    [Senate Hearing 117-636]
    [From the U.S. Government Publishing Office]

                                                          S. Hrg. 117-636

                    EXAMINING THE STATUS OF VA'S ELECTRONIC
                      HEALTH RECORD MODERNIZATION PROGRAM

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 20, 2022

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    51-647 PDF                  WASHINGTON : 2023

    -----------------------------------------------------------------------------------

                     SENATE 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 20, 2022

                                    SENATORS

                                                                       Page
    Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
    Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................     9
    Tuberville, Hon. Tommy, U.S. Senator from Alabama................    11
    Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    13
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    14
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    16
    Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    18
    Murray, Hon. Patty, U.S. Senator from Washington.................    19
    Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    21
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    32

                                   WITNESSES
                                    Panel I

    Terry Adirim, MD, MPH, MBA, Program Executive Director,
      Electronic Health Record Modernization Integration Office,
      Department of Veterans Affairs; accompanied by the Honorable
      Kurt DelBene, Assistant Secretary for Information and
      Technology and Chief Information Officer; Michael D. Parrish,
      Principal Executive Director for the Office of Acquisition,
      Logistics, and Construction and Chief Acquisition Officer; and
      Gerard R. Cox, MD, MPH, Assistant Under Secretary for Health
      for Quality and Patient Safety, Veterans Health Administration.     3

                                    Panel II

    David Case, Deputy Inspector General, Office of Inspector
      General, Department of Veterans Affairs........................    25

    Mike Sicilia, Executive Vice President, Oracle Corporation.......    27

                                    APPENDIX
                              Prepared Statements

    Terry Adirim, MD, MPH, MBA, Program Executive Director,
      Electronic Health Record Modernization Integration Office,
      Department of Veterans Affairs.................................    43
    David Case, Deputy Inspector General, Office of Inspector
      General, Department of Veterans Affairs........................    53
    Mike Sicilia, Executive Vice President, Oracle Corporation.......    86
      Attachment--Letter dated July 6, 2022, Oracle Corporation
        response to U.S. House of Representatives Committee on
        Veterans' Affairs............................................    94

                            Questions for the Record

    Oracle response to questions asked during the hearing by:
      Hon. Kyrsten Sinema............................................    99

    Department of Veterans Affairs response to questions submitted
      by:
      Hon. Thom Tillis...............................................   101
      Hon. Kevin Cramer..............................................   107
        Attachment for Question 7 response--Patient Safety and EHRM
          Information Paper..........................................   110

      Hon. Mazie Hirono..............................................   116
      Hon. Kyrsten Sinema............................................   119
        Attachment for Question 11 response--Figure 1: VA EHRM
          Interface Testing Coverage Definitions.....................   121

    VA Office of Inspector General response to questions submitted
      by:
      Hon. Mazie Hirono..............................................   123
      Hon. Kyrsten Sinema............................................   124

                            EXAMINING THE STATUS OF
                         VA'S ELECTRONIC HEALTH RECORD
                             MODERNIZATION PROGRAM

                                  ----------

                            WEDNESDAY, JULY 20, 2022

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

                  OPENING STATEMENT OF CHAIRMAN TESTER

        Chairman Tester. Good afternoon. I want to call this
    meeting to order. We are a little bit quick but this is a very,
    very important hearing and there is going to be, I believe,
    participation by everybody but two on this Committee, at least.
    If they are free they are going to be here. They have indicated
    they want to be here.
        I want to thank our panels for being here. There are two
    panels today and I want to thank the first panel. The second
    panel will get thanked when they get up. And I want to
    acknowledge the hard work of dedicated VA employees, including
    those on the front lines using the new EHR.
        For nearly two years they have done all that they can do to
    provide health care to veterans in the middle of a pandemic and
    for some five States with new electronic health records that
    has been a challenge. We know this program faces real problems,
    and we need to work together to make sure the needed
    improvements are done today, not tomorrow.
        Today the VA notified our Committee that the planned
    deployment of the new EHR in Boise, Idaho, scheduled for this
    Saturday, would be delayed, and I will tell you that I support
    that decision and I believe additional improvements are needed
    to ensure any future deployments are safe and successful. We
    need to know what is working and what is not, and we need to
    listen to local VA administrators and employees about what they
    are saying.
        It is not just the unknown queue problem. It is pharmacy,
    behavioral health, financial systems, referrals, and much more
    that needs to be fixed. The patient safety is always job one.
    Converting VA over to this new EHR system from VA's existing
    VistA system is a huge undertaking and it requires meaningful
    engagement with stakeholders, honest communication, and solid
    training.
        Two days ago, VA third-party independent analysis of the
    new estimated full cost of the program was briefed to Congress.
    The estimate reveals that the cost is going to be $50.8 billion
    over 28 years. This should serve as a wake-up call to
    everybody, including the folks at VA, Oracle, Cerner, and, of
    course, us, Congress, because we have a lot of work ahead of
    us.
        The new analysis shows, among other things, that VA did not
    factor in the cost to mitigate the decreased productivity to
    the VA workforce when the EHR was first at use at a facility.
    Other missed costs would include increased community care
    usage, surged staff to help facilities, long-term cost to
    maintain the new EHR.
        As of April of this year, Cerner, now called Oracle Cerner,
    has been paid about $2.8 billion for a product that, quite
    frankly, is not up to snuff. Since the Cerner purchase, Oracle
    officials have been candid about the challenges with the
    program and have said that they are dedicated to addressing its
    problems, and they said they would do it on their dime. That is
    something that I intend to hold them to.
        I should note a Senate-confirmed Under Secretary for Health
    has not been in place since 2017. That is roughly the entire
    life of the EHRM program. Dr. Shereef Elnahal was nominated on
    March 10, 2022, and this Committee reported that nomination of
    unanimously on May 4, 2022. But Dr. Elnahal's final approval by
    the full Senate has been blocked by one--one, one--of our
    Senate colleagues that does not even sit on this Committee.
        The critical challenges that EHRM program faces today is
    just one more reminder of why our colleagues in the United
    States Senate need to quit playing politics, quit running for
    President, and confirm Dr. Elnahal.
        And with that I will turn it over to you, Ranking Member
    Moran, for your statement.

                   OPENING STATEMENT OF SENATOR MORAN

        Senator Moran. Chairman Tester, thank you, and good
    afternoon to our panel and to you and other Committee members.
    I want to welcome the witnesses to provide testimony today on
    what seems to be a recurring difficulty, the Electronic Health
    Record Modernization program. There is no doubt that the
    project faces substantial delays and cost overruns. The
    question is, what is needed to make the system function safely
    and effectively and why is the VA not getting it done?
        The Chairman and I sent a letter listing 36 fixes that are
    needed. Chairman Tester and I requested a response, and we need
    to see much faster reaction response.
        The Institute for Defense Analyses has estimated
    implementation over 13 years at nearly $39 billion. They have
    also estimated sustainment at over $17 billion. Altogether,
    that is a $40 billion, over the cost estimate VA has been
    operating under. Until Monday we were not aware of how large
    the cost overrun truly is.
        The Office of Inspector General has issued 14 reports,
    including two new ones last week, sounding alarms about many
    aspects of the effort. We can see in the five medical centers
    where the system is being used that it is not sustainable for
    VA in so many respects. VA already considers the system unsafe
    to roll out in large, complex medical centers, and the path to
    make it safe is still unknown.
        I hope today that we can have a frank discussion about the
    reality of the situation. Veterans and VA employees expect and
    deserve no less.
        Mr. Chairman, I thank you for conducting this hearing.
        Chairman Tester. Thank you, Senator Moran, and now we are
    going to turn to our first panel. We are going to hear from VA
    officials who together share the responsibility for managing
    the very aspects of the EHRM program. Dr. Terry Adirim, who is
    the program's Executive Director, is accompanied by the
    Honorable Kurt DelBene, Assistant Secretary for Information and
    Technology and Chief Information Officer; Michael Parrish,
    Principal Executive Director for the Office of Acquisition,
    Logistics, and Construction and Chief Acquisition Officer; and
    Dr. Gerard Cox, Assistant Under Secretary for Health for
    Quality and Patient Safety at the Veterans Health
    Administration.
        Dr. Adirim will provide a statement. Hopefully it will be
    close to five minutes. Please know that your entire statement
    will be part of the record, and you may proceed.

