[Senate Hearing 117-499]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-499

                     VA ELECTRONIC HEALTH RECORDS:
                    MODERNIZATION AND THE PATH AHEAD

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 14, 2021

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                     Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
                 Jon Towers, Republican Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              

                             JULY 14, 2021
                                
                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Murray, Hon. Patty, U.S. Senator from Washington.................     7
Boozman, Hon. John, U.S. Senator from Arkansas...................     9
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    10
Rounds, Hon. Mike, U.S. Senator from South Dakota................    12
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    14
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    15
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    17
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    18
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    30

                               WITNESSES
                                Panel I

The Honorable Denis McDonough, Secretary of Veterans Affairs.....     3

                                Panel II

David T. Case, JD, Deputy Inspector General, Office of Inspector 
  General, Department of Veterans Affairs........................    21
Marc Probst, MBA, Chief Innovation Officer, Ellkay; Founder, MF 
  Probst Strategic Advisory......................................    23

                                APPENDIX
                          Prepared Statements

The Honorable Denis McDonough, Secretary of Veterans Affairs.....    39
David T. Case, JD, Deputy Inspector General, Office of Inspector 
  General, Department of Veterans Affairs........................    44
Marc Probst, MBA, Chief Innovation Officer, Ellkay; Founder, MF 
  Probst Strategic Advisory......................................    67

                        Statement for the Record

Dr. Mark Braunstein, Professor of the Practice, Emeritus, Georgia 
  Institute of Technology........................................    75

                        Questions for the Record

VA response to questions submitted by:
  Hon. Jon Tester................................................    81
  Hon. Kyrsten Sinema............................................    99
  Hon. Patty Murray..............................................   101
  Hon. Jerry Moran...............................................   103
  Hon. Margaret Hassan...........................................   107
  Hon. Richard Blumenthal........................................   109
  Hon. Marsha Blackburn..........................................   111
VA attachments in response to questions from:

  Hon. Jon Tester

    Questions 1 and 12: EHRM Solution Crosswalk Placemat.........   113

    Question 15: EHRM Functional Key Performance Indicators (KPI)
      (For information, contact the Chief Clerk, U.S. Senate 
      Committee on Veterans' Affairs, 412 Russell Senate Office 
      Building, Washington, DC 20510-6050 / Phone (202) 224-9126)

    Question 15: EHRM Non-Functional Key Performance Indicators 
      (KPI)......................................................   115

  Hon. Margaret Hassan

    Question 1: Electronic Health Record: Comprehensive Lessons 
      Learned, July 2021; report.................................   117

 
                     VA ELECTRONIC HEALTH RECORDS:
                    MODERNIZATION AND THE PATH AHEAD

                              ----------                              


                        WEDNESDAY, JULY 14, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:33 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Tester, Murray, Brown, Manchin, Hassan, Moran, 
Boozman, Cassidy, Rounds, Tillis, Sullivan, Blackburn, and 
Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this VA hearing to order. Good 
afternoon. I want to thank you all for being here today. A 
special thank you to the Secretary of the VA. Thank you for 
being here, Secretary McDonough.
    Nearly nine months ago, the VA rolled out its new 
electronic health record at Mann-Grandstaff VA Medical Center. 
At the time, VA officials described the rollout as 
``flawless.'' The former Secretary said it was revolutionary, 
boasted that ``we just pulled off the most expensive IT program 
in government history.'' He said, we only heard crickets from 
the critics because it had gone so well.
    Well, guess what? Since a lot of those statements were made 
we are hearing from VA medical staff who are frustrated and 
demoralized by a new system that is making their jobs far more 
difficult. We are hearing from GAO that prior to the launch 
last October--which I might point out was right before the 
election--VA had not resolved all the critical and high-
severity test findings that could result in system failure.
    We are hearing that the VA Office of Inspector General and 
that the VA had not reported to Congress, as required by law, 
all of the projected costs associated with deploying the EHR 
nationwide. That includes an estimate $2.7 billion in projected 
physical infrastructure costs, an additional $2.5 billion in 
projected costs for IT infrastructure. Taken together, that 
means the program could potentially cost $21.3 billion over 10 
years, not the $16.1 billion as VA previously projected. That 
is a 32 percent increase, and by the way, that is $5.2 billion.
    In January, we heard from a group of senior VHA leaders who 
visited Spokane and said that they found a dedicated but highly 
demoralized workforce, communications breakdown in the absence 
of on-the-ground program and vendor management, and problems 
leading to patient safety, risks, and productivity loss.
    We are also hearing from the IG that the dedicated VA staff 
in Washington State were not given adequate training on the new 
EHR. These folks could not fully use the EHR months after the 
go-live date. They were taught to push buttons but not actually 
how to use the new system with patients.
    In a survey, only 5 percent of the staff reported being 
able to use all four core functions of the new EHR after 
training and two to three months of use.
    So while there are some who might describe this effort as a 
flawless rollout, I think most people would use the words 
``alarming'' or something far worse. And frankly, I, for one, 
am fed up with the amount of taxpayer dollars we are spending 
on this program without any demonstrated benefits to veterans 
or VA medical staff. This simply cannot continue. We have 
literally been working on this for almost my entire time in 
Congress and on this Committee, 15 years.
    Secretary McDonough, I want to commend you for hitting the 
Pause button in March and taking a look at this program, a 
fresh set of eyes, through your strategic review. Today, with 
at least the first phase of that review complete, we want to 
hear about what you have learned and the path forward. We want 
to know more about your plans to address all of the issues we 
have talked about, from management and program leadership to 
patient safety and technical issues. And I need a commitment 
the VA will better respect Congress' oversight role over this 
program than it has the last few years. Transparency and 
truthfulness, quite frankly, have been absent.
    There is simply too much at stake to get this wrong, but 
before I close I want to touch on one more final thing. In the 
current law, the VA Deputy Secretary has the lead oversight on 
EHR modernization, the VA Deputy Secretary. And despite 
advancing that nomination out of this Committee unanimously, 
six weeks ago, that position remains vacant as I speak today, 
because of what I view as political games. This is six weeks in 
which the VA has not had a Deputy Secretary to manage this 
effort, to protect taxpayer dollars, and deliver for our 
veterans and the dedicated employees that serve them.
    So I would remind those that want to be critical of 
Secretary McDonough, of this administration on EHR, to keep 
that reality in mind. But once we get Mr. Remy confirmed, then 
we will take the gloves off.
    With that I will turn it over to Ranking Member Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Chairman Tester, thank you. I share your 
exasperation on this topic. It has been around as long as I 
have been in the Congress. Your point about a Deputy Secretary, 
I understand will be resolved by tomorrow, and we will have 
someone specifically to deal with--responsible for--the 
implementation of electronic health records at the Department 
of Veterans Affairs.
    It is exasperating because the potential benefits that can 
accrue from this effort are tremendous, and it is potentially 
cost saving, I suppose, but more importantly, it is the ability 
for the Department of Veterans Affairs to care for veterans. It 
is the ability for our service men and women to more easily 
transition from active duty to becoming a veteran. And the 
longer we delay, the longer that we have challenges with this 
program, the less likely that the veterans who are living today 
are going to benefit from this dramatic opportunity.
    So while I have a prepared opening statement, Mr. Secretary 
and Mr. Chairman, I just would again offer my assistance, the 
assistance of this Committee, to see that we get this right. I 
am critical of the Department of Veterans Affairs. I thought 
the inspector general's report was very damaging, very damning, 
and I hope that--actually, I have the expectation; I do not 
need to hope--I have the expectation that Secretary McDonough 
will respond appropriately to correct the problems outlined in 
that inspector general's report.
    I am anxious to hear our other witnesses as well. I know 
that Mr. Probst and his organization has been through this 
himself and has expertise. I just would think that the 
challenges that we have often with the Department of Veterans 
Affairs involves its bureaucracy, and I think we have 
conflicting aspects of the Department of Veterans Affairs that 
either are assuming responsibility or refusing to assume 
responsibility when all need to be working together.
    For this to be judged a success, I think the pause was 
important. A strategic review that produces quality standards 
for electronic health records gets our VA employees and the 
practicing medical community trained. All this is important. I 
just need to see and be convinced that we have a roadmap to get 
us where we need to be and gain the benefits that our veterans 
will achieve, will be able to attain as a result of electronic 
health records. So I look forward to hearing the path forward 
from you, Mr. Secretary.
    [Pause.]
    Senator Moran. [Presiding.] And in the absence of the 
Chairman I would say that today's hearing will consist of two 
panels. In the first panel we will hear from Secretary Denis 
McDonough on the VA's progress at the EHRM rollout and the 
findings of the strategic review and the Department's proposed 
path forward. On the second panel we will hear from external 
experts on VA's EHR transformation efforts, challenges faced, 
and lessons learned from the private sector.
    And, Secretary McDonough, the floor is yours.

