and clinicians in that particular VISN will be incorporated into
national workflows.
funding
With the support of Congress, OEHRM has not experienced funding
shortfalls that would impact the success of the EHRM initiative. OEHRM
reviews its lifecycle cost estimate at least once per month to reflect
actual execution and to fulfill its programmatic oversight
responsibilities. OEHRM will provide Congress with regular updates to
ensure that the program is fully funded and to support our commitment
to transparency. VA's enacted fiscal year 2019 budget of $1,107 million
allows VA to continue the implementation, preparation, development,
interface, management, rollout, and maintenance of the EHRM initiative.
The 2019 enacted budget comprises the following:
--$575 million in the EHR Contract subaccount used for Enterprise
Integration task orders, Technology Acquisition Center fees,
site assessments, and change management,
--$120 million in the Program Management subaccount used for contract
support staff, pay and benefits, travel and administrative
expenses, and
--$412 million in the Infrastructure Readiness subaccount for end
user devices, testing activities, interfaces, and Medical
Community of Interest, or MedCOI.
closing
Again, the EHRM effort will enable VA to provide the high-quality
care and benefits that our Nation's Veterans deserve. VA will continue
to keep Congress informed of milestones as they occur. Mr. Chairman,
Ranking Member, and Members of the Subcommittee, thank you for the
opportunity to testify before the Subcommittee today to discuss one of
the VA Secretary's top priorities. I would be happy to respond to any
questions that you have.
Senator Boozman. Thank you. I will go ahead and get
started. Mr. Byrne, interoperability with legacy systems
remains a challenge across the board for new VA IT systems. We
are currently watching VA struggle to implement changes to the
G.I. Bill that resulted in IT challenges. The scope and scale
of the challenges the VA will face in the EHR modernization
endeavor cannot be understated. It is something that we simply
cannot fail in.
VA will be rolling out the modernized EHR system. At the
same time, it is implementing the sweeping changes required
under the Mission Act and other changes in law, $16 billion
dollars over 10 years. Somebody was telling me, you can
appreciate this as an old Naval Academy graduate. I think--did
you tell me you had a son on submarines?
Mr. Byrne. Yes sir, I do.
Senator Boozman. Thank you very much. So we appreciate that
service, but I think the new aircraft carrier is $13, $14
billion. So this is a huge undertaking, huge expense. So I
guess, my question is, what steps is the VA taking to ensure
that we will have interoperability between new EHR system and
VISTA? How is VA going to ensure that data from community care
providers is quickly fed back into the new EHR?
Mr. Byrne. So the first part of your question, sir, I think
you asked about your concern with the implementation of Colmery
and within (VBA) Veterans Benefits Administration. And so, I
would like to differentiate the two of those, basically, and
then I would like, with your permission to pass the question
off to Mr. Windom, because I think you had several questions
within that, I hope he was taking notes on them.
Senator Boozman. He was busy.
Mr. Byrne. But the first is with the implementation of the
electronic solution for Colmery and the payment of education
benefits. That was a homegrown solution, which I will
differentiate between what we are doing now, which is an off-
the-shelf purchasing of Cerner, a system that has sort of been
proven across the industry and so I want to differentiate the
two of those, why I think we should have a higher confidence in
Cerner. It is proven in the marketspace. And so, I
differentiate the two of those. I have asked Mr. Windom to
address--I think there were six questions within that.
Mr. Windom. Thank you, Mr. Chairman. The interoperability
element is our primary objective. Not only interoperability
within the VA, between DoD and the VA and also with our
community providers. So at the forefront, I think, as we look
at the challenges and implementation like this, we face, it is
about putting the right people, the right team together. We
have been leveraging DoD and lessons learned. I can assure you,
our relationship has only grown over the past 22 months that I
have been on board. And so, being able to understand their
challenges, this is hard for a reason. And so, we are
communicating weekly with not only our weekly one-hour sessions
but our monthly sessions. So that exchange of ideas and
communication is ongoing.
I will tell you that we have got a number of strategies
that we are employing with that I am going to turn it over to
Dr. Kroupa to talk about that clinical information exchange
that data exchange, because again, this is about user adoption.
This is about the willingness of the end users to use the
technical solution that we are bringing the bear. And so that
training mechanism, those exchange management strategies are
all imperative, and I think we are doing that as part of both
our national workshops and our local workshops where we are
engaging both headquarters and field to ensure an understanding
of the direction. So I am going to pass it off, because I think
that data movement, that data migration, that data access is
important. So Dr. Kroupa, if you do not mind.
Dr. Kroupa. Sure. So we are doing a couple of things. One
thing we are doing right off the bat is moving a lot of our
data into the Cerner system for all patients across the country
before our first go live. So we have 20 domains of patient data
that will be front loaded into the Cerner product. So that
those--that data will be available to DoD sites and also be
available at our IOC sites. So that clinicians will not have to
work without the data that has been accumulated in VISTA over
time.
One of the things that we are going to accomplish with this
system is interoperability between VAs, because right now, as
you said--we have 130 different systems. So now folks will be
able to see all of the records for across the country when we
go live on Cerner as well as the DoD sites.
The interoperability with the community is obviously a
national issue. It is not just a technical issue. Using a
Cerner hub will allow us to exchange information with community
partners, and we hope to be able to grow and move that forward
as we gain traction with Cerner. So some of that comes down to
business rules and relationships and really making the case
that this is important for our veteran care.
Senator Boozman. Very good. Senator Schatz.
Senator Schatz. Thank you, Mr. Chairman. I am concerned
about VA's relationship with Congress when it comes to
oversight and so I am just going to ask you, Mr. Byrne, a
simple question, and I think you can answer on behalf of the
rest of the team.
Do you commit to responding promptly to written questions
from members of this subcommittee including the Chair and
Ranking Member beyond the quarterly reports on EHR and other
matters?
Mr. Byrne. Certainly.
Senator Schatz. Thank you. I am looking at the appropriated
money for last fiscal year, roughly $1.1 billion and you have a
planned $25 million carryover which ends up being $205 million
carryover. So then the spend plan for fiscal year 2019 is
$1.287 billion. You have got $37.5 million obligated and
roughly $9 million spent. I guess the first question is, are
you on pace to spend this money in time? That is the first
question. And then the second question, becomes, if not, how do
we know, so that we can calibrate our appropriations so we are
not appropriating money into a pile?
Mr. Byrne. So I will take a quick stab at that and then
kick it over to Mr. Windom who is intimate with those exact
numbers.
Senator Schatz. He smiled a lot.
Mr. Byrne. Because he is chomping at the bit ready to
answer this question. But I would like to insert, sir, that
IOC, we anticipate going live here in the beginning of the
second quarter, and we are going have a whole lot better
picture of our spend rate and our ability to move forward at
that time. So that is not really a specific answer to your
question, but we are in a little bit of a wait-and-see method
there.
You give us three-year monies. That was appropriate as we
spent up, and we are appreciative of that. I would ask Mr.
Windom to maybe address the very specifics of your questions.
Mr. Windom. Sir, I understand your concerns. I have had an
opportunity to speak with your staff, and I appreciate the
latitude you have given this program with three-year money. I
think, though, the way I would answer your question is, you
have challenged me to be fiscally responsible and fiducially
responsible. And that we will not frivolously spend money
without a bona fide need.
There is a bona fide need for the resources that have been
allocated. I cannot take the budget and just divide by four and
have an equal expenditure in each quarter. We want to make sure
our timing is correct. For example, many times we buy equipment
prematurely, and you have to warehouse it. You have to put it
in warehouses which now makes software go obsolete and things
like that. So you will see, just-in-time-buys that we are
employing for infrastructure buys.