                                PANEL I

                                  ----------

                       STATEMENT OF TERRY ADIRIM

               ACCOMPANIED BY THE HONORABLE KURT DELBENE;

                 MICHAEL D. PARRISH; AND GERARD R. COX

        Dr. Adirim. Thank you. Chairman Tester, Ranking Member
    Moran, and distinguished members of the Committee, thank you
    for the opportunity to testify today in support of VA's
    initiative to modernize its electronic health record, and as
    you said, Senator Tester, I am accompanied here by my VA
    colleagues. And this panel demonstrates VA's EHR modernization
    program is a department-wide effort, and I am appreciative of
    the continued collaboration with these experts.
        Additionally, I look forward to continuing to work with you
    and your staff to ensure that we are successful. We appreciate
    your support during this challenging journey.
        I want to start out by saying that we are committed to full
    transparency about our deployment efforts. Further, as a
    physician, an expert in health care quality and patient safety,
    I take patient safety, risks, and harm very seriously, and I
    work closely and collaboratively with the VHA experts who
    review and analyze these incidents.
        We acknowledge that the first deployment at Mann-Grandstaff
    in Spokane, Washington, was problematic. The events that
    occurred during the first several months after go live in
    Spokane that resulted in any degree of harm to veterans was
    unacceptable. We are unequivocally committed to providing safe,
    effective, high-quality care to veterans.
        Our health system has made great efforts into becoming a
    highly reliable organization with the number one goal of zero
    harm to veterans, and my focus, as Program Executive Director,
    is on proactively instituting measures to reduce risk to
    patients and not wait for reports of harm to make it to my
    desk.
        VA learned from this experience, conducting a department-
    wide strategic review that identified patient safety and other
    areas for improvement. Our charge has been clear: create a
    single, seamless, integrated health record for military service
    through veteran status. This complete record within a single
    system allows those who care for our nation's veterans to keep
    pace with the future and increasingly complex demands of VA's
    health system.
        Our nearly 40-year-old legacy system has served us well but
    it has reached the end of its lifecycle, and given its
    limitations it needs replacing. As Secretary McDonough has
    said, this is a leap forward we can and must get right, and we
    will.
        I was brought on board to get this effort back on track.
    With my background as a practicing physician and health care
    system leader, most recently within the military health system,
    I bring the perspective to this project as an end user and
    someone with knowledge and experience deploying a new EHR
    within a large, complex health system. I have spent the last
    almost seven months since my arrival to VA assessing what did
    not go well in Spokane and planning for doing it better. With a
    new senior leadership team in place, close collaboration and
    communication across the Department, and better-engaged site
    leadership and staff, VA now has a more informed approach to
    deployment.
        I will be blunt. In hindsight, Mann-Grandstaff was not
    ready to adopt a new electronic health record. Planning was
    inadequate and lacked a thorough assessment of the site's
    readiness. And most importantly, in October 2020, VA medical
    centers were still being seriously impacted by the COVID
    pandemic. This was not the fault of the personnel at Mann-
    Grandstaff. In fact, they have worked hard to continue to care
    for our veterans under difficult circumstances and should be
    commended.
        But that was nearly two years ago. Today the EHR
    modernization program reflects many valuable lessons learned
    from Mann-Grandstaff. While we are planning to move forward
    with other deployments we are still very much engaged with our
    past sites, closely monitoring and assessing for user
    experience and adoption. We know, from other health care
    systems, that full adoption and return to baseline operations
    can take six months or more. This is complex work and therefore
    we expect challenges.
        VA is committed to resolving our challenges and has already
    taken a number of important steps to address them. This
    includes pressing Cerner to make the needed changes within the
    system to ensure better stability and to accelerate
    installation of the capability enhancements our medical
    personnel need to do their work more effectively and
    efficiently.
        I want to be clear. Our top priority is and always has been
    patient safety. In fact, due to concerns at our first
    deployment site, patient safety and risk reduction activities
    have been incorporated into every aspect of the deployment
    effort.
        Of course, we know that some level of risk will always be
    present--that is the nature of health care--and we will
    continue to prioritize measures that mitigate as much of that
    risk as possible. But what we are doing is working. I see it in
    the metrics and I hear it from people within the enterprise. As
    in any large deployment effort, we expect to experience bumps
    along the way, but we are now organized to respond rapidly.
        Chairman Tester, Ranking Member Moran, and members of this
    Committee, thank you for the opportunity to testify today. We
    are happy to respond to any questions you may have.

        [The prepared statement of Dr. Adirim appears on page 43 of
    the Appendix.]