                            PANEL I

                              ----------                              


           STATEMENT OF THE HONORABLE DENIS MCDONOUGH

    Secretary McDonough. Thank you, Senator Moran, Senator 
Murray, and Senator Hassan. Thank you very much for the 
opportunity to be here and for your steadfast support for our 
veterans.
    Before I get into today's important topic, I want to 
highlight a simmering crisis we are dealing with. Over the last 
month, we at VA have lost four of our dear colleagues to COVID 
infection, spurred by the highly transmissible Delta variant. 
We are seeing a surge of infections that has necessitated the 
deployment of dozens of VA disaster emergency medical personnel 
to supplement our workforce, a level of deployment that mirrors 
prior surges and warns of what is to come. This underscores the 
critical need for everyone to be vaccinated, especially our VA 
personnel, to keep our veterans safe.
    Now back to today's focus. I appreciate the opportunity to 
update you on VA's initiative to modernize its electronic 
health records. The mission of EHRM has always been to create a 
platform that seamlessly delivers the best access and outcomes 
for our vets and the best experience for our providers.
    But as you, VSOs, members of the press, OIG, GAO, and 
others have now rightly noted, VA's first implementation of the 
Cerner Millennium, which occurred in October 2020 at Mann-
Grandstaff VA Medical Center in Spokane, Washington, did not 
live up to that promise, either for our veterans or for our 
providers.
    This has been exemplified for me by a story I heard from 
one of our great pharmacy staff in Spokane. A few months into 
implementation, he began hearing disquieting reports from the 
mail-in pharmacy team that they were receiving duplicate 
prescriptions at Mann-Grandstaff. The issue, it turned out, was 
that the veterans' old prescriptions were not automatically 
being canceled when new ones came in. Recognizing the threat to 
patient safety, the Mann-Grandstaff team immediately jumped 
into action, collaborating across VA to create a workaround 
that eliminated these duplications, and made sure that our 
veterans did not receive more medication than was necessary or 
safe. Those efforts were largely successful, but they also 
demonstrate the lengths to which our staff in Spokane had to go 
through to simply do their jobs and to care for our vets.
    On top of that, I heard from another clinician that helped 
with the new platform it was not always easy to find, even when 
you asked for it. When she called the Cerner help desk the 
person on the other end of the line told her he had just 
started a week prior. In other words, she had more experience 
using the platform than the person who was supposed to help her 
navigate it.
    Stories like that are what led me to launch the top-to-
bottom review of the EHRM program. Among other challenges, the 
project was being run in an organizational silo, meaning that 
some relevant stakeholders did not have a chance to shape its 
success. In fact, the IG report from Friday found no evidence 
that our health care experts at VHA had a defined role in 
decision-making or oversight of the health care record 
modernization project.
    There is also a distinct lack of testing and training for a 
real-life clinical environment. For some providers, the first 
time they used the final program was the day it went live. 
These findings are extremely disappointing, but the strategic 
review provides reasons for optimism as well, because it also 
found that we have what we need to succeed, starting with 
dedicated employees who will stop at nothing to get this right.
    Most challenges were not breakdowns of the technology nor 
of the great people at Mann-Grandstaff who did the best they 
could in the worst of circumstances, implemented this program 
in the heart of a pandemic, dutifully shared findings that 
improved the system, and ensured that our veterans were safe, 
despite the challenges they faced. Instead, the missteps were 
ours, at VA and Cerner.
    And now that we have identified those problems we can solve 
them. As a result of the strategic review, we are reimagining 
our approach to this system. First, we are establishing a 
unified enterprise-wide governance effort led by our Deputy 
Secretary, who we just discussed, and I am grateful for 
Chairman Tester and Ranking Member Moran's work to get him 
confirmed this week. This structure will incorporate the 
perspectives of key clinical, technical, acquisition, and 
finance leaders, thus guaranteeing that everyone who will build 
this platform, use it, or be affected by it will work in 
concert with one another from day one.
    Second, we will shift from site-by-site deployment of the 
EHRM to an enterprise-wide readiness and planning approach. 
This means that we will deploy the program based on evidence of 
readiness, evidence of which sites are most trained and 
technologically ready for it, therefore setting each new site 
up for success.
    Third, we will create a fully simulated testing and 
training environment so veterans and providers can properly 
evaluate and learn the system before it goes live, not during 
or after.
    By making these changes and the others that are outlined in 
my written testimony, we can and will get this effort back on 
track. That means building an EHR system where veterans are 
able to access their records in one place, from the first day 
they put on the uniforms until the last day of their lives; a 
system that empowers vets to receive care anywhere, whether it 
is from DoD, VA, or community providers, without worry about 
cumbersome paperwork or potentially harmful gaps in records; a 
system that helps providers understand injuries that veterans 
suffered 50 years ago so they can provide those vets with the 
best care possible today.
    That is the end goal, and I know that many folks out there 
are concerned that we cannot, as I have said, or will not get 
there. But we can, and we will. We are now in an excellent 
position to move ahead as one unified organization in 
partnership with Cerner and DoD, sensitive as Senator Moran 
suggested, to Congress' critical oversight role, to deliver an 
EHR system that improves the outcomes for our vets and 
experiences for our providers, and that is exactly what we are 
going to do.
    So, Senators, Senator Murray, Senator Moran, colleagues, 
thank you for the opportunity to appear here today. I look very 
much forward to your questions.

    [The prepared statement of Secretary McDonough appears on 
page 39 of the Appendix.]