We do not want to buy the equipment such that when it
arrives to us, we are able to put it where it is needed
immediately. And so things like the infrastructure buys are
going to be delayed until the last moment possible, such that
as we are installing it and taking advantage of all
technological advancements prior to that buy or that purchase.
Senator Schatz. So, I just want to be clear. I am not
criticizing you for spending slow. I am asking that we get
better fidelity into what the spend plan is so that we know--
because part of it is just as simple as, ``Hey, we don't want
you to waste money just to satisfy our need to feel like you're
on your plan.'' But on the other hand, if you are delayed, you
are delayed. In which case, we ought not to appropriate money
that can wait until a subsequent fiscal year.
So all we need is better communication as it relates to
where you are exactly.
Mr. Windom. Yes sir.
Senator Schatz. And not waiting for either an oversight
hearing or these 90-day quarterly reports, which my staff tells
me, you know, does not quite tell the picture. Especially when
you are launching, 90 days is a really long time to wait to
figure out where we are at.
Final question, a lot of people have expressed concerns
that private individuals have played in the VA procurement
decisions and there are lots of very good people in leadership
and at the line level who want to do this right. And I have no
particular reasons to suspect that anybody is doing otherwise.
But here is the question, besides workshops, council
meetings, site visits, and other routine and related community
events, have you or anyone you know formally or informally
corresponded with any private individual not officially
involved with the EHR modernization through a contract for
services or provider agreement? Mr. Byrne?
Mr. Byrne. I am not aware of anybody doing such things,
sir.
Senator Schatz. Okay, I am going to reduce this question to
writing, because I do not want to put any of you on the spot,
and I want you to get it exactly right.
This concern that there are three private individuals who
meet at a private club, who have improper influence over the
operation of the Veterans Administration is a first order for
scandal, if it is true. And we want to get to the bottom of
that particular question. I know there is going to be, I
believe, a GAO study, but I also trust you to answer the
question as straightforwardly as possible. So we will, in a
non-accusatory way, reduce this to writing so that you can
clear up who, if anyone, is being influenced by these three
private individuals who, at least reportedly, have outside
influence at a Government agency.
Thank you, Mr. Chairman.
Senator Boozman. Senator Capito.
Senator Capito. Thank you, Mr. Chairman. Thank all of you.
Appreciate what we are trying to accomplish here, and I would
say way overdue in time, and we want to see this be successful.
So Cerner is the main contractor. Obviously, they are
letting subcontracts to small businesses, which is required
through the--complying with the subcontracting plan, one of
those happens to be in my state. So I would like to know if
anybody can give me some data as to whether they are fulfilling
the 5 percent subcontract to small businesses, if Cerner is
moving forward on that. And what kind of feedback you are
getting from them in terms of moving some of that business to
our smaller businesses?
Mr. Windom. Yes ma'am. So we have a 17 percent overall
small business set aside plan associated with the work that
Cerner has been assigned, which equates to about $10 billion.
The breakout of that is small disadvantaged businesses, 5
percent women-owned businesses.
Senator Capito. Right.
Mr. Windom. Five percent up zones, 3 percent and so on. So
as you know, the oversight mechanism is what is important. And
I can tell you, my Program Management Oversight Office is very
much attentive to Cerner fulfilling those established goals.
Over 10 years, that equates to anywhere from $500 to $600
million, and that is assuming at the present level. And so, we
have the ability to not issue task orders if Cerner is not
fulfilling those goals. So the task orders that we have issued
today, Cerner has been meeting those small business objectives.
Senator Capito. In all categories?
Mr. Windom. Toward 17 percent. Keep in mind, ma'am, is that
there is overlap between the 17 percent, in that you can be a
small disadvantaged business and also be a woman-owned
business, et cetera. So, ma'am, across the categories that we
have established, they are in compliance, and we will continue
to ensure that this is the case.
In addition, as an aside, we are having in the spring, a
vendor day, if you will, where Cerner is going to be hosting
vendors that are interested in showing their expertise, their
talent, their abilities to support our overall mission
objectives as a proactive measure to ensure that we remain in
compliance and can continue to leverage good ideas that small
businesses, in fact, have.
Senator Capito. Yeah, I would appreciate having the date
and--
Mr. Windom. Yes ma'am.
Senator Capito [continuing]. And maybe you could generate
all of that to our offices. Certainly as somebody whose
proximity to the D.C. region, my state is fairly close. This
could be helpful, but it would be helpful in Hawaii as well.
Let me ask you something. Cerner is developing, I am sure,
on the other side of their non-governmental business,
proprietary products and other things for their private
businesses. Is there any concern that with a contract this
large that the firewall between developing proprietary products
and the Government products, in other words, I do not want to
see them developing their proprietary products on our
Government tax dollars. What would you have to say? What kind
of firewalls do you have in place for that?
Mr. Windom. Ma'am, I think you will find our strategy
supports the removal of the intellectual property barrier. It
from--I cannot speak for Cerner, but it is--they seek to
maintain a single base line between their commercial and their
Federal business.
I can tell you within the terms and conditions of the
contract, we put clauses in there that address the fact that we
will continue to help them innovate and hopefully we will be
introducing ideas as part of, you know, if you will, our smart
people that reside within the VA. Helping them understand, not
only our market but contributing to ideas that may support
their commercial market.
Within the framework of the terms and conditions of the
contract, we have, actually language that allows for the
sharing of potential profits that may be gained by those ideas.
Senator Capito. That was going to by my next--
Mr. Windom. So yes ma'am. So I think the cross-pollination
between the commercial and also the Federal space are important
to preserving that commercial desire to be more like the
commercial EHR platforms. So we have not faced those
inhibitors, to date. But we will be mindful of them, especially
since you have expressed that concern, but I think we have got
language in the contract. And again, enforcement is important
to where we are going to be able to cross-pollinate, share
ideas, and then the Government reap whatever benefits they so
need.
Senator Capito [continuing]. Good. Let me ask this. I do
not have much time left. This is a big question. In terms of
putting electronic medical records into the private space and
where we are doing this now with the VA, there has been an
issue with providers--maybe I will say, since I am in that
category, older providers who do not really want to, you know,
move into the electronic medical records. It is expensive. They
do not really know the technology. They do not want to mess
with the technology. You said something, just a bit ago, about
cross VA and how--it led me to believe, like this is going to
be a requirement for everybody across.
Are you going to be training through the spectrum? It is
not just going to be physicians. Obviously, it might be
physician's assistants, physical therapists, et cetera, et
cetera. Am I understanding that correctly?
Mr. Windom. Yes ma'am. There are many other types of users
besides clinicians.
Senator Capito. Right.
Mr. Windom. And so that whole user base is important for
our overall success. And so, ma'am, if you do not mind, I am
going to defer that do Dr. Kroupa, because she is at the
forefront of these clinical or these change management councils
that are supporting those.
Dr. Kroupa. So we have one advantage. We have been using
electronic health records for many years, but we are not going
from paper to an electronic health record. So everybody is used
to being on a computer. But we have a robust training strategy
and change management strategy to bring everyone to this new
technology.
Senator Capito. Great, thank you. I will just make a quick
comment since Senator Baldwin and I work on this issue with the
prescription of opioids and overuse and lack of accountability
through the VA. I am certain that this will help, but if it is
only if everybody is doing it the right way, cross VAs, cross
your sea box and everything. So I encourage you that.