        Chairman Tester. To the second. Pretty good. I appreciate
    that. I appreciate your opening statement. And I will tell you,
    I do not think there is anybody on this Committee who has been
    associated with this effort that has not known that there were
    going to be some bumps along the way. I think it is all our
    responsibilities to make sure those bumps are minimized, so I
    appreciate your opening statement, Doctor.
        Dr. Cox, you are the top person at VHA on patient safety
    and quality. I am going to make a statement and you tell me if
    you think you agree with me. The unknown queue feature in the
    Oracle Cerner EHR was not working well, and it created
    incidents of patient harm. Would you agree with that?
        Dr. Cox. Thank you, Mr. Chairman. I would. I would like to
    underscore what Dr. Adirim said in her statement that VA is
    absolutely committed to providing safe, effective, high-quality
    care to veterans. The events that occurred at Spokane that led
    to harm of any type to any veteran are unacceptable. They are a
    disservice to those veterans, their families, and to our hard-
    working frontline clinicians.
        Chairman Tester. Thank you. Has the unknown queue issue
    been fixed?
        Dr. Cox. There have been strategies put in place to monitor
    that queue and to make sure that the orders that were initially
    lost or not located at Spokane for several months are now
    identified and dealt with on a daily basis. I do not think I
    would say that a permanent fix is in place, and I would defer
    to Dr. Adirim to elaborate on whether there are other actions
    that need to be taken.
        Chairman Tester. If you can, or I will have a follow-up.
    Either way you want to go.
        Dr. Adirim. Sure, Senator. The unknown queue is not
    something really to be fixed. It is a feature of the Cerner
    software. It is the way that it is designed, and people can
    talk about whether they think it is a good design or bad
    design.
        What happened during the Mann-Grandstaff deployment was
    poor communication, there were training failures as well--
    nobody was specifically trained in using this particular
    feature--and the process was not put in place. Since then, the
    part of the system which caused people to put in orders that
    could not be filled, the location part has been reconfigured. A
    process has been put in place and is communicated very clearly,
    and staff is trained specifically in using the unknown queue.
        Chairman Tester. And so let me follow up, to either Dr. Cox
    or Dr. Adirim. Do you feel today that the incidents that could
    potentially create patient harm due to the unknown queue will
    not happen again?
        Dr. Cox. I will take that, Dr. Adirim. I feel that we have
    done everything possible to reduce the risk of any additional
    harm to any veteran. That is, we have learned from the lessons
    that our own frontline clinicians brought forward at Spokane
    and now know where the vulnerabilities are and how to take
    steps to prevent similar things from happening at additional
    sites.
        Chairman Tester. So if something were to happen moving
    forward it would be not necessarily something that would be
    caused by the program but something caused by the people that
    are running the program? And, you know, Tillis is sitting here
    thinking, God, that is the way it is all the time anyway. But
    the truth is it is something that would be caused by personal
    error, not because the program was designed in such a way that
    files were going somewhere where people did not know they were
    going.
        Dr. Cox. Mr. Chairman, when we think about problems with
    health information technology products, including electronic
    health records, we think about a range of causes, and
    contributing factors often include people, process, or
    technology, and usually some combination of the three. So all
    of those factors can contribute to error.
        Chairman Tester. Okay. Could you walk us through the
    broader list of concerns VHA is monitoring with the new EHR,
    let me tell you, like pharmacy, behavioral health, referrals,
    broader hospital operations, and kind of walk us through what
    you are doing to solve those issues?
        Dr. Cox. Yes. I would be glad to. The unknown queue is a
    problem with where orders go, as you pointed out, and issues
    regarding provider orders are just one of nine or ten
    categories of issues that we are monitoring and putting
    mitigation strategies in place to address.
        You mentioned a couple of others, questions regarding
    pharmacy, behavioral health and suicide flags, identification,
    medication management, ambulatory care, and there were four or
    five others. So for each of those, we call them domains, of
    issues that have resulted in patient safety concerns, we
    assembled teams a year ago, each led by a subject matter expert
    in that particular area. So for example, the pharmacy domain
    team is led by a pharmacist. And those teams, working side-by-
    side with the frontline clinicians at Spokane and each
    subsequent site, and with Cerner, and with EHRM program office
    personnel and people from the VISN and people from Central
    Office, are collaborating daily to address those issues, to
    reduce the possibility of any harm related to any of those
    areas, and to put mitigation strategies in place, immediately
    if possible, or if not possible immediately then to work with
    the Cerner Corporation to produce a long-term fix.
        Chairman Tester. And very quickly, who has oversight of
    those people that you just talked about? Is it you?
        Dr. Cox. I have oversight of a patient safety team that is
    led by the National Center for Patient Safety. That is one of
    the 16----
        Chairman Tester. So let me make this more clear. The
    pharmacy folks, if there are problems and they do not find them
    who has oversight over them?
        Dr. Cox. There is a pharmacy program office, as I am sure
    you know, but I would say that ultimately it is all of us
    working together that have to take responsibility.
        Chairman Tester. Okay. Senator Moran.
        Senator Moran. Thank you, Mr. Chairman. There may be an
    answer from you but maybe the witnesses could help me
    understand. One of the reasons that Senator Tester and I worked
    to get Dr. Remy's nomination in front of this Committee and
    before the Senate and confirmation was because we believed that
    his presence would be helpful in this issue of electronic
    medical records. The Chairman just mentioned another nominee
    that is pending. We worked to get Dr. Remy in place, and I am
    surprised by his absence today. Is there a reason that the four
    of you are here as compared to him and others?
        Dr. Adirim. To be honest I really do not know, but Mr. Remy
    is very deeply involved. In fact, I meet with him daily on this
    issue and he knows all of these issues and how we are trying to
    resolve them.
        Senator Moran. I am certainly appreciative of Dr. Remy.
    This is not intended to be any criticism of him whatsoever. It
    is just odd to me that he is not included in this panel, and I
    am sure as a result of my question I will soon hear from him as
    to why that is.
        Dr. Adirim, the new estimate to implement Cerner is 13
    years and $33.6 billion plus $5.3 billion for infrastructure.
    Does the Department of Veterans Affairs expect Congress to
    increase its funding or will the VA be reallocating or cutting
    internally to find that money?
        Dr. Adirim. Well, Senator, we are planning right now to
    deploy this within the 10-year time frame. However, due to some
    of these delays and changes in the schedule we are doing some
    contingency planning with regard to extending the schedule. We
    do not anticipate that the cost is going to be that much more,
    but we may need to, if we extend, have to ask for more money.
        Now, the life cost estimate that was done by IDA is really
    a different estimate than the cost for deployment. That takes
    into consideration a number of factors that do not have to do
    necessarily with the program and the deployment itself. So we
    are taking action to look for ways to be more efficient with
    the attempt to reduce costs. However, to answer your question,
    we are going to try and stay within the 10-year planning time
    frame.
        Senator Moran. If you stay within the 10-year planning
    period and there is still additional dollars necessary, would
    that be an additional budget request from the Department of
    Veterans Affairs?
        Dr. Adirim. If we do need to extend beyond the 10-year
    deployment schedule then that may be the case.
        Senator Moran. The letter that I referenced in my opening
    statement in which we listed 36 fixes--that letter is dated
    June 27th--how much will that cost and is it included in those
    new cost estimates?
        Dr. Adirim. Sure. That list of 36--I am hoping to get
    clarification for some of them--it depends on what that
    particular item is. A number of them are what is called
    ``capability enhancements,'' meaning that they are above and
    beyond the base contract or the commercially available system.
    Some of these get at how VA may have some uniqueness in how
    they want to deliver health care.
        So pharmacy, for example, is one of those capability
    enhancements. Actually, we put on contract seven enhancements
    to pharmacy. That is above and beyond the base of the contract.
    So it depends on which item you are talking about.
        Senator Moran. Most of the fixes in that list of 36 will
    not happen until after March 2023, when Seattle is supposed to
    go live with Cerner. Does it make sense to bring Seattle online
    in the absence of those fixes being completed?
        Dr. Adirim. I tend not to call many of them fixes. They are
    really enhancements to the way that VA health system wants to
    use the EHR to deliver its health care. And if you think of it
    that way you can understand why it is above and beyond the
    commercial product.
        The ones that are most important to the health system are
    the pharmacy enhancements and the suicide flags. With regard to
    the pharmacy enhancements, three of the seven changes that VA
    would like, the pharmacy community and the clinician community
    have identified top three that are the most important to them,
    that will solve a lot of issues for our practitioners.
        So those top three we have already started the contracting
    process. The ball is now in Cerner's court for telling us when
    those can be delivered. And we are hearing from them that it
    will likely be February. So, you know, we do not have the final
    milestones but we are working on that right now and should have
    that estimate very soon.
        Senator Moran. Thank you. Mr. DelBene, I just have a few
    seconds that I do not have left. During your confirmation
    hearing, I asked you to describe the CIO's role and how you
    intend, with the cooperation from others at the VA responsible
    for EHR. I asked you how you were going to get us to the point
    we need to be. What are your thoughts today?
        Mr. DelBene. Thank you for the question. I think at the
    time I said that it is not my direct responsibility on the EHRM
    program. But I have been involved in working with the technical
    people that are on the program to use the knowledge that I have
    from my long-term experience in the field to kind of identify
    those places where I see the rocks that maybe others do not
    see. One of the things you have to do in a program like this is
    to be incredibly rigorous about seeing every issue along the
    way and tracking them to ground.
        And we are really doing all the work we can to have a
    performance monitoring program, a plan for their remediation
    efforts across the board, which are quite extensive, and making
    sure they actually come to fruition, and then giving the
    feedback to the program officer to say, given where the program
    is in terms of stability, this is what we would recommend in
    terms of the technical readiness, for instance, to go further
    in the deployment. So, I am trying to stay as deeply involved
    as I can.
        Senator Moran. Thank you.
        Chairman Tester. Senator Brown.