    Senator Moran. Secretary McDonough, thank you very much for 
your testimony.
    According to the inspector general, the VA failed to report 
the program's true cost to Congress as required by the Veterans 
Benefit and Transition Act of 2018. What actions have been 
taken to correct this accounting, and what steps has the VA 
taken to hold those personnel who were responsible accountable?
    Secretary McDonough. So we have taken the beginning steps 
to ensure that we, as the IG recommended, are in a position to 
provide a full lifecycle estimate of the cost of this program. 
The way we are going about it, including by taking a readiness 
deployment method rather than a geographically based or time-
based deployment effort, will allow us to do a better job of 
that. So we are getting to the bottom of the facts. We are 
going to deploy based on the facts. I will continue to report 
regularly to you on those facts.
    And as to the question of accountability, there is that and 
then another finding that I mentioned to you recently, that was 
in Friday's inspector general report, which suggests an 
unwillingness to provide potentially information to the IG. I 
will not run an organization that withholds information from 
Congress or the IG, so if I find that to be true there will 
obviously be consequences.
    Senator Moran. Mr. Secretary, the Electronic Health Records 
Modernization Program's organizational structure seems to me to 
be dysfunctional, and I think that was indicated by the OIG in 
each of their reports. The GAO has also reported on this as 
well. I think this is the basic premise of the findings you 
speak to in your written testimony regarding the governance and 
management.
    Will we see a comprehensive reorganization of the program, 
and when will it happen? I ask this because based on your 
written testimony it does not appear anything is changing other 
than the title of the groups.
    Secretary McDonough. Yes, thank you. So you will see it. We 
do have it. It is not quite done. In all cases, I want to talk 
to our Deputy Secretary, when confirmed, because, statutorily, 
he is in charge of this and will manage this as a management 
question and as a budget question, as statute envisions. I 
would just ask forbearance to spend a couple of days talking 
with him about it, and then by next week we will be happy to 
come up and show that to you.
    I think you will see significant change, including 
reduction of what I consider to be redundant positions, and 
more importantly, clear accountability among each of us to one 
another and to you, to ensure that decisions taken are 
decisions implemented.
    Senator Moran. I can see why you are anxious to have the 
Deputy position filled.
    It is concerning--I do not know that I understand exactly 
what these words mean, but what you said was, the result of a 
strategic review, you found persistent issues with the 
definition of what constitutes a patient safety issue. When can 
we expect to see VHA's definition of ``patient safety issue,'' 
and when will it be put into practice?
    Secretary McDonough. So there is a big question now about 
how quickly we go live at the next sites. The next sites, as 
envisioned in the program of record, are in what we call VISN 
20 and VISN 10, so basically in the Upper Midwest and in the 
Pacific Northwest. I hope to make a decision on that by the end 
of this calendar year.
    The question you raise about patient safety, both defining 
it and identifying where concrete issues exist, and 
importantly, where mitigations are necessary, will be the 
principal basis on which I make that decision. The other two 
things I will consider in that decision are access--we are 
seeing, as I am sure Senator Murray can report, access 
questions as a result of the EHR in Mann-Grandstaff--and then 
questions around billing, or the revenue cycle.
    I think we can get our hands around those this fall, but I 
will not go live at those next two sites fully until I have 
answered those questions, including this definition of patient 
safety that you are asking for.
    Senator Moran. Mr. Secretary, I had another question but in 
the 39 seconds I have left I would highlight what you indicated 
in your opening comments, my conversations with a VA official 
earlier this week in regard to COVID-19 and the Department of 
Veterans Affairs, and particularly in Kansas, the numbers are 
increasing, increasing in ways that are alarming. And I would 
again use this opportunity to encourage Kansas veterans, 
American veterans, and Americans generally to utilize safety 
that comes by being vaccinated. And every day that goes by, I 
think increases the chances that there is more risk for more 
people, including those who we serve, who served our country 
and now who we care for in our VA facilities.
    Secretary McDonough. Thank you.
    Chairman Tester. [Presiding.] I appreciate those comments, 
Senator Moran. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you, Mr. Chairman. Mr. Secretary, 
thank you for being here, and thank you for visiting Mann-
Grandstaff VAMC in Spokane earlier this year. I appreciate your 
commitment to stay involved in these issues.
    But let me just say, back in 2019, I heard about 
outstanding infrastructure issues and the ongoing staffing 
challenges that could make implementation of this new EHR 
system at Mann-Grandstaff more difficult and ultimately 
threaten patient care. And because of those reports, I 
cautioned the VA back in January 2020, in a letter, to make 
sure that they prioritized veterans' access to care and support 
for the staff.
    That was over a year and a half ago, and these issues 
should have been addressed, as you know. Since the 
implementation of the Cerner program last October, I have 
heard, like you just talked about, a number of serious patient 
safety issues that could put our veterans at risk. And I am 
also very troubled by reports of exhausted staff who are 
struggling to use the system because of the workflow design 
issues, lack of adequate training, and I expect those issues to 
be resolved. I know you know that as well.
    But I would like to ask when the strategic review is 
completed I would like your team to give us a detailed briefing 
on how that is going to help folks in Washington State. I know 
you inherited this multi-year, multi-billion-dollar Electronic 
Health Record Modernization Program and all the challenges that 
come with it, but I know we confirmed you for this position 
because of your management skills and the ability to tackle 
hard problems. And I know you know, we need leadership to get 
this back on track.
    On the topic of patient safety, I just want to share a few 
examples for the Committee that I have heard from clinicians 
and constituents. The Mann-Grandstaff medical director 
reported, in an April 2021 hearing, that 247 patient safety 
reports had been documented since go-live, which is a troubling 
number, to say the least. I have heard cases of veterans not 
receiving the correct medications, and in other cases, 
medications that have been sent to incorrect addresses.
    I raised that concern about prescriptions during DoD's 
botched rollout, and I cautioned the VA about it. This could 
have been foreseen. And whether those problems are because of 
poor data migration or flaws in the system, this has to be 
fixed. It is serious, and these problems need to be resolved.
    Mr. Secretary, I would like to ask you, who is responsible 
for reviewing the EHR workflow design, specifically for patient 
safety?
    Secretary McDonough. Well, right now we have a patient 
safety team on the ground, and so one of the things that came 
out of my visit is we sent a team, a patient safety team, to 
Spokane. We now have a patient safety team resident on the 
ground. But at the end of the day, I guess my presence here 
today, I am telling you that I am taking responsibility for 
these decisions.
    Senator Murray. Okay. Can you commit to reviewing the 
system and giving this Committee the results of that?
    Secretary McDonough. Yes.
    Senator Murray. Okay. And I am also really troubled by 
staff burnout and attrition. I know you know this. And when it 
comes to training staff or not being adequately prepared to 
navigate a system that makes what used to take just a few 
clicks now is a lot more complicated. Providers are burning out 
as they try to balance caring for the veterans, which is their 
charge, and navigating this new EHR system.
    How is the VA support staff, through this transition, 
working to keep morale up and avoid burnout?
    Secretary McDonough. Well, it is a perfect question. I 
mean, we do have, consistent with the pandemic, as well as with 
the added requirements of DHR, some management incentives 
available to our team there, so we are making sure that we are 
using those. We are trying to be sensitive to the many demands 
on the team on the ground, so we are trying to manage the 
obvious intense interest across the enterprise and what is 
happening there. But we are trying to make sure that people 
have distance to do their work.
    And then I also am trying to communicate directly, as I did 
earlier today, with the med center director, Dr. Fischer, that 
they are not in this on their own, that we are in this 
together.
    Senator Murray. Okay. I had extensive discussions with the 
VA before the rollout in Spokane, and I insisted that the VA 
have plans for mitigating the loss of productivity, so veterans 
did not lose their access to care, increasing staffing in 
clinical space to compensate, making sure that the physical and 
IT infrastructure was ready. And I was told repeatedly that 
everything was under control, yet the VA could not get 
additional clinical space, there was not enough staff or 
providers, even before COVID hit, and that is just one example. 
The facility actually had to put a tarp over one of the new 
servers to keep water from leaking on it and destroying it.
    So as we transition to other facilities, we have got to 
make sure that they have space and staffing and infrastructure 
and anything else they need before they go live.
    And my time is out, but I just want to say one thing really 
quickly. I was very disturbed, that the leaders from the VA 
EHRM change management withheld some training evaluation data 
that was requested by the OIG, and altered other data prior to 
sending it to the OIG. The integrity and thoroughness of 
information provided by VA is required by law, and it is 
critical to the OIG's mission. So lying to, withholding 
information from the IG, or from Congress for that matter, is 
really outrageous and unacceptable. I know you agree with me on 
that. But I just want to say, very clearly, that I expect 
anyone found doing that to be held accountable immediately.
    Secretary McDonough. Yes. I absolutely commit to that. I 
was as struck by the finding as you are, and I know you will 
hear from the Deputy IG in the second panel. But I also know 
that the IG is looking at that specifically. I will look into 
it myself, and if it is confirmed, obviously there will be 
ramifications for that.
    Senator Murray. Okay. Thank you so much for your attention 
to all of this.
    Secretary McDonough. Thank you.
    Chairman Tester. Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman, and thanks to 
Senator Moran for having the hearing, and the focus on this so, 
so very important subject. It is not a very glamorous one, but 
I think it is the key to getting the VA into this century. So 
it is going to take a lot of work.
    I also appreciate the emphasis on the training aspect of 
things, and then too, as Ranking Member of the VA 
Appropriations Subcommittee, I remain committed to providing 
the VA with the resources that you need to take care of our 
veterans. However, in order to be helpful, we have got to have 
accurate costs and execution estimates from the Department.
    Last year, the electronic health modernization in the VA 
system was allocated roughly $2.6 billion. This year the 
request is for $2.7 billion. Mr. Secretary, was the VA able to 
execute last year's allocation, despite pauses in the program, 
and do you believe that the funding request for fiscal year 
2022 is executable and appropriately programmed, given what you 
learned during the review?
    Secretary McDonough. Yes. We were able to execute the 
appropriation from last year, so thank you for that. The 
request, we are not asking to alter or to change the request 
for next fiscal year, based on the review. But in all cases--
and as I have said to many of you, I recognize the importance 
of staying within the budget envelope that we have. I have said 
to many of you, and I reiterate again today in public, that if 
there are changes to that we will be early and transparently 
before you.
    Senator Boozman. No, we appreciate that very much.
    You mentioned that following the 12-week review of the 
program, it is clear that training and technology will be a 
focus of the VA moving forward. Without providers receiving 
proper training, the program will fail to meet the goals of 
this modernization, certainly. I appreciate the example, you 
know, of the person calling and they knew more about the 
system, regarding, you know, when they were trying to receive 
help. The other thing I was impressed with is the fact that you 
knew about that. You know, you're the top guy at the rung, and 
again, that information getting up as high as you, and you 
taking that interest, because that is how we are going to get 
this solved at your level, and then again, at the committee 
level, that is doing the same thing.
    Secretary McDonough. I agree.
    Senator Boozman. It is so, so very important.
    After evaluating the resources allocated to the first test 
site in Washington, were funding levels and time dedicated to 
training adequate, and did they contribute to any issues seen 
with the training of providers?
    Secretary McDonough. So I think a principal finding--I 
spent a lot of time with the IG report on training, and we have 
had a lot of feedback on training, including direct feedback 
that I got. I think there is just no doubt that the training 
was wanting. I do not believe, however, that was a function of 
funding. I think that was a function of probably a range of 
things. I think it is very obvious that the pandemic played 
into that. And basically you have a system that, in best of 
examples you have basically an elbow-to-elbow deployment of 
clinician with trainer. And when you are socially distancing, 
that is not possible, so that is a big challenge.
    I think it is really important, though, going forward, for 
us to learn the lesson that some more clinically relevant 
training is necessary in the lead-up to go-live, not just 
starting at go-live. So one of the things that you have seen in 
my prepared testimony is a focus from us on a more clinically 
relevant training module that will allow us to get more people 
through that, in a more timely way, so that when we do flip the 
switch to go live, for example, in these next two sites, more 
broadly in the Upper Midwest, in Senator Brown's state, and 
back in the Pacific Northwest, more people have had more time 
on the target in a clinically relevant way, so that they can 
then intensify that training on the job.
    Senator Boozman. Okay. Well, Thank you, Mr. Chairman.
    Chairman Tester. Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Thank you, Mr. Chairman, and thanks to you 
and the Ranking Member for this hearing, and thank you, 
Secretary McDonough, for being here today.
    I have three questions for you. The first one has to deal 
with veterans' feedback. It is really important, obviously, 
that the VA hear about how the new electronic health record 
system actually impacts the veterans' health care experience. 
And to build on the comments we heard from Senator Murray, and 
just now Senator Boozman, a July 2021 VA Office of the 
Inspector General report found that VA facility patient 
advocates did not receive direction or training to consistently 
track and report patient complaints about the new electronic 
health records system.
    So how will the VA go about establishing guidelines, 
training, and a method to capture patient complaints about the 
new electronic records, and ensure that it implements 
improvements to address patient concerns?
    Secretary McDonough. Thank you very much. Just working 
backward, I think the OIG focus on the patient advocates is 
really smart. As a general matter, I think an underutilized 
tool for us. And so they have made some recommendations to us. 
We have indicated to them that we will take those and implement 
those, directly relevant to your question.
    On the question of vet feedback, more generally, this, I 
think, is an obvious point, but one of the things we have to 
make a decision about is the portal into the electronic record. 
And I remember being confronted relatively early--well, very 
early in my tenure--where somebody said, ``Well, you are going 
to have to make a decision on the patient portal.'' And I said, 
``Well, why would I make a decision on the patient portal? I am 
neither a patient there nor am I going to be using the 
portal.'' So what we did is we pushed that into our Veteran 
Experience Office. They have just now completed a months-long 
review, engaged with veteran patients, on what they want to see 
in the various options of a portal.
    We look to, as a general matter at VA, and this will be a 
particular concern of mine, ensuring that questions around 
usability are decided not by Cerner and not by us, but informed 
by the user.
    Senator Hassan. Okay. Good. Thank you. I want to go to a 
New Hampshire-specific concern now. New Hampshire is going to 
be one of the last states where implementation occurs. It is 
currently scheduled for 2026, and that seems pretty optimistic, 
under the circumstances. That is going to potentially create 
problems for veterans who move from a state like New Hampshire 
that has not yet implemented the new system to a state that 
has. So what is your plan for ensuring that VA health care 
professionals have consistent access to both old and new 
electronic health care records so that there will not be gaps 
in care or medical errors from incomplete medical records?
    Secretary McDonough. Yes, that is a very fair question. I 
guess what I would say is, as I indicated earlier, this 
question about the next two go-live sites, VISNs 20 and 10, 
after we get past those we will be going to a system readiness 
decision-making matrix, whereby we will make a decision as to 
where to go next, in which case maybe it is New Hampshire, 
based on infrastructure readiness. This is also a finding from 
the IG. Training readiness, we are building this more 
clinically relevant training facility, and then change 
management or leadership readiness. So it could be that--this 
is a long way of saying the deployment schedule itself will 
change.
    Second, as it relates to ongoing training, we recognize 
that we are going to have to continue to have an ability to 
walk back and forth between the two. In an ideal world, that 
does not drag on for more than a decade, after all we have 
invested in this.
    Senator Hassan. And I appreciate that. I think just 
focusing on future outreach needs, so that the system is not 
caught short as veterans begin--you know, veterans move around. 
We all do. So I appreciate that.
    Last issue is cybersecurity. It is a focus of mine on the 
Homeland Security and Emerging Threats work I do. Hospitals are 
obviously a big cyber target. So how is the VA prioritizing 
cybersecurity as it implements the Electronic Health Records 
Modernization Program and in its continued use of legacy 
systems?
    Secretary McDonough. So we are continuing to make cyber a 
fundamental priority. It is a personal priority of mine, and I 
have had basically regular interactions with our CISO. I have 
also recently asked the director of the National Security 
Agency and the commander of Cyber Command to come take a look 
at our systems to make sure that we are in a position to be 
confident that our highest priority assets are well protected. 
And I would be more than happy to make sure that given your 
personal interest in this that we have a regular back-and-forth 
with you to assure you that we are asking the right questions 
and making the right decisions.
    Senator Hassan. That would be great. Thanks so much.
    Thanks, Mr. Chairman.
    Chairman Tester. Senator Rounds.