Sorry I went over. Sorry.
Senator Boozman. Senator Tester.
Senator Tester. Thank you, Mr. Chairman. I want to thank
you and Ranking Member for having this hearing. I welcome all
the co-folks on the panel.
Before I get into my questions on EHR modernization, I have
a couple of things I just want to hit on very quickly.
Yesterday, members of Congress charged with oversight of the
VA's policy in funding, including myself and the Chairman and
Ranking Member of this subcommittee.
Sent a letter to the Secretary with a simple message that
the VA needs to be more transparent. And the VA needs to work
more collaboratively with Congress. I hope there are not folks
within the VA that see us an enemy, because we are not. Our job
is oversight, and if in fact, there are folks within the VA
that think we are an enemy, then they need to change their
opinion.
We have got a lot of work to do, and we can get a lot of
work done by working together, and I hope you folks agree on
that. And let me give you an example, the Access Standards. I
do not know anybody in Congress that knew what was in those
Access Standards before they were announced, okay. Maybe one
person. It has impacts on appropriations. It certainly has
impacts on the Authorization Committee. And quite frankly, a
better job should have been done in that regard. Why, because
ultimately what we are talking about is that Dartmouth Report
that you talk about, Mr. Byrne. Where the VA does have good
healthcare and the Access Standards are bad or have
unintentional consequences. It could result in privatization of
the VA.
So secondly, last week the Federal Court of Appeals ruled
that territorial seize should be included in the definition of
the service of the Republic of Vietnam. This is the Age in
Orange Act. The Age in Orange Situation.
Mr. Byrne, does the VA intend to appeal this ruling to the
Supreme Court?
Mr. Byrne. So these types of matters are handled by the
Department of Justice in consultation with us.
Senator Tester. That is right. You will be the driver. They
will have to do the work.
Mr. Byrne. That is correct, sir. And so we are taking that
under advisement right now on what our recommendation is going
to be.
Senator Tester. So a decision has not been made yet?
Mr. Byrne. Correct.
Senator Tester. Okay. Mr. Byrne, it is no secret that
making joint decisions and balancing priorities with the
agencies, the size of the VA and DoD, which are very
significant, is a challenge. Yet, we are only a year away from
the first roll of the new EHR at the VA and no one has been
designated as the ultimate decisionmaking authority between the
two agencies. The Secretary committed back in September to
create a joint Government structure. It still has not happened,
and we have known since the Cerner contract in May that this
process will be impossible without an entity at the top, the
food chain to make final decisions.
I understand there will be an upcoming report laying out
some of the joint governance options, but we have not received
any commitments about when there will be a final solution. In
the meantime, important decisions are being made without formal
interagency structure, and more importantly, many decisions are
being kicked down the road, because there is nobody in place to
make them.
Senator Reid and I recently sent a letter to both agencies,
because we are growing increasingly concerned about the impact
that this is going to have on the success of this project. So
tell me where we are at in this process and explain to me why
this committee should not be concerned about what I just
described?
Mr. Byrne. So sir, we do have a governance construct in
place, an interagency program office that is working. We have
asked DoD Tiger Team--VA Tiger Team to work together to
determine whether there is a better solution going forward for
the long term. At the end of February, we will receive a report
out from them on what they think the recommended course of
action will be regarding some type of a joint or interagency
organization to supplant or take over for this IPO office that
is existing right now, allowing us to move forward undistracted
to implement at the IOC sites.
The agreement between the two Secretaries, then General
Maddox and Secretary Wilkie was a 50,000-foot agreement.
Senator Tester. Yep.
Mr. Byrne. I can tell you that on a more operational level,
I work with the acting Under Secretary over at DoD on the joint
executive council. And ultimately, we are the decision makers
if there is a dispute that cannot be resolved at the lower
levels between DoD and the VA.
All of us have agreed, despite any rumors that are out
there, that we would like to consider the option, and we are
looking forward to the recommendations at the end of February
to have one arbitrator, whatever the title, a purple person,
who we all agree would make decisions, whether it is a dispute
between DoD and the VA. And that is a purple person, though.
Not somebody from DoD. Not somebody from the VA.
Senator Tester. Yep.
Mr. Byrne. And the example I have used would be--this is a
bad example, but it is like a marriage. You give 90 take 10.
Senator Tester. So when is that purple person coming on
board?
Mr. Byrne. Well, we are looking for the recommendation.
Senator Tester. Yeah.
Mr. Byrne. That that is the right solution. And we are
still seeking names and looking for that person right now. So
we do not even have the--if that is the idea we choose. If that
is the construct that we are going to use going forward, we
have not decided on that person yet. We have not even
interviewed them yet.
Senator Tester. So--and I will put the rest of my questions
in writing for the record.
But my concern is DoD--VA's no small partner, here. It is
big, but DoD can steamroll VA if they want.
Mr. Byrne. I do not agree with that, sir.
Senator Tester. Well, I hope you are right, but they have
been down the road. So I think they have some experience that
the VA does not have, that they could say, ``You know, we know
better than you,'' and unless you have somebody who is able to
look at it from both perspectives, because it is critical. Just
one final thing, and it will be very quick, Mr. Chairman. When
does the VA intend to determine whether they are going to
appeal the Blue Water Navy issue?
Mr. Byrne. So the DOJ has 90 days, I believe, to submit
their package from the Solicitor General to the Supreme Court,
and I am not sure exactly what our deadline is. I probably
should know that, at the 45 or 60-day point. We have to put for
what our recommendation to DOJ.
Senator Tester. It would be really good to get some clarity
on what is going to happen, here, because as you know, we
almost had a Blue Water Navy Bill at the end of last Congress.
We did not. This will have an impact whether we are going to
move forward or not.
Mr. Byrne. Yes sir. Thank you.
Senator Tester. Thank you, Mr. Chairman.
Senator Boozman. Senator Daines.
Senator Daines. Thank you, Mr. Chairman. I am honored to
join you and the members of the Mil-Con VA subcommittee for the
116th Congress.
The topic of today's hearing is timely. When I met with
Robert Wilkie last summer, he shared a story about his father's
service in Vietnam. The indorser's father incurred, the years
he spent carrying around reams of paperwork to get treatment at
VA facilities. As a son of a Marine myself, I appreciate the
unique challenges that our service members face.
Today we are reviewing a plan to create a viable,
electronic health record system at a cost of $16.1 billion.
That is with a ``B'' over 10 years. I spent years in the cloud
computing, Novell software business data integration and so
forth and had a fair amount of experience in this. Frankly,
$16.1 billion, when I look at it, is a lot of money. I
appreciate the witnesses' time and optimism, but I think these
numbers demand some scrutiny.
Mr. Byrne, you pointed out that new Office of Electronic
Health Record Modernization emphasizes transparency. As a
Senator from Montana, my first question in preparing for this
hearing was simply, when will Fort Harrison go live? I cannot
find this information on the VA's website nor any public facing
outlet.
Furthermore, VA documents provided to the committee show
conflicting information. One schedule showed fiscal year 2020.
Another showed fiscal year 2027. Mr. Byrnes, when will Montana
veterans be able to use a modern electronic health record
system?
Mr. Byrne. Well first, sir, I am glad that you are excited
about this being rolled out in your state. I believe there is a
roll out schedule. I just do not know it off the top of my
head, and unless Mr. Windom does, we can take that for the
record and get it back to you.