                         SENATOR SHERROD BROWN

        Senator Brown. Thank you, Mr. Chair, and Senator Moran
    thank you, Ranking Member. Before asking questions I want to
    call out and thank the frontline employees in Columbus, Ohio,
    for their dedication to VA's mission, providing high-quality
    care to veterans in a timely fashion, Doctors Arensman and
    Cooperman, the frontline doctors, nurses, pharmacists, and
    administrative staff, who have worked day in and day out since
    April 30th to make a seamless transition from VistA to Oracle
    Cerner's PowerChart. The team still has significant concerns
    about pharmacy issues and system latency.
        OIG has reported on many patient safety, interoperability,
    and readiness concerns since the initial go live in October, a
    year and a half ago. My colleagues have already raised last
    week's OIG report, regarding the unknown queue patient safety
    and patient harm. The fact that end users were not trained on
    this feature prior to go live is unacceptable. During briefings
    with staff at the Chalmers facility in Columbus, the Chalmers
    Wylie facility in Columbus, my office heard about two other
    queues, the VA needs scheduling and the Virtual Room.
        Dr. Cox, if you would, walk us through why the VA needs
    scheduling queue could pose patient safety concerns, especially
    for behavioral health problems.
        Dr. Cox. For behavioral health problems or for any clinical
    service that a veteran needs, if the scheduling queue is not
    working properly or if it is not providing answers back to the
    clinicians scheduling those consults and referrals, then there
    is a risk that the veteran may not get the service that they
    need.
        Senator Brown. Dr. Cox, prior to Columbus go live they
    increased the number of community care referrals to plan for
    the decreased productivity of switching, in those days, Cerner.
    This created a backlog in community care referrals. They are
    still working through some delays regarding scheduling.
        Do you have concerns regarding patient care or safety when
    more veterans are referred out into the community because of
    the EHRM deployment, especially since community providers also
    have a long wait time?
        Dr. Cox. Thank you, Senator. Yes. So there is an expected
    decline in productivity for several months after any hospital
    takes on a new electronic health record, and VA and the
    Veterans Health Administration indeed did plan for that. One of
    those strategies is to rely on community partners.
        But you are absolutely correct. Particularly in many areas
    of the country where the availability of services in the
    community is not as great as that in the VA, sometimes veterans
    end up waiting longer.
        Senator Brown. So, since that day in October 2020, since
    the go live date, how many degradations or outages of the EHR
    system have there been? That is for Mr. DelBene. I am sorry.
    Mr. DelBene, that is for you.
        Mr. DelBene. I believe 48 in total, of which I think 24
    were degradations, versus outages.
        Senator Brown. So, half and half.
        Dr. Adirim. There were a smaller number of outages.
        Mr. DelBene. Right.
        Senator Brown. Twenty-four is half of 48. Okay. These are
    because of issues mostly on Oracle Cerner's side?
        Mr. DelBene. When we talk about an outage we are talking
    about the core software being unavailable if it is an outage,
    or degraded in service, if it is a degradation. Now some of
    that degradation could be a design flaw and some of it could be
    the way it is configured. So, whether it is a software flaw per
    se, it is a mix in that degradation space in particular.
        Senator Brown. Overwhelmingly on Cerner's side?
        Mr. DelBene. Yes. Absolutely.
        Senator Brown. How are you working to address Oracle Cerner
    server issues then? Walk through that with me, Mr. DelBene,
    please?
        Mr. DelBene. Yes. There are a number of places. If I step
    back there are a number of places where the stability has been
    an issue. The first, is around change control, and there we are
    getting very rigorous in terms of how we look at how they are
    doing testing, how they are doing change control. The second,
    is around how much capacity they have in the system, and we are
    pushing them to increase the capacity as more DoD people come
    on and VA people come on.
        The third is around particular functional problems in every
    place and getting those resolved. The fourth, is around
    resiliency. A lot of the problems have been where the system
    was designed to be resilient, but did not perform in a
    resilient way, so a piece failed, and it is supposed to fail
    over to another piece of capacity and it did not. And so, we
    are pushing them to get those problems solved.
        And then the final area is around disaster recovery. If the
    entire thing went down, do they have another site that is fully
    available and deployed that they could switch over to?
        And so, we are pushing them to have an engineering plan
    across all those dimensions.
        Senator Brown. So, it is pretty clear where the
    shortcomings have come from, and the failures have come from,
    not frontline employees, in Columbus, or for that matter in
    Spokane or Walla Walla or Roseburg or White City, but from
    Cerner, or now Oracle Cerner.
        My question, Dr. Adirim, to you is will you recommend to
    the Secretary to stop the rollout to future health facilities
    until these patient safety concerns are addressed and fixes are
    in place?
        Dr. Adirim. I think we have already done that. So today we
    held what we call a go/no-go decision with Boise, the VA
    Medical Center, and using what we know and our checklist for
    what needs to be in place to be successful and safe, we worked
    with the VAMC director as well as the VISN director, and on
    this particular call we had VHA leadership in order to discuss
    what the pros and cons and how we should move forward.
        So today we made the decision that the system just was not
    in a place, because of the latency, as you described, as well
    as other pieces that were not in place for us to be confident
    that we could have a successful deployment. And that is the
    change in the deployment strategy that I was able to bring to
    this particular program.
        With regard to the bigger medical centers, we presented to
    the Secretary that we were not quite ready to go to larger,
    more complex sites because of the system stability issues that
    Mr. DelBene has described, and we wanted to give Cerner more
    time to address those issues before going to the larger medical
    centers.
        Senator Brown. And last comment. Thank you for that. These
    fixes need to be addressed before the rollout, before the
    rollout, when you talk to the Secretary.
        Dr. Adirim. The system stability issues, yes, absolutely.
        Senator Brown. Thank you.
        Chairman Tester. Senator Tuberville.