                      SENATOR MIKE ROUNDS

    Senator Rounds. Thank you, Mr. Chairman. Mr. Secretary, 
first of all, thanks for your service. I recognize that in the 
middle of a rollout of a major system you find yourself coming 
in and defending and trying to explain major problems with it. 
I would like to just have a conversation with you about it.
    Secretary McDonough. Sure.
    Senator Rounds. Let me lay out the concern and the reason 
for pushing in this particular direction. The VA OIG has 
released a report regarding the training deficiencies with the 
new electronic health record system. Employees who went through 
the training at the first hospital to use the system were given 
a test afterward to see whether they had learned to use it 
proficiently. The data provided to the VA OIG showed that 89 
percent of the proficiency checks were passed with a score of 
80 percent or higher, in three attempts or less. Now that was 
in the report.
    However, it was later discovered that the employees within 
the Office of Electronic Health Record Modernization had 
altered this data. In fact, only 44 percent of proficiency 
checks were passed with a score of 80 percent or higher in 
three attempts or less.
    Have you been able to determine yet what was the reasoning 
by the folks within the Office of Electronic Health Record 
Modernization for altering the data?
    Secretary McDonough. I have not. It is obviously a 
particular interest of mine, as I have indicated a couple of 
times, and I know the IG has gone back at it too. So it is a 
particularly pertinent set of facts I want to get to the bottom 
of.
    Senator Rounds. Yes. I think it points out--I recognize 
that any time you move to a new system you have a learning 
curve, but part of the learning curve requires integrity in the 
data results, and I think you agree with that as well. 
Individuals that mess with that, and intentionally dishonor 
that responsibility, they make the lives of veterans at risk. 
And I would hope that you would deal very sternly with that 
type of activity. And I do not even think I have to ask for 
your commitment. I am just assuming that would be the case.
    Secretary McDonough. Correct.
    Senator Rounds. Thank you. Correspondence in the OIG's 
reports notes an exchange between the OEHRM staff regarding the 
altered data prior to its submission to the OIG. In the 
correspondence, a VA change management leader asked the VA 
Director of Change Management, and this is in quotes, ``Do we 
need to add a bullet discussing the outliers, or let it ride 
and defend it if they ask?'' In response, the VA Director of 
Change, the OEHRM Director of Change Management, replied, ``I'm 
good with--,'' he basically said, ``the changes. Thanks.''
    I am concerned that these employees once again willfully 
chose to literally not tell the whole thing and to hide the 
information. I presume you are aware of it----
    Secretary McDonough. I am.
    Senator Rounds [continuing]. And I presume that that will 
be part of the review that you are doing----
    Secretary McDonough. Yes.
    Senator Rounds [continuing]. And that will be dealt with.
    Secretary McDonough. Correct.
    Senator Rounds. Thank you. And then finally, this system, 
the Cerner system, this was chosen in part because DoD is also 
going to use it. And so the idea is the transition should be 
simpler to move from DoD back into VA's, we are hoping 
seamlessly. Have you found that it is a near-seamless 
transition for information, or is it substantially a start-
over-again process?
    Secretary McDonough. At the moment, I am told by the 
clinicians that all the data is available to an individual 
clinician, data from the DoD data pool, data from the VA data 
pool, and then data from care in the community. Unfortunately, 
I am also told that it does not all populate the same screen at 
the moment, so that the place where--and it is not all apples 
to apples across those three data pools, which is kind of the 
point.
    One doc told me today, reminded me today, that the place 
where it is all aggregated is in the clinician's head. We 
obviously have got to get to a place where that is not the 
case.
    Senator Rounds. Absolutely. Look, this is not something 
that we should be reinventing the wheel on, and I know that 
when it was first put in the intent was, it was a commercially 
available product and that it would work, and that other 
systems were using it as well. If that is found not to be the 
case, and if this really is to the point where it is not doing 
what was expected, I presume we will hold them accountable and 
that we will find either a fix for it or we will count our 
losses and actually get a system that works.
    Secretary McDonough. Yes. So what I would say, Senator 
Rounds, is, through this review, I have satisfied myself to the 
answer of that question, which is I think that the technology 
is basically sound. And I think, as I have talked with a number 
of you in different settings, so much of these technology 
questions, in terms of execution, really end up being 
governance and management challenges, which is why it is, I 
think, on me. So I do not think we are going to find an answer 
that says--I have not yet found and I do not believe I will 
find an answer that says the technology is wanting.
    On this question of the three data pools, we have the best 
data scientists in the government at VA, and we are going to 
fix that. And we are a learning organization. The part that is 
so troubling about the anecdotes that you and I are both 
focused on, and the IG is focused on, is that VA is, I think, 
uniquely a learning organization that holds itself to a very 
high standard on performance, and when there are outliers like 
that it is particularly noteworthy.
    So I guess what I am trying to say is I don't anticipate 
changing this. I have said that publicly. I say it publicly 
again now. It is now a question of management and execution, 
and that is on us.
    Senator Rounds. Thank you. Thank you for your answers, sir, 
and, Mr. Chairman, thank you for the time.
    Chairman Tester. Thanks for your questions, and I would 
just say I agree wholeheartedly. If there are people out there 
that are intentionally changing metrics within the VA, not only 
will they be held accountable but the people who oversee their 
physicians need to be held accountable.
    Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman, and Mr. Secretary, 
thank you. I have been on this Committee, beginning my 14th 
year, I think, 15th year, and I have never seen a VA Secretary 
as responsive as you. Thank you. Your call last night, and just 
many things you have done. I know Chairman Tester, who came on 
the Committee the same day I did, shares those sentiments.
    You said that the VA has the best data scientists. I hope 
that the tax commissioner has equally good data scientists to 
get the child tax credit checks out today, tomorrow, and 
monthly.
    Secretary McDonough. I get the impression that there is a 
lot of attention on that.
    Senator Brown. I think there is, yes. A little less on you, 
but your day will come, if it has not already, so thank you.
    Secretary McDonough. I am reminded of that.
    Senator Brown. I know we have seen, since 2007, we have 
seen VA has had several EHR update iterations before deciding 
to go to Cerner four years ago. We know these projects are 
challenging. I hear from VA employees in Spokane, your first 
stop, if you will, and Columbus now, about these challenges.
    There are concerns in Columbus that VA facilities lack the 
proper physical infrastructure, server rooms, cable, HVAC to 
accommodate the new system. Any thoughts on that?
    Secretary McDonough. Yes. I am worried about that too. The 
IG laid that out quite clearly for us. I will say that the IG, 
GAO, your letters, your interactions with us helped undergird 
the strategic review. I think our review confirms much of that. 
This is why I think it is really important to go to this 
readiness deployment posture rather than as against a 
deployment schedule that is tied geographically to DoD.
    That was a mistake, I think, for two reasons. One, we are 
off-kilter with DoD now anyway, geographically. Two, we are not 
in a position to kind of adequately prepare for the structural 
and maintenance requirement, and as a result ended up not being 
as transparent with you all as we should have been in that 
process.
    So, yes, I am worried about it. Yes, this period between 
now and when we make a decision about go-live in Columbus will 
allow us to get to the bottom of those concerns. But we are 
also going to be doing that across the enterprise, to make some 
determinations on who is ready, when, based on infrastructure, 
leadership, and training.
    Senator Brown. Okay. Let me drill a little deeper on 
Columbus. It is the largest city in my state. It is the home of 
the Chalmers Wylie facility. It is an ambulatory care facility. 
You know all this.
    Secretary McDonough. Yes.
    Senator Brown. It is not an inpatient hospital, which means 
veterans have to rely on local hospitals for inpatient care. 
Maybe that is one of the reasons Columbus was selected. I am 
not sure on that.
    Walk me through the steps you take to ensure 
interoperability between Cerner and other hospital EHRs, and 
based on that review, when do you think that these issues will 
be resolved and go online?
    Secretary McDonough. So we are in the midst of an 
aggressive process to get Columbus prepared for deployment, and 
that has been going on, as you have indicated, now for more 
than a year. That will continue. We are taking, because of the 
IG investigation, a particular look at infrastructure and make 
some determinations about readiness. I also indicated earlier 
that there are three big questions remaining about the 
experience in Spokane that I need further clarification on 
before I agree to go live in Columbus.
    Lastly, the interface between any other hospital or private 
care setting and Cerner is a relatively straightforward 
process, but we will test all of that before we press go-live 
in Columbus.
    Senator Brown. Thank you. Mr. Chairman, thank you.
    Chairman Tester. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman. Secretary 
McDonough, thank you for being here, and thank you for reaching 
out to me and meeting with me a week ago Friday. It was good 
information, a good preview to this meeting. You know, when you 
and I talked it sounded like the kind of problems that large 
enterprise systems encounter, and so I would expect the next 
iteration, your readiness assessment.
    And I wanted to just ask a question about that. Are you 
going to be in a position where you have got one or more 
facilities that you could implement in, so that if Columbus is 
not ready you could move to one, if it meets the criteria for 
your readiness assessment, or does it slip to the right?
    Secretary McDonough. No, I think notionally the answer to 
that is yes, and one of the things that really appeals to me 
about this readiness assessment, deployment posture, is it 
draws on something that I have now witnessed in our Health 
Operations Center, out of how individual facilities are 
handling the pandemic.
    What is really interesting is there is a daily call at 10 
o'clock--medical center directors, VISN directors from all 
around the country sitting there, comparing performance with 
one another, which is really good information exchange, but as 
interestingly, it is a pretty competitive group. And if we have 
a scenario where inside this now increasingly integrated system 
there is competition for readiness, because our clinicians do, 
as Senator Boozman suggested, see great promise in the 
technology. If they are competing on that basis, I think that 
is a good thing for the vet, at the end of the day.
    Senator Tillis. And so part of the readiness assessment is 
also the use and proficiency with the same boxes you are 
creating?
    Secretary McDonough. Correct. Correct.
    Senator Tillis. Good. I wanted to go back to the inspector 
general's report, particularly with respect to questions that 
Senator Murray and Senator Rounds asked. You know, a cynical 
view could be that you had people in the process that were 
doctoring the records and inflating the preparation, the 
readiness for implementation up in the Northwest VISN. But to 
what extent could some of these failures have just been 
systematic? I mean, to what extent are we talking about 
somebody who did not do their job, knew what it was, and to 
what extent could there have been process errors that led to 
some of the misreporting of information?
    Secretary McDonough. As a general matter, I think that the 
people who have been carrying out this effort are unbelievably 
earnest, doing it in a very difficult scenario, and with a very 
vet-first focus. So I start from the proposition that I think 
that, whether it is a systemic or a process reason for this, 
that is where I start. But the enormity of that concept is 
such, as now several of you have suggested, that I want to get 
to the bottom of it and answer that question.
    Senator Tillis. Yes, that is why I wanted to ask it. I 
mean, you may have somebody who acted irresponsibly, but in my 
experience with reviewing test problem reports and readiness 
assessments when I was doing things of the scale that you are 
talking about doing in the private sector, you can find a lot 
of that is a culmination of process faults, which is why I 
would not want the people who are out there working today, 
getting ready for the next deployment, to think that this is 
some sort of a witch hunt for bad actors. My guess is you are 
going to find maybe a modicum of bad actors, but probably some 
processes that need to be tightened up, and I look forward to 
seeing more reports on that.
    The implementation, the longer-term full implementation, 
how far is it shifting to the right from the last deployment to 
a VISN?
    Secretary McDonough. I do not have an answer to that 
question yet.
    Senator Tillis. Do you have to make up for lost time, or do 
you think there will be slippage?
    Secretary McDonough. You know, I want to be careful to not 
overpromise there. But, you know, there is a logic to it. But I 
guess before I am kind of getting over my ski tips here I want 
to make sure that we can dig into the readiness stuff, to make 
that determination.
    Senator Tillis. I know it is kind of hard when you are 
dealing with the first iteration and you have got a lot of 