Mr. Windom. Sir, I will have to take it for the record. We
do have a full deployment schedule that reflects the 10 years
of the 9 years, 6 months, that does, in fact, capture Montana,
the great State of Montana. And we can tell where your facility
lies at that and so I will take that for the record.
Please, the terms and conditions of the contract has an
agreed-to a deployment schedule. We will make sure your staff
has that, sir.
Senator Daines. I think transparency is really important
here. Especially in light of the huge amount of money being
spent as well as the importance of this project here to help
our veterans. So I look forward to that response.
Last month, the GAO released a report finding the VA spent
$1.1 billion over 5 years on two previous attempts to update
its health information system. This latest effort by VA is
expecting to cost upwards of $16 billion over 10 years. I am
just skeptical. I have watched in the days of the private
sector, particularly, in the public sector, as well as private
companies but spending huge amounts of money. Anytime I hear
about 10-year roll outs in project timelines, consider me in
the camp of skeptical. We can spend a lot of money, and by the
time something gets implemented after that long period of time,
oftentimes it is obsolete from the day it goes live.
Mr. Byrne, you noted that, ``With congressional support,
the VA has been able to been able to stay on track.'' In its
report, the GAO stated the VA must work expeditiously to reach
its goal. My question is, is 10 years an ambitious timeline,
and would you describe the VA's efforts as expeditious?
Mr. Byrne. So 10 years is a long time, sir. And I
appreciate that. And the technology that we are starting with
in the Northwest will be different than those roll outs later
on in the deployment schedule. What I will share with you--what
I am looking forward to, has a big metric, is a big decision
maker, has some visibility into where we are, is the roll out
of the IOC sites in Washington State. Up in Spokane and Seattle
and Tacoma. How those are rolled out. Deficiencies we have
learned from those. The challenges we learned from those are
going to give us a picture of how much this is actually going
to cost.
And so for us to guess--we are guessing right now on the
amount. I think it is an educated guess, but after the IOC
rolls out, I believe we are going to have a much clearer
picture to then be able to address your question more
specifically.
Senator Daines. So I am running out of time. I am going to
follow up with Mr. Windom. If the idea behind this initiative
is to leverage ``commercial best practices,'' where in
industry, do we see software solutions being introduced over a
10-year horizon?
Mr. Windom. Sir, I think it is important to understand that
the signing of the contract is a static document for a very
dynamic environment. And so, we will continue to evolve with
the commercial product. Things like cloud computing that you
mentioned, definitely something that is on the horizon. You
know, when you put a mechanism in place, you challenge me to
manage cost, schedule, performance, and risk. And so, I will
continue to update you on our strategy moving forward, but the
vehicle we have in place, the IDIQ, indefinite delivery,
indefinite quantity structure will allow us to take advantage
of the technological advancements. So what the product looks
like today in year one, may look like something different in
year nine, but it will be interoperable, and I think that is
key.
Senator Daines. It may look different two quarters later,
at the state of technology.
Mr. Windom. Yes.
Senator Daines. And lastly, I will make a comment. We used
to say as we working toward--and any time these great big
enterprise solutions are put in place like this with a 10-year
time line and $60 million dollar-price tag, that is a recipe
for disaster. It is a recipe for, frankly, not spending tax
dollars wisely, but the people that are hurt the most are our
veterans here who will not see a timely implementation here. As
we say, these great big erector set, kingdom building with an
IT organization. Systems like this, they are dinosaurs.
Mr. Windom. Yes sir.
Senator Daines. They just do not know they are extinct yet.
Thank you.
Mr. Windom. Sir, may I comment, and that is why IOC is so
important. Secretary Behr indicated that it is that bite of the
apple that is a manageable bite that will be allowed to assess
what efficiencies can be gained. I can assure you, Cerner wants
to go faster. It is our implementation, ensuring we employ the
appropriate change management strategies to ensure the
embracing of the user that is important. So sir, we will be
pushing to go as fast as we can, and I can assure you, under my
watch, we will be incredibly judicious.
Thank you, sir.
Senator Boozman. Senator Baldwin.
Senator Baldwin. Thank you and I want to thank you Chairman
Boozman and Ranking Member Schatz for holding this hearing.
Thank our witnesses for being here.
The Wait Time crises that was brought to light in 2014
really revealed tragic deficiencies in caring for our nation's
veterans and the need for modern and functioning scheduling
system at the VA. And 5 years later, I am fearful that we are
not closer to a solution.
Mr. Byrne, is the VA currently operating a Cerner
scheduling program in any VA medical center?
Mr. Byrne. I am concerned to answer that question. I know
there is an intent to do so. Rolling it out simultaneously with
the overall roll outs of the EHRM system, starting with the
three locations in Washington State. We are also rolling out
this portion of the suite of options offered by Cerner. And so,
I know we are intending to.
Senator Baldwin. Is the answer no?
Mr. Byrne. I am not sure. I can ask.
Senator Baldwin. When will a pilot Cerner scheduling module
go live?
Mr. Windom. So ma'am, the answer is no to the Cerner
Millennium Scheduling Suite. We have deployed separately in
Columbus, Ohio, an EPIC-based solution. We have committed to
deploying a Cerner scheduling module out-of-sequent post IOC,
and the intent is to leverage the learnings of IOC to deploy,
if you will, out of the vessel suite solution, simply the
scheduling module.
Senator Baldwin. So what is the tentative date that a pilot
Cerner scheduling module will go live?
Mr. Windom. So I would, by itself, so within the framework
of the best of suite March of 2020.
Senator Baldwin. March 2020?
Mr. Windom. Post March 2020.
Senator Baldwin. Okay, when will the Cerner scheduling
module go live nationwide?
Mr. Windom. The nationwide is 9 years and 6 months from
that point, because nationwide means incorporating all the
medical centers, and so that would be at the end of the
deployment timeline.
Senator Baldwin. And so 9 months or 9 years and some months
after March of 2020?
Mr. Windom. That would be the total solution, deployed
nationwide to all VA facilities. The scheduling piece, alone,
our intent is to deploy the scheduling piece separately to the
appropriate facilities. The timeline for that has yet to be
fully fleshed out, because we have not developed fully, our
execution strategy, but we expect that to start shortly after
we achieve IOC milestones in March of 2020.
Senator Baldwin. What is the total cost for the Cerner
scheduling to go live nationwide?
Mr. Windom. Ma'am, those estimates are rough-order
magnitude right now. In the coming months, we should have the
full profile of our execution strategy built out, and we will
gladly come brief you or your staffers on that full profile.
I think--what I would like arrange.
Senator Baldwin. What is the range?
Mr. Windom. Pardon me?
Senator Baldwin. What is the rough range?
Mr. Windom. Ma'am I would not even offer you a rough
estimate, because it is important, in hearings like this, to be
accurate. And so, in the coming months, we will have that full
profile for you.
Senator Baldwin. Last week the Secretary announced proposed
access standards for veterans seeking care in the community and
there, once again, tied to wait times. Last week, the VA also
announced that it was canceling the medical appointment
scheduling system that you just referred to, the mass pilot
project deployed at the Columbus VA Ambulatory Care Center.
Here are some of the results of that pilot: There was a 30
percent improvement in primary care wait times. An 18 percent
improvement in behavioral health wait times. 30 to 50 percent
reduction in the time required to schedule an appointment by a
scheduler. The mass pilot allowed schedulers to schedule across
VA medical centers and into specific departments without
multiple phone calls and faxes. This is not possible to do
today. For VA medical centers that are using the Legacy VISTA
scheduling system.