                        SENATOR TOMMY TUBERVILLE

        Senator Tuberville. Thank you, Mr. Chairman. Thank you for
    being here today and your help with our veterans. Dr. Adirim, a
    Columbus VAMC town hall concluded, among other things, that the
    Cerner implementation had significantly impacted pharmacy
    service. We talked about that. However, pharmacy staff still
    remain dedicated to providing the highest level of care
    possible to our veterans.
        What steps is the VA taking to ensure pharmacy service
    continues to support veterans while Oracle moves forward with
    Cerner's electronic health record rollout, especially given the
    complications at Columbus?
        Dr. Adirim. Thank you, Senator, for that question, because
    there is actually a little bit of good news here. As I
    mentioned, we have really pushed to get the pharmacy
    enhancements in place to help reduce the burden on our pharmacy
    community and our clinician community, and so that is
    progressing pretty well.
        But the other thing that I did after the town hall--and I
    meet frequently with Drs. Cooperman and Arensman--they have
    been super helpful with the program, by the way--we have
    contracted with an FFRDC, MITRE, to look at the workflows at
    pharmacies, starting the first one, to determine where there
    are areas where we can create efficiencies and improvements for
    our frontline providers while we wait for these pharmacy
    enhancements to be put in place.
        Senator Tuberville. Has the average time for a pharmacist
    to complete orders in Cerner decreased, and if so by how much?
        Dr. Adirim. I do not know the specific numbers, but what we
    do know is that when you do deployments that when you first are
    using the system there is a period of time, and we call that a
    period where you are learning to adopt the system, where it may
    take more time to perform those tasks. And then over time, as
    you learn the workflows better and you become more confident in
    the system, that time goes down.
        Now I do monitor the metrics on a part of the system called
    ``Lights-On.'' We call them adoption metrics, to determine how
    the clinicians, including the pharmacists, lab, and so on, how
    they are doing with their turnaround times and their work. All
    the sites have improved since they have gone live, so that is
    good.
        Senator Tuberville. And in your testimony you confirmed
    that over 50 percent of the Department of Defense's electronic
    health record rollout has already been completed, with 100,000
    active users. Meanwhile, the VA has rolled out EHR to five
    sites. What is causing the difficulty at the VA rollout not
    seen at the DoD over the same modernization effort?
        Dr. Adirim. No, that is a really good question, and
    actually to be precise it is five sites but there are 22
    community-based outpatient clinics, 52 remote sites, and we
    have about, a little over 10,000 users. So we are making a
    little bit of progress.
        DoD had similar issues at their start, their initial
    operating capability, a lot of bumps, same complaints, and they
    pushed through it and made changes and improvements to the
    system. And this is all before we began our deployments. But
    there are some areas where VA prefers--or I should not say
    prefer, but provides care in a different way that is better--
    around pharmacy is one of those areas--that DoD does not do the
    same thing.
        For example, VA has mail order pharmacy internally, and
    they want to be able to communicate between the pharmacy system
    and the patient chart, versus DoD that does not have that same
    functionality requirement. There are other examples like that,
    but they experience the same instability issues as we do with
    the system. And so we are working with them, closely, through
    the Federal EHR Modernization office as that governance piece
    for the two departments, to work on making those improvements
    and pressing Oracle Cerner to make those changes that we need
    for a stable system.
        Senator Tuberville. You know, where the VA maintains a 10-
    year implementation timeline, along with a total of $16 to $18
    billion cost estimate, of which $6 billion has already been
    spent, you know, the Institute for Defense Analyses estimates
    that at least 13-year implementation timeline and a cost
    estimate of nearly $39 billion.
        What is the VA doing to ensure the 10-year implementation
    timeline holds, especially when the new electronic health
    records is only at five medical centers so far and will likely
    not expand any more this calendar year?
        Dr. Adirim. Yes, no, it is a struggle, and we are looking
    for places where we can achieve efficiencies. We want to get
    the system to a place where, what some of us call the core EHR
    and the core package of training, change management activities
    and all of that, so that we can take it across the enterprise
    in waves much more quickly. And clearly we are not there yet.
    We are still in initial operating capability, making all those
    changes and enhancements that we need to do in order to do
    that.
        DoD was able to do that. They got to a point where they
    could take the deployment through waves, and I want us to be
    able to achieve that.
        With regard to the lifecycle cost estimate, comparing that
    to what our budget is, is really comparing apples to oranges,
    and here is why. That is a lifecycle cost estimate so it is a
    25-year horizon as well as including a risk premium in there.
    In case certain things do not happen it is going to cost more.
    They also include reductions in operations that may be of cost.
    So it is really difficult to compare that. I work with a
    deployment budget, and we are doing everything that we can to
    ensure efficiencies within that budget.
        Senator Tuberville. Thank you.
        Senator Moran [presiding]. Senator Hirono.

                          SENATOR MAZIE HIRONO

        Senator Hirono. Thank you very much. This is for Dr.
    Adirim. You noted in your testimony that this same system has
    been successfully implemented at DoD sites across the country,
    which should have given the VA kind of a blueprint to follow
    and some lessons learned, but we are having major problems,
    including this queue situation, unknown queue, where all these
    orders go out to someplace and nobody knows where. It is very
    unusual how that could have happened but there you go.
        So have VA and DoD not been working together to avoid the
    kind of big problems that resulted in, as was acknowledged,
    harm to veterans?
        Dr. Adirim. No, that is a great question, and I think, too,
    we did take some of the lessons learned from DoD. I brought a
    number of those lessons over to VA over the last several months
    in our change and deployment strategy, which includes close
    attention to leadership at the local site and collaborating and
    really integrating within the health system. But DoD is
    different than VA. VA is larger, more complex, and the way that
    care in some areas are delivered is different. So there are
    differences between the two.
        Now with regard to working together, we do, and we do a lot
    of this togetherness through the Federal EHR Modernization
    office. I probably interact with that office at least a couple
    of times a week, and we have to work jointly--you are exactly
    right--because anything that we need to do to the system,
    configuration changes, the pharmacy enhancements, for example,
    have to also be agreed upon by DoD, which they did, by the way.
        So we do work with DoD. They are, as you acknowledge, much
    further ahead in their journey than we are, and I do believe
    that we should be learning from--actually, I like to say
    learning from other people's mistakes.
        Senator Hirono. Well, there was a time when I recall good
    news, when DoD Secretary Gates and VA Secretary Shinseki said
    that they were going to work together to integrate these record
    systems because we are, after all, dealing with that one
    person, whether that person is in active service or
    transferring to VA status, and it is that one person and the
    health record should be. But after something like $1 billion,
    nothing much happened to integrate these two systems, and we
    continue to have these issues.
        Then I am told that, for example, the VA Pacific Islands
    Health Care System, which includes Hawaii, is anticipating that
    40 percent of their current orders will not transfer to EHR. I
    do not understand that either. Which means what? I do not know.
    Then somebody has to actually physically, manually input these
    orders?
        Your faces tell me that this is news to you.
        Dr. Adirim. Yes. We will have to dig into that, and I
    promise you we will. But just so you know, the system that we
    are implementing is the same instance as DoD, so it is the same
    EHR that DoD, which they call MHS GENESIS.
        Senator Hirono. So what I am hearing is that there is going
    to be significant staff time needed to physically or manually
    input information into this new system, and already we are
    having chronic staffing shortages. So how is all of this
    supposed to happen?
        For example, can you contact the VA Pacific Hawaii Island
    System and find out what problems they are having with
    inputting whatever they need into the system? I do not know
    what kind of steps VA has taken to assess the potential impact
    to veterans of information getting into the system, therefore
    delay in their care. It just seems like yet again we are faced
    with a rollout that is not rolling out very well.
        Dr. Adirim. Well, the VA medical centers in that area are
    not scheduled to be deployed any time soon, and we need to look
    into what their specific concerns are and try and help them.
    But the data migration that we have done in the other sites has
    been a pretty ambitious, fairly successful--actually, very
    successful--for all the sites that we have deployed so far.
        So we need to look into that issue and understand what
    their concerns are.
        Senator Hirono. We certainly will follow up with you. Thank
    you.
        Senator Moran. Senator Tester. I am sorry. Senator Tillis.
    One of the T's.