other VISNs to implement, but one of the things when you all 
were going through the Cerner decision, Epic, I think there 
were a few other platforms that the Department was sorting 
through, we also recognized this is--I mean, this is Rev 1, and 
Rev 2, I think, gets into some of the more exciting things 
where you fill the white space and you have bolt-ons, you have 
other things that add value to the clinicians and to the 
veterans and to men and women transitioning from active status 
or reserve guard status into veteran status. Are you all 
already thinking about what Version 2 in the Northwest looks 
like, what the next gen?
    Secretary McDonough. I think most importantly the 
clinicians are thinking that through, to be honest with you. I 
can think of a lot of things, but I guarantee you that I would 
not be a great value-add in that exercise. But what I do know 
is, you know, I spent time this afternoon with the VISN 
directors on this. I see them thinking this through, and I see 
our clinicians thinking through the possibilities here, and I 
think that is the exciting part of this.
    Senator Tillis. I think, you know, if you are going to 
drive up adoption and have more people embrace it, if they see 
that vision for what you can build on with this platform you 
are probably going to find a success of VISNs' implementations 
easier to do.
    I have got other questions. I am not going to ask them 
except for one. How did you do on the opening pitch?
    Secretary McDonough. The announcer said it was a strike.
    Senator Tillis. Okay. He had an opening pitch that Friday 
afternoon at a ballpark in Charlotte. Thank you.
    Chairman Tester. I assume it was an off-speed pitch.
    [Laughter.]
    Chairman Tester. Senator Blackburn.
    Secretary McDonough. It was fast for me.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and Mr. 
Secretary, thank you for being here today. The OIG reports have 
pointed out the VA's continued misrepresentations to Congress, 
and you have got the cost estimates, the employee training, 
things that we have discussed here already in this hearing. 
And, of course, we all want to get us moving toward an 
electronic health record that would be seamless from the day 
someone enlists until the last day of their life, there at the 
VA.
    But let me ask you this. With the inadequacies that have 
been pointed out, has anybody been removed from their position 
because of the findings that we have?
    Secretary McDonough. No.
    Senator Blackburn. No one?
    Secretary McDonough. Not yet, no.
    Senator Blackburn. And why has that not happened, if you 
have trouble with the talent pool and the training to stand 
this up? Why are we not viewing that?
    Secretary McDonough. Well, look. I find, as I have said, 
that, you know, any suggestion of withholding information to an 
IG or not being fully candid with Congress, I consider to be 
uniquely important developments, so I am getting to the bottom 
of those, and I know the IG is also--you will hear from the IG 
yourselves, but I am told that they are following this up 
directly themselves. And if I have confirmation of that, yes, 
there would be consequences.
    Senator Blackburn. So we can expect accountability to be 
forthcoming.
    Secretary McDonough. Yes, and I am here because I expect 
you will hold me accountable.
    Senator Blackburn. All right. Let me ask you this. The 
overview, the report you have submitted to us is an overview 
but not a comprehensive strategic review. Correct?
    Secretary McDonough. Well, there are a lot of different 
parts of documents. There are a lot of different documents that 
we have generated here. But we have provided you with our 
lessons learned, and will obviously, as I have indicated 
earlier, be talked through some of our management changes in 
the coming weeks.
    Senator Blackburn. All right. So when should we expect that 
fuller review?
    Secretary McDonough. Well, the questions about how we are 
going to structure, govern, and manage the program will be 
coming as soon as Donald is confirmed and we have a chance to 
sit down with him to talk those through. I think I owe that to 
him, since he is statutorily, if confirmed by you all, in 
charge of this. And so I want to talk with him and then we will 
come talk to you guys.
    Senator Blackburn. And then talking to Senator Boozman you 
made a comment, ``if costs change,'' talking about the system, 
but the OIG had already tagged $5 billion in overruns. So you 
are anticipating additional cost? Is that what I am to infer 
from that?
    Secretary McDonough. No. You may have inferred something I 
did not imply. The IG cited a series of technology upgrades 
that are necessary at facilities and maintenance upgrades 
necessary at facilities. We, as part of our readiness 
deployment schedule, will be looking at that across the system. 
I think it is very fair point that the IG asked, have raised. 
And, in fact, it helped inform the decision we made to go with 
this readiness standard.
    So as it relates to the question that Senator Boozman 
asked, I think he was asking specifically about the EHR 
programmatic money, and our view is that that money--my view is 
that that money has been executed this year. We just got the 
last quarter from the Treasury, based on the Appropriations 
Committee reaction, and we are not changing next year's request 
either. We think that request is correct.
    Senator Blackburn. You think that is ample.
    Secretary McDonough. I do, yes.
    Senator Blackburn. Okay. All right. Now let me ask you, if 
Cerner is not able to meet your quality standards or metrics--
we have talked a couple of times in this hearing about metrics 
changing. So if they are not able to meet your quality 
standards then what is your Plan B?
    Secretary McDonough. Well, we took a real hard look at 
that, at the technology. I have no reason--I have, you know, 
publicly that we think that the technology is sound, that the 
remaining challenges, there are technological challenges for us 
to fix, including these data questions we have just discussed. 
But really what we face here are management and structural 
changes, governance changes, and those are on me.
    Senator Blackburn. Okay. Thank you, Mr. Chairman.
    Chairman Tester. Senator Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary, for being here today.
    Secretary McDonough. Hello, Coach.
    Senator Tuberville. Thank you for visiting Alabama. I hope 
your trip went well.
    Secretary McDonough. It was great.
    Senator Tuberville. Yes. And I will say this, after being 
here for five months I get more calls about VA, but I know it 
is not your fault, to this point--we are not going to blame you 
to this point. But your situation kind of reminds me of me 
taking over a football program when I did not have a 
quarterback and offensive line, and everybody wondered why, you 
know. It was not my fault but somebody else. But thank you for 
being here to answer these questions.
    I have just got one question here for you. You mentioned 
the governance and management changes to the EHRM program.
    Secretary McDonough. Yes.
    Senator Tuberville. I am concerned about, you know, who is 
leading the governance and the management of your digital 
modernization. You know, the medical logistics system, FMBT, 
the financial accounting systems, all these systems have to 
work together. You know, there are three legs. How are you 
going to ensure that, you know, we do not get set aside--these 
two do not get set aside from the EHRM?
    Secretary McDonough. Yes, so a very fair question. You 
know, we are undergoing really three fundamental technological 
upgrades in the building right now--the electronic health 
record, the business management system, as you suggested, and 
then our supply chain management. And so each of those is a big 
piece of action. Each of them touches the other, and so 
continue to be a major priority for the management team, led by 
me and the Deputy Secretary. And it will be a major question 
for the CIO, the chief information officer. That is a vacant 
position that we are in the process of filling. So that person 
will be before you hopefully in the coming months.
    Senator Tuberville. Thank you. Thank you, Mr. Chairman.
    Chairman Tester. That is it?
    Senator Tuberville. Thank you, Mr. Secretary. That is it.
    Chairman Tester. That is it? And we all know that you 
always had quarterbacks, running backs, whiteouts, a sublime 
offensive line. There is no reason you should not have won a 
national championship every year.
    Senator Tuberville. You go into a game, you better have--
you can miss everything else but you better have a defense.
    Chairman Tester. That is fact.
    Senator Tuberville. You better have a defense. Thank you.
    Chairman Tester. Spoken from a true pro.
    Okay, Mr. Secretary, once again thanks for being here.
    Secretary McDonough. Thank you.
    Chairman Tester. As I said in my opening statement, recent 
IG reports show that there are several categories of costs that 
the VA has not been reporting to Congress related to this EHRM 
program. And, by the way, those reports are required by law. I 
do not need to tell you this is not acceptable. From the IG's 
work, we know that the program is, or likely will be at least 
$5 billion over budget, as has already been pointed out, when 
the VA infrastructure and other IT costs are included. That 
will likely push this program to more than $21 billion.
    I know that you mentioned cost analysis in your testimony, 
but let me ask you directly. Can I get your commitment that the 
VA will provide this Committee all projected costs----
    Secretary McDonough. Yes.
    Chairman Tester [continuing]. For the remainder of the EHR 
project, as well as costs already incurred since the program 
started?
    Secretary McDonough. Yes.
    Chairman Tester. That is good. So going back to 2017, quite 
honestly, the VA has not been candid with Congress. I know you 
are committed to transparency, and I hope that you affirm that 
commitment, and you already have.
    Will you provide the Committee with the following 
documents, most of which we already have requested but we have 
yet to have provided to us. They include the complete Institute 
for Defense Analyses, the IDA, review of the EHR program?
    Secretary McDonough. Yes.
    Chairman Tester. Okay. The Deloitte review of the program?
    Secretary McDonough. Yes.
    Chairman Tester. Any additional reviews of the program done 
by third parties, including consultants?
    Secretary McDonough. Yes. I am not sure what those are, but 
yes.
    Chairman Tester. Okay. And VA's action plan in response to 
those reports.
    Secretary McDonough. Yes.
    Chairman Tester. So I said in my opening statement about 
how long we have been working on this, and to be honest with 
you, you are a guy from Minnesota, great dairy industry, and I 
have had the impression for some time that there are folks out 
there that are milking the cow. And every day they go out and 
they see this is a cash cow, and they are getting every dime 
they can get out of it, and there has been damn little 
accountability. And, quite frankly, these folks are in this 
business, okay. We all have our own areas of expertise.
    And I would just tell you--and I hope Cerner is watching 
this--if Cerner is not up to making a user-friendly electronic 
health medical record, and, in fact, what is transferred here 
is we are going in the opposite direction, then they ought to 
admit it and give us the money back so we can start over. And I 
would just say that this is really important.
    What was it, 2001, I think, we started working on 
electronic health records, 20 years ago, and we are still not 
where we need to be. This is not all your fault. I do not know 
if any of it is your fault, yet. But the truth of the matter is 
that we have not gotten to where we need to go. There have been 
many administrations between 2001 and today, and none of them 
have gotten the job done.
    And so I would appreciate it, number one, and you have 
already committed to it, that we get the reports that we are 
entitled to lawfully and that you are as transparent as 
possible, and that if this turns into be just another pile of 
you-know-what, that you let us know.
    Secretary McDonough. Yes. There is no sense managing the 
status quo on this. There is just zero sense of that.
    Chairman Tester. That is all I have got. Do you have any 
final statement you want to make before we bring up the second 
panel?
    Secretary McDonough. No. I just want to underscore the fact 
that all the questions you asked is a lot of money the 
taxpayers and you all have entrusted with us is why our 
partnership with you is so important, why our partnership with 
the IG, GAO, you as overseers is so important. And if there is 
any sense that we are not being transparent on that then I hope 
that you will let us know. And that is bug, that is not design. 
We will make sure that we are being--we need your help on this.
    Chairman Tester. We are here to help. We all want to see 
this be successful. We think this could improve the work that 
the VA does and the experience that the veteran has. We think 
it is really important. And, by the way, we have not even 
gotten into the point that if VA is able to do this right it is 
a game-changer for medicine.
    Secretary McDonough. Hear, hear.
    Chairman Tester. So thank you for being here today, and we 
will move on to the next panel. I appreciate it. Good luck.
    Secretary McDonough. Thank you, Mr. Chairman.
    Chairman Tester. You bet.
    Now as we have concluded our first panel--and thank you 
again, Secretary McDonough--I want to hear from two independent 
experts on electronic health records.
    First I want to introduce David Case, Deputy Inspector 
General for the VA's Office of Inspector General, who will 
discuss oversight efforts related to VA's EHRM. I would also 
like to commend the IG and the entire staff there for their 
tireless work examining these issues. They released two EHRM 
oversight reports just last week, which is very timely for this 
hearing.
    Next I would like to introduce Marc Probst, Chief 
Innovation Officer at Ellkay. He is an outside expert from 
health IT world who has actually been through an EHR 
deployment, so I am interested to hear his advice for the VA.
    Fellas, thanks for being here. We will start with you, Mr. 
Case. You have the floor. You each will have five minutes, and 
your entire written testimony will be a part of the record.
    Go ahead, David.