So Mr. Byrne, will this higher level of functionality be
required under the Cerner scheduling model?
Mr. Byrne. Yes ma'am.
Senator Baldwin. Okay. Will the Cerner model allow VA
schedulers to schedule outside of the VA?
Mr. Byrne. Yes ma'am, community care.
Senator Baldwin. In fiscal year 2019, the subcommittee
included report language that required the VA to report back on
the status of the scheduling system component.
VA notes in its response that will not implement any of the
existing scheduling pilot programs and will instead go with the
Cerner scheduling solution, and the response says, ``VA
believes that there is a return on investment in productivity
and efficiency realized by accelerating this scheduling
system.'' Now that is a really great statement, but I would
like to see some of the metrics attached to this conclusion,
this statement. So I asked the VA to provide the actual data
and metrics used to justify that statement.
Another statement made was, ``This will improve access for
veterans and streamline workflow for staff.'' Since no VA
medical center is currently operating on a Cerner scheduling
module, I am not sure how the VA can make such a statement. And
so I would like you to provide the committee with metrics and
actual data on how this decision will improve access for
veterans and streamline the workflow for staff.
Almost 5 years after the scheduling problems at the VA came
to light, the VA is telling Congress that veterans are going to
have to wait another 5 years or more for nationwide deployment
of a modern scheduling system. A system that VA has not tested
and does not know the capabilities of.
In its report to this committee, the VA says that we should
trust this new solution and that it will provide improved
access to care and streamline workflow for staff. I have to
tell you, I am skeptical, and I would like to hear those
answers from the VA. I think our veterans have waited too long,
and we have spent over $30 million on a cancelled scheduling
pilot that showed tremendous progress and promise. And now we
are being told cost will not change, but resources will be
needed sooner. And somehow, this is going to lead to better
outcomes for our veterans. So given the track record, I am
highly skeptical, and I hope that you will be able to provide
some answers that elaborate on the conclusions that you gave on
in your report to this committee.
Senator Boozman. Senator Collins.
Senator Collins. Thank you, Mr. Chairman. And thank you for
holding this hearing on this very important issue.
This modernization effort is incredibly important. I do not
need to tell the witnesses who are here that fact. It should
mean a great improvement for veterans in the State of Maine,
once it is finally implemented nationwide. And I cannot
emphasize enough how important it is that we get this right. So
that Mainers and others who are leaving the military and going
into the VA system have a seamless transition. I have never
understood why we had different electronic medical record
systems in the first place, and I am glad we are finally acting
on that. We also need to make sure that in addition to the
seamless transition between the DoD and the VA that there is
interoperability between the Togus VA Hospital in the State of
Maine, the oldest VA hospital in the nation and community
providers, because there is only one VA hospital in Maine. And
a lot of veterans get their care at community-based clinics or
through what used to be known as the Arch Program in northern
Maine.
So one of my questions is when DoD encounters a problem
implementing the new electronic health record systems and comes
away with lessons that might be helpful to the VA, how are
those lessons learned? What is the system for ensuring that,
that is transferred to the VA or vice versa, Mr. Windom?
Mr. Windom. Ma'am, we have had an ongoing relationship with
DoD since day one. Those lessons learned are not only
physically captured in a database, but they are addressed
individually with mitigation strategies to prevent us from, if
you will, duplicating elements that may have been challenges
that they faced. And so, we have got, not only a database
associated with that, we have an ongoing interchange a monthly,
all-day interchange with DoD to share ongoing progress. A
weekly interaction with DoD and VA to exchange weekly
interactions. So I think we are getting to that in a number of
ways, and we also have workshops that DoD is participating in
as part of our clinical workflow development process that I
will defer to Dr. Kroupa to touch on.
Dr. Kroupa. So we have 18 councils that are made up of VA
clinicians from across the country. They meet on a regular
basis over the next eight to 9 months to design and build and
configure the Cerner product for VA. We have DoD
representatives on each of those councils who participate in
the both online and in-person workshops to help us understand
why they made the decisions they made, the consequences of
those, and to work together to build the system.
Senator Collins. Thank you. Mr. Byrne, as DoD works to
overhaul its electronic health records system, I was chagrined
to read a Bloomberg story that reported that DoD had discovered
cybersecurity vulnerabilities. Now the good news is that these
vulnerabilities were discovered by a team of military hackers
and IT specialists. But the test conclusion is very disturbing,
because it was that the system was not survivable when hit with
staged attacks.
As a member of the Senate Intelligence Committee, we are
dealing a lot with cybersecurity issues, and I am well aware of
just how vulnerable our Government systems and private sector
systems are. And here we are having this huge merger of two
enormous Departments that are going to have very sensitive,
personal information, plus identifying information. How will
the VA go about identifying and addressing cyber
vulnerabilities in the new system?
Mr. Byrne. So ma'am, what I can answer to you on that is
that we have a new CIO, Mr. Jim Gfrerer, and his strength, I
believe is in cybersecurity. Not that that is relevant, because
he is leading a very large organization. And I will have one
comment, and I am going to ask Mr. Short, who I know, in fact,
I heard him give the answer the other day much better than I
could to address your question. But the Red Team at DoD is the
best of the best. And so, I do not know that they are
penetrating the environment necessarily means it is not a
robust defense, but I am not an expert. Mr. Short is. And if
you are okay, ma'am, I would like to kick it over to him.
Senator Collins. Absolutely, but I would just say that,
believe me, there are a lot of foreign actors who are also
very, very capable in this area.
Mr. Byrne. Yes ma'am.
Mr. Short. Ma'am, I reviewed the DoD report before it came
out in the press and spoke with DoD about it. The good news is,
every month since MHS Genesis, DoD's name for the new EHR has
gone live. Every month Cerner has drove down the
vulnerabilities that DoD discovered. So every month, the number
of vulnerabilities in the system keeps going down, because
Cerner's improving the system. Cerner has also moved all their
platforms, even on the commercial side, to using this a
standard setting for all security, improving all the security
platforms. So DoD's conclusion, in discussion with me is, this
was a good thing, because our team found it. We expect DoD Red
Team to always get in to any system they go after, but the good
news is that every day, Cerner is reducing those
vulnerabilities and DoD feels confident, as well as I do, that
we are safe.
Senator Collins. Thank you, Mr. Chairman.
Senator Boozman. Senator Udall.
Senator Udall. Thank you very much, Chairman Boozman. Thank
you, Ranking Member Schatz for pulling together on this,
because this, I think, is a crucial issue to really helping
veterans right on the line every day. It was good to hear, Dr.
Kroupa, that you said that the clinicians are going to be
actively involved in coming up with a system. I hope that you
will inform your new CIO about that, because he said recently,
James Gfrerer, now the VA CIO said in his confirmation hearing,
``Clinicians, clinicians,'' he said, ``Will have to go through
a substantial, rigorous process to conform their workflows to
the IT systems.'' To me, that is backwards. The clinicians
should be driving the process, and so I hope that with what you
have said, that that is the direction that we are headed.
But my question today, Mr. Byrne, last year members of
Congress called this transition process ``deteriorating and
rudderless.'' The rising cost underscore that the
administration did not start this process with a clear view of
what would be required. That is unfortunately a particularly
acute example of what is a Government-wide problem with
upgrading IT systems.
Senator Moran and I were actively involved in passing
(FITARA) Federal Information Technology Acquisition Reform Act
and the Modernizing Government Technology IT Act. Does the VA
plan to use the newly authorized working capital fund to
reprogram their IT budget to fund this modernization project?
