[Senate Hearing 116-]
[From the U.S. Government Publishing Office]



 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2020

                              ----------  
                              


                       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.]