                            PANEL II

                              ----------                              


                   STATEMENT OF DAVID T. CASE

    Mr. Case. Thank you, Chairman Tester, Ranking Member Moran, 
and Committee members. Thank you for the opportunity to discuss 
the Office of Inspector General's oversight of VA's Electronic 
Health Record Modernization Program.
    First, we want to applaud the VA employees working hard at 
the Mann-Grandstaff VA Medical Center and across VA to ensure 
veterans receive timely, high-quality health care during the 
EHR transition, particularly during the pandemic.
    Since April 2020, we have issued five reports, primarily 
focused on planning, system training, and other deployment 
activities at Mann-Grandstaff. They are meant to help VA 
leaders improve future deployments. While VA has implemented 
some of our recommendations from 2020, there is much work 
remaining. We, like other stakeholders, look forward to the 
strategic review's results as VA seeks to improve the program.
    VA needs to spend billions of dollars on physical and IT-
related infrastructure upgrades. The OIG conducted two audits 
of cost estimates for the infrastructure upgrades. These audits 
followed our April 2020 report that found VA did not meet its 
own deadline for infrastructure upgrades at Mann-Grandstaff.
    We found the cost estimates were unreliable. They were not 
comprehensive, not well documented, inaccurate, and not 
credible. We also found that VA did not report accurate and 
complete information to Congress in nine congressional reports 
to date. OEHRM did not report the estimated $2.7 billion for 
physical infrastructure upgrades and the estimated $2.5 billion 
for IT infrastructure upgrades, because they believed the 
upgrades were outside their responsibility, despite VA and GAO 
guidance requiring lifecycle cost estimates to include all 
costs, regardless of funding source. That said, we did observe 
some improvements in IT infrastructure cost estimates.
    Last week, we published a health care inspection of the 
development and delivery of training content to users of the 
new EHR and the assessment of post-training staff proficiency. 
We found decision-making did not appropriately engage the VHA 
staff who will use the system. VA's training program was 
structured to benefit from the lessons learned after DoD 
encountered problems with staff training during its initial 
deployment of the Cerner system. Nevertheless, we found VA 
suffered many of the same problems.
    Training on these new workflows educates the staff on how 
they fit into the overall delivery of care, but we found that 
training content was inadequate. We also found the training 
delivery to be problematic, with issues concerning the time for 
training, the training domain, the assignment of user roles, 
and training support.
    Finally, VA failed to effectively evaluate its training. 
When we asked OEHRM to provide training evaluation data, VA 
initially told us, quote, ``Eighty-nine percent of proficiency 
checks were passed with a score of 80 percent or higher, in 
three attempts or less,'' end quote. However, we found an 
earlier version, drafted by OEHRM staff, showing only, quote, 
``Forty-four percent of proficiency checks were passed with a 
score of 80 percent or higher, in three attempts or less,'' end 
quote. The OIG concluded the data was removed and altered prior 
to submission. We are reviewing the issue more thoroughly after 
informing VA leaders.
    Two themes emerge from these reports. First, a need for a 
governance structure that meaningfully engages all components 
of VA in a modernization program on a sustained basis. Second, 
there is a need for better transparency, including between VA's 
components.
    The OIG will continue oversight and has several additional 
projects ongoing. We are working with the DOD OIG to review the 
extent to which the new system will achieve interoperability 
among departments and community health care providers. We have 
started a review of the national deployment schedule, and we 
are reviewing patient care issues and pharmacy operations at 
Mann-Grandstaff.
    Chairman Tester, this concludes my statement. I would be 
happy to answer any questions you or other Committee members 
may have.

    [The prepared statement of Mr. Case appears on page 44 of 
the Appendix.]

    Chairman Tester. I appreciate your testimony, Mr. Case. Mr. 
Probst, you have the floor.

                    STATEMENT OF MARC PROBST

    Mr. Probst. Thank you and good afternoon, Chairman Tester 
and members of the Committee. As stated, I am Marc Probst, and 
I am the Chief Innovation Officer of Ellkay, a health care 
technology services organization. But likely more relevant to 
this, I recently retired as the Chief Information Officer of 
Intermountain Healthcare in Salt Lake City, Utah, where I 
served for 17 years.
    For over 35 years, I have been involved with electronic 
health record systems. Never have I witnessed a simple 
implementation of an EHR. My goal today is to share some of the 
lessons I learned in my career with EHRs and health IT that may 
be of use to the Committee and to the VA.
    For decades, Intermountain Healthcare, where I spent a 
significant part of my career, relied on internally developed 
information systems. As these systems aged, we made several 
attempts to modernize and replace them. After several years, 
these efforts were stopped, and Intermountain began a process 
to select and implement a commercial, off-the-shelf EHR 
solution. Eventually, Intermountain selected the Cerner suite 
of applications.
    Initially, the Cerner project was heavily focused on 
enhancing and modifying the Cerner solutions to meet the unique 
needs of Intermountain. In 2018, Intermountain and Cerner 
executives refocused the EHR implementations projects toward 
better use of the proven and existing functionality in Cerner. 
The overall approach changed from, ``making the system do 
whatever the end users wanted,'' to ``how can we best meet the 
needs of end users with the least modification to the Cerner 
system.''
    With the new approach, and under the committed leadership 
of both organizations, the Cerner set of solutions were 
successfully implemented, but it was by no means easy. It took 
a lot of work and time.
    From my experience, I have observed several keys that 
increased the likelihood of success in a major initiative such 
as this. Number one, you need a strategy for the project. 
Stephen Covey's second Habit states, ``Begin With the End in 
Mind.'' The early EHR efforts at Intermountain began with the 
goal of building the EHR of the future, which is an aspiration, 
not a strategy. However, we achieved success when we defined a 
strategy based on actual operational needs, with technology 
supporting those operational needs. Too many times the strategy 
is ``implement an EHR'' versus ``improving care and making 
processes more efficient through the implementation of an 
EHR.''
    Number two, accurately understand the current environment. 
Sir Terence Pratchett, an English author, wrote, ``If you do 
not know where you come from, then you don't know where you 
are, and if you don't know where you are, then you don't know 
where you're going. And if you don't know where you're going, 
you're probably going wrong.''
    Too many times in a technology implementation such as an 
EHR the true current state, problems trying to be resolved, are 
not well understood. In these cases, time, energy, and 
resources are spent either explaining the misunderstanding or 
worse, pursuing solutions to a problem that does not really 
exist.
    For example, I have heard a number of times that the way to 
move medical records in the DoD and VA EHR systems today is 
manual, through paper charts or flash drives. However, from 
what I understand, the electronic transfer of records between 
these systems has been automated for years between VA and DoD. 
The two organizations transfer medical data electronically 
today. Significant time is wasted if we do not clearly 
understand our current environment and the real problems trying 
to be solved.
    Number three, realistic user expectations and detailed 
requirements. The old saying ``measure twice, cut once'' is 
sage advice in implementing EHRs. When my wife and I built our 
home, we had ideas for what we wanted and how it should look. 
Like many couples, our ideas did not always match. It took as 
much time working with the architect on defining our 
requirements as it took to build the home. Many times the 
architect would have to manage our expectations, citing the 
realities of engineering and the cost of what we wanted. 
However, before the first brick was laid it was clear what we 
were building.
    An EHR must meet expectations of thousands of people. 
Documenting the requirements to meet these diverse expectations 
is arduous and time consuming. However, understanding the 
expectations of users becomes a foundation for either meeting 
those expectations or for managing them when engineering and 
cost realities arise.
    Number four, a team of qualified, experienced 
professionals. This almost seems too obvious of a point to even 
include. However, I cannot overemphasize the importance of 
relevant experience in successfully implementing an EHR. I 
doubt many of us would like to fly in a commercial airliner 
that has been designed and built by car mechanics. Success is 
much more likely if project leadership has experienced EHR 
implementations, hopefully several, and has team members who 
understand the technology and the operational workflows of the 
medical workforce being automated.
    Five, synergy is real. It takes a large team to implement 
an EHR, and the team is many times composed of multiple 
organizations. It takes a team, a partnership. It is my 
experience that partnerships do not happen just because there 
is a contract. Partnerships are made when incentives are 
aligned, when leadership demands cooperation, and when all 
parties involved understand that the project success is the 
only path to individual success.
    Thank you for the opportunity to share my thoughts on 
successful EHR implementations, and I am happy to answer any 
questions.

    [The prepared statement of Mr. Probst appears on page 67 of 
the Appendix.]