                          SENATOR THOM TILLIS

        Senator Tillis. That is the second time today I have been
    confused with Senator Tester. They thought I voted when he did.
    But I thank you all for being here.
        The first thing I want to get to is reporting going
    forward. You know, we passed the Electronic Health Care
    Transparency Act, which is regular reporting from the VA on
    this project. It is a quarterly report, I think 30 days within
    the end of the fiscal quarter. But honestly, I think it would
    be helpful to you as we go through this, go through the
    implementation, to think about a framework that gives us more
    timely feedback than that. That is minimally what we expect,
    but if you think about your program office, you think about
    some of the test problem reports you are dealing with, some of
    the cutover decisions, those sorts of things, it is a natural
    outgrowth of a competent project management office, and I am
    assuming we have gotten one.
        So it would be helpful for us to sit down and see whether
    or not we can get something on a more frequent basis that then
    the report that we have required now almost becomes incidental
    because we are getting that information more frequently. I do
    not think you want 90 or 100 days to lapse before we get an
    update on some of these things. And I think it is also
    important to give us an idea of when you have, like the unknown
    queue, reach out to us, update us quickly, tell us what the
    remediation factors are versus having to come before the
    Committee in the future.
        So that is just some friendly advice for you in terms of
    how to address the spirit of the Transparency Act but maybe
    front-end load some of that information so that we can
    understand it.
        When you are talking about the lifecycle costs I do not
    necessarily want you to break it down here, but I understand
    what you are talking about, what are the core implementation
    costs versus the ongoing costs of operations. I think it would
    be helpful to communicate back to the Committee for the record
    exactly what that breakdown is so that we do get to an apples-
    to-apples comparison on costs going forward.
        Mr. DelBene, you mentioned resiliency. In the underlying
    contract with Cerner was that already negotiated what the
    service-level agreements needed to be for backup, recovery,
    resiliency, and are they meeting those requirements right now?
        Mr. DelBene. Thank you for the question. Yes, it was. I
    think three 9's, or 99.9 percent uptime is what was expected.
    And I believe there is a schedule in terms of the disaster
    recovery piece, but I believe, generally speaking, think about
    it as four hours to be able to come back to service with the
    core functionality if there is a disaster.
        Senator Tillis. Okay. Have there been any of the contract
    milestones or service-level agreements where they have not
    satisfied their contract?
        Mr. DelBene. Yes. They have not. There was a period of time
    of several months, and others can give you the exact dates, of
    when they were not meeting that three 9's reliability.
        Senator Tillis. What are the contractual ramifications for
    them if they fail to hit the SLAs, service-level agreements?
        Mr. DelBene. I think I would pass that to my contracting
    expert, Mr. Parrish.
        Mr. Parrish. Well one, I am proud of everybody speaking
    acquisition-ese needs, but there are financial impacts for
    failing to meet the levels. It is on a graduated scale, and we
    can get you a copy of that, Senator.
        Senator Tillis. Yes, I think that would be helpful,
    particularly so that everyone here understands that there is a
    motivation on the part of Cerner to achieve the SLAs. I assume
    that there were financial consequences or other contractual
    provisions. I think it would be helpful to communicate that to
    the Committee as well.
        I think it is also important, again, not necessarily for
    this, but there is more of a standard, roughly speaking, more
    of a standard approach in DoD, in their implementation. I can
    understand why, if you take a look at the scheduling system
    that we want to implement in the VA, that is a hairball because
    of the various VISNs and the various health care facilities and
    various methods that they use to augment their scheduling
    baseline. Was there a lot of variability in the way they dealt
    with electronic health records across the VISNs or health care
    centers?
        Dr. Adirim. Just so you know, I came from DoD, and when
    they were having their issues I was asked by the then Assistant
    Secretary to help oversee their, what they were calling ``get
    well plan.''
        The implementation at VA mirrors what DoD did. VA has
    learned from what DoD went through. For example, they found
    that they had some stumbles because they did not have the sites
    on what they call the Med-COI, the network, prior to six months
    before deployment. We learned from that. We do that 13 to 32
    months beforehand. So that is just an example of some of the
    ways that we have mirrored what they do.
        The other way that we have done it, on the functional side,
    is that they have clinical communities. We have clinical
    councils, which are frontline providers from the various
    services that make decisions about workflows and requirements
    and how they want to deliver care. They have the same thing.
    And, in fact, when I created the organizational chart for the
    Office of the Functional Champion, in April, I called DoD and
    asked to see their organizational chart. It is not exactly the
    same but it is similar. So every which way that I can, where
    they have had success or where they have had fumbles, we have
    been able to work with them to make sure that we do whatever
    they did right and avoid whatever they did wrong.
        Senator Tillis. Okay. My time is up. The only other thing I
    would ask that you all submit to the Committee is whatever your
    remediation plan is for the various issues that the OIG found
    in the report. I am assuming that you have got a project plan
    that you are executing. That would be very helpful to see,
    number one, if you agree with the findings, and if you
    disagree, where you do, and if you agree with the findings what
    specific remediation strategies have you implemented. And if
    you could submit that for the record I would appreciate it.
        Dr. Adirim. We would be very happy to, and I want to make
    sure--and I think you are aware--that we meet monthly with the
    Eight Corners staffers on any topic that they want to talk
    about and any information they need. We also push out
    information when we have outages or things like that. We push
    information to all the Eight Corners. So you all should be
    getting that information.
        Senator Tillis. Thank you.

        [VA response to Senator Tillis appears on page 101 of the
    Appendix.]

        Senator Tester [presiding]. Senator Blumenthal.