Mr. Byrne. So if I may, I would just like to address one
quick matter you had addressed. Our CIO, during the
confirmation hearing, making a particular statement about
clinicians. And if you were to ask him that same question
again, I think the answer would be very lined up with Dr.
Kroupa.
Senator Udall. Oh, good.
Mr. Byrne. He is a good man and we are very, very fortunate
that he is on board with our team. And sir, I have to tell you,
I do not know the answer to your question, and I am hoping one
of my colleagues up here knows the answer about the working
capital group.
Mr. Windom. Senator, I think that is a CIO's call on how he
is going to employ the new policy or law regarding FITARA. I
can tell you that OEHR adheres to the existing structure of
FITARA that the CIO has approval authority on our expenditures,
and we have the appropriate interactions with them in advance
of obligating monies.
I think that Congress has been very clear to me with
regards to the accounting of EHRM expenditures, and they do not
want that money co-mingled with other IT investments. But I can
tell you from our joint infrastructure strategy that we worked
hand in hand with OIT to develop--we are exchanging ideas. We
are cross-pollinating. We both understand our fiscal
responsibilities and have no desire to waste taxpayer money on
not being aligned.
So we are doing that. And sir, I will talk with the CIO
when I return. But I think that question is likely in his
corner.
Senator Udall. Okay, well I am going to submit that
question for the record and hope that you get me back a
thorough answer with regard to the working capital fund.
Because I think when you are doing such a big project, you are
going to need those kinds of dollars, and I would be happy to
hear what you say.
Senator Udall. Mr. Byrne, just a final question and really,
it is more of a statement but I have a pending request to meet
with Secretary Wilkie. Unfortunately it has been pending since
July, and I have heard from other members that have similar
difficulty meeting with VA leadership. I would like to ask you
personally to commit to being responsive, but also that you
would advise the Secretary to respond to our congressional
request. Would you please do that? Would you commit personally
today to be responsive when we have requests of the VA
administration and the leadership?
Mr. Byrne. Yes, to both your questions, sir.
Senator Udall. Okay, thank you. Thank you both. Appreciate
it.
Senator Boozman. Thank you. Let me just ask a couple of
more things. Dr. Kroupa, Mr. Byrne talked about the importance
of the roll out as we go forward. DoD, I think they would
agree, we would all agree that they stumbled a little bit.
Maybe a little bit more than a little bit with their roll out.
You are doing your councils and things like that. I guess, my
thought is, it is one thing to do them, but we really do need
to listen to the problems that are coming up with the
specialties and things. Reassure us that that is happening.
Dr. Kroupa. So even before the contract was signed, we
started talking to DoD about their experiences at all levels of
the organization. As I mentioned, we have our clinical councils
which are made up of both national program leaders and people
from the field who have a lot of experience with electronic
healthcare records. Many of them use electronic health records
at their academic sites. So it not just VA expertise.
We have brought DoD folks into those councils so we could
hear firsthand from them. So after the national workshops, we
take it to the local sites, our IOC sites, so we have a week in
Kansas City where our clinical councils are working together.
Then we take it to the local sites where the folks in Spokane,
in Seattle, they can actually see what decisions have been made
and say, ``Yes, that's going to work for us, or no, no let's
tweak this. Let's change that, or we have a question about
that.'' So in doing that, we are not only configuring it and
designing it, but we are also educating our users of what is
going to happen so that they can anticipate and participate in
the challenge.
I think we also have industry best practice advisors on the
councils. These are folks from various academic and centers
that have rolled out large integrated electronic health care
records, to advise our council chairs on some of the pitfalls
and problems that they might run into.
Senator Boozman. Very good. Another issue I think you have
heard discussed at length today is the scheduling. And 10 years
is too long. You are going to have to figure out a way to do
that much more rapidly with the new access standards that have
come out which will help veterans.
One of the things that we are being told by VA is that
efficiencies in the VA systems will help pay for that, because
we are going to become more efficient. The way that you do
that, the critical way that you do that is through scheduling.
Senator Baldwin, you know, talked about the efficiencies that
were gained, and you are choosing the system that we do, but we
simply have to have those efficiencies, and we have to have it
in a timely fashion for our mission to work and for it to be
affordable.
So that is something that we are going to have to, I think,
push really hard. I think we are all in agreement on the
committee, that again, a 10-year reprogramming, that is just
simply unacceptable.
Mr. Byrne. So I will make a comment on that scheduling
solution, and I will ask John and company to correct me if I am
wrong, but my understanding is, it is going to be well before
10 years that this scheduling solution will be across the
United States, will be in every medical center in the United
States. We are doing a dual effort as the EHRM rolls out within
the various medical centers, we'll, of course, implement the
scheduling solution. But there is a separate effort in other
locations to do the same. So I will not say that it is going to
be in 4 or 5 years, but that is probably more likely than,
certainly the 9 years, right?
Mr. Windom. Yes sir, that intent, Mr. Chairman. The
scheduling again, IOC is our testing platform, if you will. And
we intend to get scheduling out to our veterans as soon as we
possibly can. The commitment is the reason the return on
investment was what it is we paid for the Cerner licenses.
And so, in promoting interoperability objectives,
installing two different systems, we would, in fact, complicate
that interoperability objective. So I think we have got a plan.
It is being refined over the next 3 months including what the
cost profile looks like, what the timing of the deploying
scheduling is and look forward to coming back and updating
either you or your staff, sir, on that progress. I can assure
you we have the same concerns that you have, sir. And we are
going to address them and be able to formally present that to
you, the plan.
Senator Boozman. Good. No, we appreciate that. The last
thing and Senator Tester alluded to this, General Maddox,
Secretary Wilkie, you know, got together and said we are going
to do this, made this statement. And we are all patting each
other on the back. The reality, though, is that somebody has to
be in charge. We have to have an organizational flowchart as to
how things are decided.
We have all been around governance for significant years
and simply, that will bog down tremendously. So what we would
like for you to do is provide an update on joint oversight, how
this is going to work, including the organizational structure
and accountability mechanisms that facilitate, consort,
coordinated decisionmaking oversight, and we really want that
like soon. That should already be in place. I doubt that it is,
and I am not really being critical about that, but it is a
necessary function for us to go forward efficiently. And we are
going to push really hard to see that, and if not, you are
going to have to come back here and explain why it is not being
done.
Senator Schatz.
Senator Schatz. Just following up on the Chairman's last
request. Do you already have this? An organizational chart that
clarifies who does what?
Mr. Windom. Sir, we have an existing governing structure
that is supporting us today. The more efficient, more agile
governing structure that you are speaking to that identifies,
if you will, that single belly button, that single point, that
is part of the assessment that is ongoing.
I can assure you that we are working hard, daily, to gain
joint efficiencies, joint process improvement.
Senator Schatz. Right. But do you know--I mean the question
he is driving at, right, is push comes to shove, who is in
charge? Do you know the answer to that question?
Mr. Windom. Sure, push comes to shove, who is in charge,
the Deputy Secretary is in charge. I am a 30-year naval
veteran, sir. And so, I relish that single person to ask. One
thing I would like to highlight is that governance is working
at the lowest levels, and which is where it has to work. I can
tell you, there is very few issues on the table that are
immediate with regard to that person being in the seat, and we
have not hit critical path on any of those decisions yet. So we
are very--we want that mechanism in place with letting the
assessment team flesh out, if you will, all the buckets of
consideration that have to take place.
Senator Schatz. Okay.
Mr. Windom. And so we look forward to that reporting out on
that.