    Chairman Tester. I appreciate your testimony. Thank you.
    Mr. Case, to start out with, you had said that the cost 
estimates were unreliable. I assume those are cost estimates 
that the VA had made, or are these cost estimates that came 
from Cerner, or where did they come from?
    Mr. Case. Yes. Looking at the cost estimates, we break them 
out between physical infrastructure cost estimates. Those were 
done by VHA. And if you look at the IT cost infrastructure 
estimates, those were prepared by OEHRM. And the ones that we 
have called out in our reports would be funded, though, by VHA 
and OIT. So, they were VA-prepared cost estimates.
    Chairman Tester. Okay. And when was the last cost estimate 
you got?
    Mr. Case. The last one we have seen on physical 
infrastructure was a draft that was dated June of 2020, and I 
think it needs to be worked to finalized, at least last time we 
reviewed. And the same on IT cost infrastructure.
    Chairman Tester. Okay. So I am sure you did--did you do an 
analysis of the rollout in October 2020?
    Mr. Case. So, the three reports we have published, really, 
the one that does the analysis is focused on training, and that 
was a window that allowed us to go in and look at several 
aspects of the rollout. But in our view training illuminated a 
lot of the issues.
    Chairman Tester. And so going off to Senator Rounds 
questions, were you the one that found out that stuff had been 
changed on testing?
    Mr. Case. Not me, personally, but an OIG team did.
    Chairman Tester. So OIG team did?
    Mr. Case. Yes.
    Chairman Tester. Do you have the ability to tell me whether 
you think that was done because people intentionally did it?
    Mr. Case. We have not addressed motive yet. We felt it was 
important to identify the issue, the change, and our Office of 
Special Reviews is now undertaking an in-depth review of that 
particular incident and the information we got in terms of the 
rollout.
    Chairman Tester. So what do you think the biggest training 
deficiency that the VA needs to address is?
    Mr. Case. There are really three, to make it short. One is 
the training content. It needs to address the workflow changes 
as part of the training. The second would be the training 
presentation, which needs more time, and a better training 
domain. They need better people assisting in training. And the 
third is they need better evaluation of the training once it is 
out there. Is it effective? How is it working?
    Chairman Tester. Mr. Probst, thank you for being here 
today. You oversaw an electronic health record. If it is a 
health care facility in Salt Lake it is probably a pretty good 
size, right?
    Mr. Probst. Yes. We had 23 hospitals. We are about a $10 
billion operation.
    Chairman Tester. Okay. I mean, that is significant. That is 
a pretty big outfit in my book. Do you think it is possible for 
the VA to implement electronic health records, based on what 
your experience is with those 23 hospitals?
    Mr. Probst. Yes, I absolutely believe that is possible.
    Chairman Tester. And you started out by talking about a 
number of things--accountability, understanding your 
environment, a strategy for getting to the end in mind. I do 
not know how much you know about the VA EHR. You obviously know 
a fair amount about Cerner, if that is the one that you 
implemented. But just based on what you know or what you think 
is correct, what is the issue here? Because, man, I tell you 
what, we have pumped a lot of money into this bad boy.
    Mr. Probst. So I think the issue--well, it is presumptuous 
of me, but let me tell you what happened----
    Chairman Tester. That is all right. We like a little 
presumption.
    Mr. Probst. Yes, well, let me tell you what happened to me. 
I inherited a project in 2018, that was going tremendously 
south, and it was the Cerner implementation. And the challenge 
of it was we hadn't well managed the expectations of the end 
users, that whole part about defining what the requirements 
are. So we could never manage those expectations, because they 
had never been set. And I think that was a key challenge to 
what we were doing. And from what I understand around the VA 
implementation, the expectations, the requirements were never 
done to the level they would need to be done to manage those 
expectations.
    Chairman Tester. So as you look back on your 
implementation--and I am going to turn it over to Senator Moran 
here in a second--but as you look back on your implementation, 
after it was implemented was it a system that was easier for 
your employees to utilize and easier for the patients to 
understand, or was it more difficult?
    Mr. Probst. It absolutely was more difficult, because it 
did more. So I told you we self-developed our own applications 
at Intermountain. That took 40 years of development. So these 
systems were very much modified to the specific needs of 
individuals and individual departments and individual clinical 
areas. So when we went to a more standardized system, like 
Cerner, it required a lot of people to meet us halfway. And 
that goes back, again, to managing those expectations. You 
cannot just bring the system to the people and say you are 
going to do everything they want. There is a give and take. 
They have got to come to the system as well, and that takes 
time.
    But it was more difficult, and it continues to be more 
difficult, and to think that every user at Intermountain is 
happy with the Cerner system, that would be impossible to say. 
But overall has it been successful? Yes.
    Chairman Tester. So how did you measure success?
    Mr. Probst. We measured success by the number of functions 
we were able to automate, the standardization we were able to 
bring across the organization, our ability to better secure the 
system, because we did not have so many applications, and 
overall the use, the ability to automate new functions that we 
never had before.
    Chairman Tester. Okay. Thank you. Senator Moran.
    Senator Moran. Mr. Probst, thank you for being here. In the 
circumstance that we are in now, you read or heard, and heard 
today's testimony where the VA is in its implementation. What 
should Congress expect from the VA as we try to provide 
oversight? What should we hear from them six months from now, 
or three months from now, or a year from now? What should our 
benchmarks be?
    Mr. Probst. Well, if you do not have a clear vision of what 
this is going to do, the benefits that you are going to get 
from it, I would hope that those are well defined, so that you 
understand the goal, right? What is at the end of the project.
    I think you are going to need to see reductions in the 
number of complaints, or tickets that come through. You know, 
hopefully, over time, you are going to see that, but you are 
going to see them pretty heavy up front. In every 
implementation you are going to see that.
    I would like to see, or if I were in your seat, I would 
like to see real milestones, and are they hitting those 
milestones, and if they are not, why are they adjusting, 
because it is very common in these implementations for those 
milestones to change. But you need to have rationale for why 
that is happening, so that everyone is aligned with what we are 
doing.
    I would like to see a real partnership develop with each of 
the parties involved, and that includes the VA, Cerner, and 
anyone else that is involved in the project, and see that they 
are well aligned and that that partnership, that synergy is 
happening.
    Senator Moran. Are there a couple of things--and, you know, 
it is never easy to boil things down to one or two things, but 
it is useful as you try to wrap your mind around this big 
project--are there a couple of things that stand out to you 
that you would insist on, encourage now, beyond what you have 
already said?
    Mr. Probst. If I were involved I would want to go back and 
start to manage those expectations. So even though the 
requirements were not developed at the beginning, it is not too 
late to go back and define what those requirements are. So I 
would love to see that put in place, because that allows 
everything else to be managed. That would be one.
    I would like to see the milestones and the detailed project 
work plan and the goals that we are trying to achieve.
    Senator Moran. Thank you very much. Mr. Case, your reports 
mention what costs may actually be as compared to the reported 
costs. Could you tell me what you are meaning there?
    Mr. Case. Yes, Senator. The reported costs included $10 
billion contract cost and $6 billion for IT infrastructure 
upgrades and for project management. What is missing in the 
reports to Congress is $2.7 billion in physical infrastructure 
costs. Now, we have not a lot of confidence--that is not a 
reliable estimate--but let's just use $2.7 billion. What is 
also missing in that number is roughly $2.5 billion in IT 
infrastructure upgrades, which will be funded by OIT and VHA. 
So that gives you a rough missing number of over $5 billion.
    Senator Moran. Is there a good explanation for why those 
costs were not reported? Are they so unique or different that 
someone would not understand they should be included in that 
report?
    Mr. Case. So VA provided their rationale to us, which was 
that the costs that were not reported were coming out of 
different funding sources. It was a VHA funding source, and a 
VHA and OIT funding source, not the OEHRM funding. We did not 
find that rationale persuasive. We thought the legislation was 
clear, from 2018. We think the requirements of a life cycle 
cost estimate are clear, which is that it is all costs, 
regardless of funding source. And we also thought it was clear 
that those costs were necessary to a successful implementation 
of EHR.
    Senator Moran. Was there some advantage that could be 
obtained by understating those costs?
    Mr. Case. Not that I am aware. Transparency usually has no 
disadvantage to it.
    Senator Moran. Well said. Leadership vacancies and changes 
in personnel impact governance and the follow-on ability to 
close out the recommendations. My question is, are those 
problems that exist here in the follow-on?
    Mr. Case. Well, it remains to be seen in the sense of what 
will happen in the follow-on. We want to see the results of the 
strategic review that is happening. But we know there has been 
some consistent leadership at Mann-Grandstaff. We know that the 
Secretary has undertaken the strategic review to try to get in 
place a management team that will work together across all 
components of VA and also, I think importantly, there is going 
to be transparency across all components of the VA--VHA, OEHRM, 
OIT, they all need to be transparent as to what is going on.
    Senator Moran. Should we, should you be satisfied with the 
VA's response to date, and is their response in any way 
different than a response to other reports in the past?
    Mr. Case. Well, I think the VA has concurred with all our 
recommendations. We have made 38 recommendations. Some have 
been implemented. Some they are in the process of developing 
plans and implementing, and we monitor that on a 90-day basis. 
And, we have other projects underway already where we are going 
to be able to look, in part, at how are they doing in 
implementing our recommendations to date.
    Senator Moran. You are the second inspector general I have 
spent time with today. Mr. Horowitz was with us on our 
investigation into the U.S. Olympics amateur athletes and 
sexual abuse, which report was issued today. I value the work 
of an inspector general, and I thank you for your testimony and 
that work.
    Mr. Case. Thank you, Senator, and it is really the teams 
that did the work here. They deserve all the credit.
    Senator Toomey. I echo the Ranking Member's comments, as 
usual. We appreciate the IG and the work you guys do, and 
appreciate your eyeballs on the agency, which basically we 
utilize. So thank you very much.
    I have one more question. It is for Mr. Probst. In your 
written testimony you said it was very important to have an 
experienced team running the EHR project. I agree. You said, 
and I quote, ``I can't emphasize the importance of relevant, 
experience in successfully implementing an EHR. I doubt many of 
us would like to fly in a commercial airliner that has been 
designed and built by car mechanics''--nothing against car 
mechanics, but you are right.
    Mr. Probst, can you talk to us a little bit more about what 
type of skills, qualifications your teams had when you were 
involved in these projects in the private sector, not just 
technical but leadership skills? And if you can think back to 
when the project was going south, what kind of people were you 
looking for to make it go north, assuming north is a good 
thing?
    Mr. Probst. Yes. I mean, beyond the specific skills that 
were required, it started at the top. I had a CEO that was my 
partner in doing this, and he worked with us. We brought in the 
CEO of Cerner, and we worked out the plan on how we were going 
to successfully implement the product.
    Now the team itself, we needed people that had implemented 
electronic health records. These are extremely complex systems. 
If you think about it, we are automating every function in a 
health care delivery system. That is hundreds, if not 
thousands, of functions. So we needed people that were 
experienced not just in those individual functions but how 
those individual functions related to each other and processed 
with each other.
    We also needed doctors where we were doing work for 
doctors. We need technology people that understood physicians 
and how physicians did their business. Those are physicians, 
nurses, respiratory therapists, pharmacists. Think about it. 
For an organization my size, which is a fraction of what the VA 
is, we had hundreds of people that were relevant in their 
clinical areas, supporting the implementation of the product. 
We needed technical expertise because of all the infrastructure 
problems that we had, that I am sure the VA had. We had people 
that needed to understand data and data integration. We needed 
data scientists.
    So not just relevant expertise, but relevant experience in 
doing this, because the problems happen immediately, and we can 
either go to committee and figure out how we are going to solve 
the problem or we can have people there that have been through 
it and understand what to do in those situations. That is what 
I wanted on my team.
    Chairman Tester. So I would imagine with 23 hospitals you 