                       SENATOR RICHARD BLUMENTHAL

        Senator Blumenthal. Thank you so much, Mr. Chairman. Thanks
    for having this hearing.
        I was around when we heard from then Secretary Gates and
    Secretary Shinseki, going to be done within a year.
    Interoperability, right over the horizon. And not just
    interoperability but state-of-the-art, first class,
    recordkeeping and availability. But it was not just them. In
    fairness to them it was just about every Secretary of DoD and
    the VA after them, year after year.
        So I just want to tell you, you are guaranteed immortality,
    because you are going to be part of a case study, I am sure,
    either at a business school or school of public administration,
    or a law school, or many of them, not you personally but your
    agencies, and maybe you personally. If you can get it right you
    would be the hero in this story. Because my own thinking about
    this has gone from disbelief to anger to humor to simply
    outrage.
        And I will tell you what really troubles me most deeply in
    the documents that I have reviewed is the reports that, and I
    am quoting, ``senior staff gave inaccurate information to OIG
    reviewers of EHR training,'' and that is in the July 2022
    report. So you can get things wrong, but to give inaccurate
    information to the inspector general I think is a step beyond
    in terms of lack of accountability.
        So I would like to know from each of you whether you know
    of inaccurate information that has been given to the Office of
    Inspector General.
        Dr. Adirim. I think I will take that. So that is something
    that happened last year. When I came on board it is clear we
    provide all information that is requested of us to our
    oversight bodies. I understand the importance of oversight, and
    it is regrettable that anybody would submit information that
    was not accurate.
        You know, anything that has been asked of us we provide,
    and I have, in fact, issued a letter to all of our staff that
    says that we expect timely release of information to the IG and
    that everybody is free to speak to the IG, if contacted.
        Senator Blumenthal. Have you identified the senior staff
    who gave inaccurate or untimely information to the OIG?
        Dr. Adirim. I am aware of the staff that was involved with
    that, yes.
        Senator Blumenthal. Have they been held accountable?
        Dr. Adirim. They have been held accountable, yes.
        Senator Blumenthal. How?
        Dr. Adirim. I am happy to discuss HR issues with you one on
    one. I do not publicly talk about employees. But we have
    followed all the recommendations of the IG in that report.
    Hopefully we will be able to report that to them soon, so that
    they can close that out.
        Senator Blumenthal. My understanding is that this system
    will not be operable in Connecticut until 2026. Is that
    correct?
        Dr. Adirim. We have not finalized our schedule from 2024 to
    2028 just yet. It is going through the approval processes right
    now. So we have not published that. We currently have a
    schedule from now to the first quarter of fiscal year 2024.
        Senator Blumenthal. Well, I am just looking at the report
    that was given to me. ``VA does not plan on commencing the
    deployment of the system until 2026, at the earliest, in VISN
    1,'' which includes VA Connecticut.
        Dr. Adirim. Oh. You are correct. I stand corrected. That is
    the infrastructure readiness piece. Because the infrastructure
    has to be in place well in advance of implementing the EHR, we
    are about two-thirds of the way done, I think, with the
    infrastructure pieces. So we are going to follow the
    implementation of the EHR to where infrastructure is ready for
    it.
        Senator Blumenthal. Well, I am not an IT expert. I am about
    as far from it as you could possibly get. But it strikes me
    that four years from now, even two years from now, there is
    going to be a whole new world of software and hardware and
    stuff that is going to make all this system a lot less
    efficient and effective than it should be.
        Mr. DelBene. Let me address that. One of the things we have
    identified in the system is the architecture that exists is
    somewhat dated at this point. It is more of a traditional
    client-server architecture as opposed to a multi-tiered cloud
    capacity system, which is how we would design it today. And we
    are working with Oracle Cerner to get them to do a roadmap for
    us as to how they would migrate to a more modern architecture.
        The second thing I would probably say is that as we roll
    out the infrastructure you do not want to do it too far in
    advance so that you can take advantage of improvements in the
    infrastructure itself and the components as they come.
        Dr. Adirim. And I would save that question for Oracle
    Cerner because they are the ones who are responsible for the
    software, the updating of the software. That is a really good
    question.
        Chairman Tester. And they are on the next panel. Senator
    Blackburn.
        Senator Blumenthal. I can take a hint, Mr. Chairman.
        [Laughter.]

                        SENATOR MARSHA BLACKBURN

        Senator Blackburn. Thank you, Mr. Chairman, and Senator
    Blumenthal is a lot more tech savvy than he is making out to
    be. I can attest to that.
        Ms. Adirim, am I saying your name properly? It has been
    pronounced so many different ways.
        Dr. Adirim. Thank you so much for asking. It is A-DIR-im.
        Senator Blackburn. A-DIR-im. Okay. Well, that is great. In
    your testimony you paint a very rosy picture, and you use
    phrases like ``sustained success.'' We are very busy and we are
    productive. But OIG testimony paints a very different picture
    of where VA is with this. They even noted that the program
    created significant risk and caused harm to multiple veterans
    when they were referring to VA leadership, and saying that
    leaders exhibited a lack of care and due diligence. Every time
    we have a hearing about the EHR rollout and modernization
    program we kind of get the same story. VA says, ``We are on the
    road. We have got a plan,'' and OIG lays out all the issues and
    the problems.
        From April 2020 to July 2022, there have been 14 reports
    with 68 different recommendations, and I assume you have seen
    every one of these. Now six of these recommendations are over
    two years old, and they still have not been implemented or
    addressed.
        So what actions is VA taking on the recommendations that
    OIG has pointed out, and why have these recommendations been
    languishing and not acted upon?
        Dr. Adirim. Thank you for letting me clarify a number of
    issues. I do not think we paint a really rosy picture. What I
    do want to say, at the outset, is that this is doable, and what
    is in those reports we take seriously. We do review them. We
    report out on them, especially on the recommendations.
        Senator Blackburn. But you do not implement.
        Dr. Adirim. Some things are more longer-term, take more
    time to implement. But the IG reports look retrospectively.
    They are from when we first went to our first site in Mann-
    Grandstaff. We take those recommendations, from our
    stakeholders, where we have issues, and we apply them to our
    new way of moving forward with our deployments.
        We have had four, what a lot of people would say,
    successful deployments. Do we still have things that we need to
    work on? Absolutely. But we----
        Senator Blackburn. All right. And then let me move on with
    this because time is limited. Now Senator Blumenthal asked you
    about the two employees that had misled OIG and you said you
    cannot discuss that. I would like to know if they have been
    removed from their positions.
        Dr. Adirim. Senator, the IG report says that they did not
    commit any wrongdoing. They provided information that was
    inaccurate and had to be corrected.
        Senator Blackburn. Okay.
        Dr. Adirim. And action has been taken to hold them
    accountable for----
        Senator Blackburn. Leadership is important, and
    accountability is important, it seems.
        Dr. Adirim. Absolutely.
        Senator Blackburn. DoD has completed 50 percent of their
    EHR rollouts, and you mentioned earlier that you would like to
    be able to move for that. But the perception is, and what it
    seems to us, is you have an unwillingness of employees who are
    willing to get trained and move forward and to pick up this
    task. And as you can see there is really bipartisan frustration
    with the fact that this implementation is on schedule. You have
    got five completed deployments, and you are a long way from
    hitting your benchmarks. But there does not seem to be a
    definable plan for how you are going to do that.
        And it appears that DoD employees are doing the job, but VA
    employees are not doing the job. And regardless of what you say
    about technologies or changing technologies, what you have to
    have is people that are capable to implement what is now your
    legacy system, the Cerner system, in order to move to something
    that is going to be a next-generation system. And we would like
    to see a timeline for how you plan to achieve that.
        And my time has expired. Mr. DelBene, I have a question for
    you. I am going to submit that to you for the record.
        Chairman Tester. And we would appreciate a timely response
    on that. I would say that the DoD did get a three-year head
    start on the VA on these electronic records with Cerner.
        Dr. Adirim. May I respond to that, Senator?
        Chairman Tester. Yes, if you want to go ahead and respond
    to Senator Blackburn, not to me.
        Dr. Adirim. Okay. Not to you. To Senator Blackburn. So DoD
    and VA are very different situations. This is really hard work.
    VA has had a system for almost 40 years that people were used
    to, and was created by physicians and frontline providers. DoD
    had three systems that they needed to integrate, and everybody
    knew that they had to move forward with a different system. So
    I think from a change management standpoint we were in
    different places.
        This is going to be a huge lift for us to help our
    frontline providers to use a new, more modern system. It is a
    very different system. And we understand that and we want to
    help them with that.
        Chairman Tester. Senator Murray.