Senator Schatz. Mr. Byrne, being general counsel for the VA
is a full time job?
Mr. Byrne. Yes sir.
Senator Schatz. When are we going to get a Deputy Secretary
nominee so we can relieve you of one or the other of these
duties?
Mr. Byrne. I do not know how to answer that, sir. That is
up to the President and Mr. Wilkie, the Secretary of the VA to
determine. And, of course, with the consent of this body.
Senator Schatz. Okay. Let us talk a little bit about
VISTA's sustainment. Obviously, you are going to be making a
transition and some of these are operational questions. I know,
Mr., Windom, that you will reassure me that there will be no
operational glitches. I guess, the question is, since some of
these are really moving targets, does some of these slide
appropriations either to the left or to the right, depending on
how long you have to keep VISTA sustained, you know, this can
get a little clunky as you are launching to maintain sort of
seamless experience from the customer side. So that part we
have not really talked about and how it could impact the need
for appropriations, either positively or negatively.
Mr. Windom. Sir, again, you have entrusted me to support
our veterans. We are not going to prematurely turn things off.
Senator Schatz. I do not think you are going to do anything
stupid.
Mr. Windom. Thank you sir.
Senator Schatz. We are satisfied that you are trying to
make the right choices.
Mr. Windom. Yes sir.
Senator Schatz. What I am not satisfied about is that you
are going to tell us as we go along so that we can make
appropriations that are dialed in, right. So that we give you
enough runway to make smart choices.
Mr. Windom. Yes sir.
Senator Schatz. We do not penalize you for not spending,
you know, one fiscal year's money. And we do not put so much
political pressure on you that you do a dumb thing, but we
still need better fidelity from the standpoint of our staff's
ability to do a markup that does not appropriate money into a
pile.
Mr. Windom. Yes sir.
Senator Schatz. So that is the part I want you to get a
little bit clearer with our staff about. We get that there will
be a transition. We get that VISTA has to be operational all
the way, really until the end, at least portions of it. We want
to know how much more or less that may cost.
Finally, there were reports last fall on the condition of
IT infrastructure in the Pacific Northwest. Pilot sites to try
to figure out whether you had the IT infrastructure to roll a
new system out. Were there shortfalls in IT infrastructure and
from a planning standpoint and the standpoint of this
committee, does that indicate something system wide that we
should be planning for? Or is that all baked into the 10 odd
billion that we are planning for?
Mr. Windom. Sir, I am going to make a quick statement, then
turn it over to John Short. First of all, the carryover from
fiscal year 2018 allowed us to cover what we perceived to be
about a $70 million-dollar expenditure for infrastructure
upgrades that were on plan. Things like user devices and things
like that. We have been working hand in hand with the CIO such
that there is a joint strategy, such that, we are going to be
able--
Senator Schatz. Yeah, but let me stop you there. You have a
$200 million carryover, I think?
Mr. Windom [continuing]. Yes sir, $203 million, yes sir.
Senator Schatz. $250?
Mr. Windom. $203.
Senator Schatz. $203, okay.
Mr. Windom. Yes sir.
Senator Schatz. You have a $200 million carryover and part
of that is like contracting delays. So out of the presumably it
was $270, you spent $70 to deal with IT infrastructure, but it
is not like you found savings. You just moved money to the
right on your appropriations schedules. So the question is, on
a year over year basis, are you able to absorb the needs for
new infrastructure, or are you just pushing this out to the
right, and as you delay contracting and cumbering money and all
the rest of it, that you sort of book that in the current year
end savings, plow it into infrastructure, but we are going to
be left with a two or three billion-dollar infrastructure bill
on the back end.
Mr. Windom. Well sir that is why I think it is important
that the CIO and I have an incredibly cooperative effort.
Again, he has a budget that supports maintaining infrastructure
today. Our funding supports the installation of the Cerner
Millennium Solution. So those have to work hand in hand.
Senator Schatz. But the question is, you do this analysis
of the Pacific Northwest.
Mr. Windom. Right.
Senator Schatz. It tells you what you need. Presumably, you
can do some back of the envelope and say, ``Well this is x-
percentage of our system. We should probably multiply that by
whatever and figure out whether the number we have for IT
infrastructure upgrades, you know, sort of rhymes with what we
now have some hard numbers that can extrapolate.'' So the
question is, have you done that, and does it look okay?
Mr. Windom. Sure, we are doing that as part of--as OI and
IT creates its budget, they are incorporating the challenges
that we are finding with regards to what infrastructure
upgrades. We have the ability to go out and do current state
reviews and we are out in front of our deployment efforts that
we are identifying those costs, if you will, early. And we
intend to report those out.
Senator Schatz. So the answer is, you actually do not--I do
not mean this as a criticism. The answer is you do not know the
answer to that.
Mr. Windom. The answer is we have not been to every site to
assess what deficiencies may exist but as part of our
deployment strategy, we are going to be out front enough to
make sure that we understand whether there are any funding
needs. Right now, there is no additional funding needs in
support of the IOC requirements as it relates to
infrastructure.
Senator Schatz. Right, but I do not want you to wait until
you are 100 percent sure to tell us. If you are at 98 percent
sure, look this looks like it's going to be more money.
Mr. Windom. Yes sir.
Senator Schatz. We do not want to find out at the last
minute in one of your quarterly reports. I guess I will let Mr.
Short answer the question and then that will be my last.
Mr. Short. So far, sir, our early indication is our budget
for infrastructure is on track. We do not see any indications
otherwise. We would have alerted that. We have a lot of
communication. Last thing I will mention. We did provide to the
Hill, last year, within the last year, integrated
infrastructure plan with OIT, and they are looking at the big
things we are finding that alter the system, and they are
incorporating that in their fiscal year 2020 budget and beyond
to make sure all of the system is taken care of. So right now
we do not believe we are going to find something like that, but
we will let you know.
Senator Schatz. Thank you.
Senator Boozman. Senator Hoeven is on his way, so. Senator
Hoeven is on his way, and would like to weigh in but let me go
ahead and just kind of close up and we will gavel it out once
he gets done, but thank you all so much for being here. I know
that you all are working very, very hard and have huge jobs to
do. This is certainly not a small or insignificant undertaking.
In fact, it is just the opposite of that. It is huge. This new
medical record system, though, has tremendous opportunity for
efficiency and all of that translates down to better care for
veterans and that really is what it is all about. So we look
forward to working with you, and I think we can be a huge help
in pushing things forward and, you know, we have got the
easiest thing in Government, when you bog down is just not to
make a decision. And so, we are going to do our best to help
you come up with a decision one way or the other. So we do
appreciate all of your efforts.
Have you got any other things on your plate?
I think we have asked about every possible question that
can be asked.
Let me ask you about the fiscal year 2020 budget. Are you
maintaining your commitment to funding initiative through the
electronic health record account and not relying on transfers?
Mr. Windom. Yes sir, we have given you a budget that we
believe supports our implementation strategy over the next 3
years. And so, we are not relying on transfers. I guess what I
would offer is that, as I stated before, static contract
dynamic requirement or dynamic environment. And so, as there
are emerging requirements, I think we will remain transparent
with your staff and be proactive in identifying whether we
think there are any prospective funding shortfalls, but right
now, we feel very good with the budget that you have allocated.
And we are pressing forward.
Senator Boozman. Very good. Okay, we will wait just a few
minutes. Catch your breath and get sacked up for the next.