have got a fair number of employees.
    Mr. Probst. We had about 40,000 employees.
    Chairman Tester. And those 40,000 employees, I would 
imagine, most if not all of them deal with electronic health 
records. Maybe not your custodial staff, but probably everybody 
else.
    Mr. Probst. Most everyone but the administrators, yes.
    Chairman Tester. And so if you were going to do an 
assessment today as to how many people of those 40,000 actually 
liked this medical record, what would that percentage be?
    Mr. Probst. Wow. Like it--under 50 percent. Tolerate it, 
will use it, are finding advantage in it--80, 90 percent.
    Chairman Tester. Okay. Wow, that is helpful. Thank you. Go 
ahead, Senator Moran.
    Senator Moran. You are not done.
    Chairman Tester. I am never done, but I will yield to the 
honorable Senator from Kansas.
    Senator Moran. Well, it is a follow-up to your question to 
Mr. Probst. Mr. Case, you heard the description of who is 
necessary to make this work. Is there anyone at the VA that has 
that EHR rollout experience that is involved in this process?
    Mr. Case. There are people at VA that have experience in 
various aspects of EHR. I do not think there is probably one 
person or one set of people, and the Secretary referenced this. 
This is going to require an all-hands effort across VHA, OEHRM, 
particularly the data scientists who are going to have to deal 
with the new data streams that Cerner provides, as opposed to 
the old VistA system. And for a long time VA is going to have 
to have both data streams and be able to use them both.
    So there are people. Whether there is a sufficient number 
of people, whether they can be best augmented by working with 
Cerner and subcontractors, that is something I think the 
strategic plan will have to address.
    Senator Moran. Thank you both.
    Chairman Tester. So to give Senator Cassidy due deference, 
I am going to hold--oh, there he is right there. You are on 
this side, Senator. You are right there.
    So when the good Senator from Louisiana gets squared away 
here, you are up to bat, Doctor.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Folks, if you have answered these 
questions, because I have been a little bit like Lord Voldemort 
today, split into six different places, trying to do six 
different things.
    Mr. Case, according to an OIG report on the EHRM training 
deficit in Spokane, quote, ``Facility staff reported an absence 
of workflow training content--"
    Chairman Tester. You might need your mic on.
    Senator Cassidy. ``Facility staff reported an absence of 
workflow training content and associated reference materials 
that prevented them from not only understanding how to apply 
what little they had learned to their daily work but also 
prevented a basic understanding of the meaning behind the 
workflow processes.''
    Well, you know, I am doc. I have been in hospitals where 
you sit there for an hour and a half, have a training seminar, 
and you walk out and you go to where you are supposed to be, 
and you have no clue how to apply it. You are just given a 
whole chunk of material--now go use it. Very impractical.
    So I guess, you know, a couple of questions. You know, 
didn't somebody think that through? You do not just like load 
them up. I will start with that one.
    Mr. Case. Yes. It was not thought through adequately. I 
think the new EHR fundamentally changes how every clinician is 
going to do their work at VA. Just to use an example, if there 
is going to be a prescription renewal, how it is communicated 
to VA by the veteran has changed, how it is communicated to the 
doctor has changed, how the doctor is going to enter in his or 
her findings and communicate that prescription to the pharmacy, 
and how it is going to be delivered has changed.
    And so it is that workflow, and how the new electronic 
health care systems goes into that workflow, is what needs to 
be addressed. It has not been addressed adequately.
    Senator Cassidy. So then it suggests to me that it is not 
intuitive.
    Mr. Case. That is the feedback I have heard from our 
clinicians.
    Senator Cassidy. So then let me ask, were the clinicians 
involved in the development of the workflow process?
    Mr. Case. Yes, initially they were. There were teams that 
were put together, amongst the clinicians----
    Senator Cassidy. Now, Mr. Case, let me ask you. There is a 
key word modifier you used there--initially.
    [Laughter.]
    Mr. Case. Yes.
    Senator Cassidy. Were they initially, and then 
subsequently, and subsequent to the subsequent, et cetera, et 
cetera, et cetera?
    Mr. Case. You picked up on a deliberate modifier. Yes, they 
were involved in the design of the workflows, but they were 
notably not involved in the design of the training and how to 
present the training to the clinicians at Mann-Grandstaff.
    Senator Cassidy. Okay. That is frustrating, as you might 
guess, because I have found the EHRs--and my physician 
colleagues verify that it is not just my anecdotal experience--
is a real time killer. That is a real time killer. And so 
productivity is just squashed by that.
    So let me ask, I think under the original law there is 
supposed to be a quarterly program update on the annual cost, 
which stated that the life cycle cost estimate should be 
regularly updated. It does not seem as if that has occurred.
    Mr. Case. That is correct, Senator. It has been understated 
by roughly $5 billion.
    Senator Cassidy. So is anybody being held accountable for 
this? Who was responsible, and to what degree is the taxpayer 
being reassured that the person responsible is being held 
accountable?
    Mr. Case. The decision on how to hold people responsible 
lies with the Secretary. I think the Secretary will want to 
investigate the facts and potential motives involved in this 
before the Secretary decides, but that is uniquely within his 
purview. VA did provide a rationale for what they did, or 
failed to do, but we did not find it persuasive.
    Senator Cassidy. Do we know the individuals who are 
responsible?
    Mr. Case. We have not identified those individuals for the 
actual decision not to disclose those. We have heard their 
rationale and the fact it has not been disclosed.
    Senator Cassidy. Now it seems almost unfathomable that you 
would not know who the decision-maker was.
    Mr. Case. Well, I think that is part of the issue with the 
overall management of EHRM, to a degree, is decision-making can 
be opaque. And we have started an investigation that is 
separate, that goes into issues of candor and potential 
manipulation of information, both toward the IG and toward 
Congress. And as part of that, I think we can try to narrow 
down the individuals.
    Senator Cassidy. So really then we are talking about even a 
broader issue than incompetence. It also includes mendacity, if 
you will.
    Mr. Case. I cannot say that yet, Senator. We have not 
delved into motive or reached a conclusion as to motive, but 
all possibilities are open.
    Senator Cassidy. And then I will finish by this, knowing we 
are almost out of time, and I thank you all for allowing me to 
be the last. DoD obviously had some problems. Were there any 
lessons learned from the DoD experience with the EHR, number 
one. And number two, is the desire to have interoperability, to 
what degree did that complicate issues?
    Mr. Case. Yes. So there were DoD lessons learned, 
particularly with their initial rollout.
    Senator Cassidy. There were?
    Mr. Case. Yes, in the Pacific Northwest, and they included 
the problems with training, insufficient computer-based 
training, lack of clear role definitions, lack of support, and 
others, and a lack of content. And those lessons appear not to 
have been embraced by VA when they did their own training and 
rollout at Mann-Grandstaff. Some of the same issues have 
occurred again.
    So there are lessons to be learned. There are probably 
further lessons to be learned, but those lessons have to be 
attended to and really addressed as VA proceeds on its way 
forward.
    Senator Cassidy. Can I have one more question?
    Chairman Tester. You bet.
    Senator Cassidy. Now I do not quite understand what I am 
about to say, but you will totally. I was told that part of the 
problem in terms of the interoperability is that it was 
happening--the responsibility lay on a sub-Secretary level. Now 
there was turnover last administration, in Secretaries of both 
Departments. But we received a commitment, at some point, that 
on a Secretary-to-Secretary level that this interoperability 
was going to be made a priority. And what I was told at the 
time, led to believe, was that once you had this Secretary and 
this Secretary responsible, then that is when things would 
actually begin to move, because it would become a sufficient 
priority that it would be driven.
    Now you may dispute that. You may say, ``No, that is not 
true.'' But I guess my question is, did this ever rise, the 
interoperability issue, to being a Secretary-to-Secretary issue 
with, what I am told, the inherent prioritization and the 
inherent increased accountability?
    Mr. Case. Senator, we have a joint project ongoing right 
now with a draft report, looking at the very issue you just 
described. It is a joint project with the DoD Office of 
Inspector General looking at the question of interoperability, 
will this be able to achieve it, and is there a governance 
structure that can get those two parties together to make sure 
it is achieved. And we are looking at the governance structure 
as part of that.
    So it is an issue.
    Senator Cassidy. Mr. Case, just so I understand----
    Mr. Case. Yes.
    Senator Cassidy [continuing]. And I thank you for kind of--
your hair is as gray as mine. I suspect you have had more 
frustrations than me. But my question is--to make sure I 
understand it--when you speak of governance, did it ever rise 
to the Secretary-to-Secretary level, but you are still not sure 
of the governance, or no, it never rose and you are not sure of 
the governance?
    Mr. Case. I am not sure it ever rose--where the Secretaries 
were in the same room or on the same call, addressing the 
interoperability issues with any level of specificity, and I am 
not sure the current governance structure can really accomplish 
the mission, in terms of doing that, and bring it to the 
Secretaries for decisions as they need to make them. So that is 
one of the strong points of our current joint project with DoD 
IG.
    Senator Cassidy. Is to see if that actually occurred.
    Mr. Case. Exactly.
    Senator Cassidy. Now one more thing. I mean, there is a 
parable, or there is, in the gospels, the centurion speaks to 
Jesus. And Jesus says, ``You do not need to come to my house. I 
am a leader. I can tell somebody to do it for me.'' So I do not 
actually expect the two Secretaries, who probably know nothing 
about EHRs, to speak to themselves, but I do expect that they 
have a lieutenant who makes it a priority, if you will. So that 
is what I always assume Secretary-to-Secretary meant. My 
trusted lieutenant, whom I speak to three times a day, is going 
to take charge of this and make it happen. Is that what you are 
describing you are not sure occurred?
    Mr. Case. That is exactly what I am describing as not sure 
occurring. The Deputy Secretary has the congressional 
responsibility at VA to make sure this is happening. The buck 
stops with the Deputy Secretary in terms of VA. Do they have 
themselves, or people that they trust who are working together 
with DoD to make the right decisions on interoperability so 
that it can be accomplished?
    Senator Cassidy. And you are doing that on both sides, the 
DoD and the VA side?
    Mr. Case. That is correct, Senator. This is one of the few 
projects where IGs are working together on a strong, 
cooperative basis to make a joint report, and that is because 
it is the same Cerner system, or fundamentally, at DoD and at 
VA.
    Senator Cassidy. I am going to ask one more.
    Chairman Tester. Yes.
    Senator Cassidy. Are you also looking at whether or not 
Cerner inherently has the ability, the Cerner product 
inherently has the ability to do the job?
    Mr. Case. Generally, what we found is that the system 
itself, from a technical basis, is working. Now there are 
opportunities for us to review--has Cerner done the job so far, 
and are they going to do it in the future. Those are projects 
we can try to plan for. We have not made any review or decision 
on that yet.
    Senator Cassidy. Okay. I thank you all. Thank you for 
indulging.
    Chairman Tester. I appreciate your line of questioning, 
Senator Cassidy. I am glad we waited and I am glad you made it. 
I would also say that at 5:30 we have got a vote on Donald 
Remy, the Under Secretary of the VA, that is going to be in 
charge of this. And I can tell you that under the last 
administration that position was very fluid and open a lot of 
the time. And I think that could be--I am not saying it is, but 
I am saying it could be part of the problem. But I would hope 
that Mr. Remy gets confirmed so that we have people to hold 
accountable. And I agree with you. If Remy cannot get the job 
done he should certainly take it up to the Secretary so they 
can do it.
    It is there to be done. It needs to be made a priority. I 
think there are plenty of screwups we can point to. I think the 
IG has given us a roadmap. I do think that with good oversight 
by this committee we can make serious progress on this, and 
with your help.
    Senator Cassidy. Thank you, sir.
    Chairman Tester. So thank you all.
    Look, I want to say thank you to Mr. Case and Mr. Probst 
for being here today. I look forward to hearing more details 
from the strategic review findings and how the VA plans to 
right the ship in order to properly prepare VA staff for the 
transition, safeguard taxpayer dollars, keep veterans safe, and 
improve quality of care. Having proper leadership team in place 
at the VA to manage this change, the changes this program 
needs, is also critical, and it also needs, as I pointed out, 
Deputy Secretary, in this case Donald Remy, which we are going 
to vote on in about eight minutes.
    As I said earlier, the VA must be straightforward with 
Congress on the cost, the challenges, and the path forward on 
this program. If they cannot be, there, of course, will be 
consequences.
    The record will be open for a week. Thanks again, fellas. 
We are now adjourned.
    [Whereupon, at 5:21 p.m., the Committee was adjourned.]

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