Okay, you are off the hook. What he is going to do is, he is
running a little bit late. Today is unique, you know, we have
the State of the Union, the prayer breakfast is going on. The
National Prayer Breakfast and the list goes on and on. And so
that is another reason you all are in the same situations. You
have got a lot going on. So we appreciate you taking the time
to come over.
ADDITIONAL COMMITTEE QUESTIONS
And with that for members of the subcommittee, any
questions for the record should be turned into the subcommittee
staff no later than the close of business Tuesday, February
12th.
Questions Submitted by Senator Senator John Hoeven
Question. Last week, the VA announced its proposed access standards
for community care which were required under the VA MISSION Act of
2018. The new access standards will give our veterans more of a choice
when it comes to their care and where they would like to receive that
care. As the VA rolls out its new, interoperable EHR platform, how will
the Department work with, educate, and train VA community care partners
to ensure that providers can properly access and update a veteran's
medical record?
Answer. Understanding that many transformation efforts fail due to
lack of leadership buy-in and/or cultural resistance to change, VA has
a robust training and change management strategy to support the
implementation of its new EHR solution. The Office of Electronic Health
Record Modernization (OEHRM) analyzed the lessons learned from
Department of Defense (DoD) and will continue to collaborate with VA
clinicians, government stakeholders, and industry partners to identify
effective end-user retention and adoption strategies to optimize the
success of the new EHR solution. To engage frontline staff, VA is also
hosting several roadshows and workshops to enable end-users to present
their concerns and suggestions. Furthermore, VA will be providing on-
site training for clinicians and providers prior to deployment of its
EHR solutions.
Question. It is critical that the VA and DoD maintain an open line
of communication as the new EHR system is implemented. I understand
that the Departments have established an inter-agency working group to
ensure that interoperability objectives are reached between the two
agencies. How is the working group performing? Have potential
challenges to implementation been identified? Are there any specific
challenges the Departments are experiencing while operating under the
current organizational structure?
Answer. VA and DoD are committed to successfully deploying their
EHRs to improve access and the quality of healthcare for our Nation's
Servicemembers and Veterans. The Federal Electronic Health Record
Modernization (FEHRM) Working Group (WG) has been established to ensure
VA and DoD have an effective and efficient inter-agency arbiter.
FEHRM WG will assess the Departments' current EHR implementation
strategy and requirements, management and governance structures, and
existing legislative authorities to recommend the optimal
organizational construct for aligning plans, strategies, and structure
across VA and DoD. The goal is to ensure both organizations receive
timely decisions regarding the architecture and operations needed for
the core technology.
Since November 2018, the WG met with technical, legal, acquisition,
financial, functional, and data management subject matter experts from
DoD and VA. Additionally, the WG has met with the Interagency Program
Office to develop functional, technical, and programmatic functions for
the ongoing success of the inter-agency working group. There have been
no issues that would adversely affect the WG or its mission.
Question. VA fiscal year 2019 appropriations include a little over
$1.2 billion for the VA to continue the implementation, development,
rollout and maintenance of VA's new EHR system. What do you see as the
most significant items of concern that could either drive up the cost
or delay the rollout of VA's EHR system?
Answer. There are three items that could potentially impact the
cost or timeline of VA's EHR deployment: system training and change
management, information technology infrastructure upgrades, and
creation of clinical workflows. End-users must receive adequate
training on the new EHR solution to provide safe, high-quality care to
our Veterans. VA seeks to mitigate this risk by developing and
executing a training schedule 8 weeks prior to the Go-Live date at each
rollout site. Infrastructure upgrades must be implemented at the
enterprise and site levels to deploy a fully operational EHR solution.
In addition, VA infrastructure must be capable of supporting the
simultaneous operation of legacy systems (i.e., VistA) and the new EHR
solution during the transition period. To mitigate infrastructure
risks, VA is evaluating Initial Operating Capability site Current State
Reviews conducted by Cerner to identify infrastructure requirements
through gap analyses. VA is also developing acquisition strategies to
meet identified infrastructure needs. Clinical workflows must be
developed to improve clinicians' ability to provide high-quality care
to Veterans. Cerner must provide education to VA to structure and align
the workflow development process. VA must collaborate with clinicians
and community care partners to design the workflows. VA held a Model
Validation event in September 2018. This event resulted in an 8-stage
process, which includes conducting eight follow-on national and local
workshop events to identify potential workflow issues.
Question. Electronic health records are an important part of how we
receive healthcare today. Having a record that one's healthcare
provider can readily access can help save both time and money. That
being said, given today's cybersecurity risks, there are also
legitimate concerns about what is being done to safeguard private
health information from cybercriminals. What steps are being taken to
ensure that a veterans' private health information is protected? Are
there additional safeguards that need to be taken in order to ensure
that this information remains secure?
Answer. The joint EHR is stored within the DoD-authorized enclave
(MHS GENESIS) hosted at Cerner Corporation. MHS GENESIS risk management
and continuous monitoring activities are supported through Defense
Health Agency, DoD Health Management System Modernization Program
Management Office, and OEHRM unified interagency cybersecurity
programs.
VA and DoD cybersecurity and network operations teams are working
as one team to fight against cyber threats. Both departments are
employing every reasonable measure at their disposal to ensure
Servicemembers' and Veterans' patient records are secure.
VA will deploy security boundary protections including jointly
agreed upon DoD authorized security architecture. VA and DoD require
and employ data encryption both in transit and at rest using Federal
Information Processing Standards-certified cryptographic modules. VA
will use two factor authentication for access to the system as well as
audit access to ensure users have correct access to the data their
profile allows. Both VA and DoD use National Institute of Standards and
Technology requirements and guidance to design, employ, and test
security controls throughout the lifecycle of a system and the joint
electronic health record initiative is no exception.
Furthermore, VA will embed personnel within the DoD's Cyber
Security Service Provider forming a joint Network Security Operations
Center (NSOC) specifically focused on the joint EHR initiative. Forming
a joint NSOC will allow the agencies to integrate their respective
protect, detect, respond, and sustain services allowing for more
efficient, effective, and integrated vulnerability monitoring and
management, network security (and performance) monitoring, intrusion
detection, attack sensing and warning, vulnerability analysis,
vulnerability assessment, and threat intelligence sharing.
Questions Submitted by Senator Brian Schatz
Question.I have concerns about the role that private individuals
have played in VA procurement decisions. There are a lot of good men
and women at the VA working in earnest to make decisions in the best
interest of veterans and American taxpayers. I have no reason to
suspect that any of you have acted otherwise. However, when it comes to
the largest transformation in the history of the department, people
need to be confident in how decisions are made.
Besides workshops, council meetings, site visits, and other routine
and related community events, have you formally or informally
corresponded with any private individual not officially involved with
the EHR modernization through a contract for services or provider
agreement?
Answer. No.
Answer. I have not formally or informally corresponded with any
private individuals not officially involved with Electronic Health
Record Modernization (EHRM) through a contract for services or provider
agreement.
Answer.No, I have not formally or informally corresponded with any
private individuals not officially involved with the EHRM effort
through a contract for services or provider agreement.
Question.If so, what was the nature of that correspondence and did
it directly affect, in any way, a procurement decision?
Answer. N/A
Question. Please provide the committee with any formal or informal
correspondence that relates to the above request.
Answer. N/A
SUBCOMMITTEE RECESS
Senator Boozman. And with that, we are adjourned. Again,
thank you very much.
[Whereupon, at 11:52 a.m., Tuesday, Feburary 5, the
subcommittee was recesssed, to reconvene subject to the call of
the chair.]