                          SENATOR PATTY MURRAY

        Senator Murray. Thank you. As you all know, I have spent
    the last few years cautioning the VA against moving forward too
    quickly with implementation of this EHR program before the
    facilities and the system were ready to go. A year ago we held
    a hearing about the EHR program with Secretary McDonough where
    I raised those concerns, and in the 12 months since then I have
    heard even more concerns, from the staff on the ground in
    Spokane about how this faulty system is making their jobs
    unacceptably difficult.
        Now we have some more inspector general reports
    substantiating many of their concerns, and equally disturbing
    has been VA's lack of transparency and cooperation with the IG.
        Just this month, I met with veterans and providers in
    Spokane to hear about their experiences with the Cerner system,
    and frankly, I was pretty outraged by what I heard. There
    continues to be flaws with the EHR that risk patient care and
    safety, and VA's written testimony does not match what I heard
    from the providers.
        I do not want to hear rosy picture, minimizing the
    concerns. I do not want to hear any of that. VA might have
    inherited this program, but you own it now, and VA owes our
    veterans a system that works and that puts patients first. And
    I have said it before. VA cannot roll out this system anywhere
    else in Washington State until the issues with this system are
    resolved and the inspector general's recommendations are
    implemented by the VA and closed by the inspector general. And
    the focus right now has to be fixing this in Spokane.
        Now I want to ask you, Dr. Adirim, you answered in regard
    to someone else's question a few minutes ago about how many
    outages there had been, and you said 24 outages and 48
    performance degradations, or Assistant Secretary DelBene?
        Well, the Spokesman-Review printed an article just now,
    just yesterday, that they have a document that suggests those
    numbers underestimate the true frequency of disruptions in the
    system. The document they say they have included more than 180
    incidents classified as degradations, down time, and full or
    partial outages that have affected the system users just since
    September 2021. Do you know why that might be, Dr. Adirim?
        Dr. Adirim. I really do not know what document you are
    talking about. We have ways of determining what are
    degradations and outages directly, so I really cannot explain
    that document that I have not seen.
        Senator Murray. Well, I am happy to see if we can get that
    for you, but there appears to be a huge discrepancy between
    what the VA is publicly saying and how many are reported. So we
    need an answer back to that.
        Dr. Adirim. Sure.
        Senator Murray. I also want to say, you know, I have been
    really concerned about the EHR's impacts on patient safety,
    including the well-documented instance of veterans getting the
    wrong medication or having their medication stopped. Now we
    have a report from the inspector general on another example of
    patient safety risks, this unknown queue. The IG has documented
    that despite having received evidence of patient harm as early
    as December 2021, the Program Executive Director told the House
    Veterans Affairs Committee in April 2022 she did not believe
    there was evidence the system had harmed patients or that it
    will, going forward.
        Now as I just said I talked to veterans who have suffered
    serious harm--I have talked to them personally--as a result of
    the EHR failures. I have talked to providers, personally, who
    are doing double the work to make sure they meet their
    patients' needs while navigating this system. I continue to
    insist that facilities like Spokane keep their over-hires to
    manage this workload.
        So Dr. Cox, is it responsible for VA to continue rolling
    out this program with its existing flaws and its inadequate
    workarounds when there have clearly been instances of patient
    harm and when monitoring patient safety reports could become
    unsustainable?
        Dr. Cox. Thank you, Senator Murray. I would like to say
    that like you I have traveled to Spokane--I did twice last
    year--and got firsthand from those hard-working clinicians and
    frontline staff a demonstration of the challenges and the
    struggles that they were facing. And I believe we owe them a
    debt of gratitude, because the first step in solving any
    problem is to know about it.
        Senator Murray. No one is suggesting that they do not
    deserve a huge debt of gratitude. They are working incredibly
    hard there. My question to you is, is it responsible to
    continue to roll this out?
        Dr. Cox. I believe that because of the dedication and the
    vigilance of those clinicians at Spokane, who have reported
    issues and raised them to our attention so that we could begin
    to work on them and mitigate them and ultimately provide
    permanent solutions to them that we have been able to
    anticipate where we need to put additional safeguards in place
    to reduce the risk at Walla Walla, at Columbus, and at the two
    sites in Oregon that have gone live since then.
        The only way that this system is being used effectively, I
    believe, is because, as you said, our dedicated employees are
    putting in double time, double checking, triple checking things
    to make sure that the care that they intend to deliver to
    veterans is, in fact, delivered. That is not the way it is
    supposed to work. So we are hearing that from our employees,
    just as you have heard from them directly, and we are taking
    those concerns seriously and working shoulder-to-shoulder with
    them.
        Senator Murray. You believe that the system should continue
    to be rolled out?
        Dr. Cox. I believe that we have taken sufficient steps to
    build additional safeguards, knowing where the vulnerabilities
    are, based on the experience at Spokane, to reduce the risk of
    additional harm or to reduce the likelihood of similar problems
    occurring at other sites.
        Senator Murray. I am way over my time, Mr. Chairman. Thank
    you. But I do want an answer back on the number of outages.
        Chairman Tester. Dr. Cassidy.

                          SENATOR BILL CASSIDY

        Senator Cassidy. I am sorry I came in late. So a couple of
    questions I may address that have already been addressed. When
    was this project originally scheduled to be completed, and what
    is the projected completion date now?
        Dr. Adirim. The original 10-year time frame, the contract
    was signed in 2018, so it is a 10-year project, 2028. We are
    currently looking at the schedule--not looking at it--we are
    completing the schedule for a 10-year time frame but we
    understand we are going to need to have contingency plans,
    since there have been a couple of periods where we needed to
    move the schedule to the right.
        Senator Cassidy. So that is without specificity.
        Dr. Adirim. Right.
        Senator Cassidy. Ballpark, do you think it will take 5
    extra years, 10 extra years, 20 extra years, 2 extra years?
    What is a ballpark of the extended time frame?
        Dr. Adirim. Senator, I cannot be specific right now.
        Senator Cassidy. I am not asking for specificity. I am
    asking for hand grenade, almost there. Do you see what I am
    saying?
        Dr. Adirim. So a total wild guess, I would say one to two
    years. I do not believe that once we get this right and we are
    able to take this to scale, and able to do it----
        Senator Cassidy. How are we doing now--I am sorry to
    interrupt--how are we doing now? How many facilities were
    scheduled that had implementation as of this date, originally?
        Dr. Adirim. We have pushed into 2023.
        Senator Cassidy. No, but how many--just period.
        Dr. Adirim. Sure.
        Senator Cassidy. By this day we expected to have ten sites
    up and running. We expected to have eight sites up and running.
    We expected to have six. How many were expected to be up and
    running by this date?
        Dr. Adirim. I am not sure of the number pre-pandemic, but
    the schedule that I was given we should have had about two or
    three more sites.
        Senator Cassidy. And pre-pandemic, what was it?
        Dr. Adirim. I cannot answer that question.
        Senator Cassidy. Gentleman, anybody know?
        Mr. Parrish. Senator, I think we could take that for the
    record and get back with you on what the original plan was.
        Senator Cassidy. That sounds like a pretty basic question,
    but sure, if it takes going to the record.
        I ask because the Coast Guard, using the same program, has
    now completed, despite the pandemic, and DoD, despite the
    pandemic, has now completed. They are up to 72 sites. Now you
    said earlier they had a three-year running start. Okay, I will
    grant you that. But they are on schedule. And frankly, if you
    are telling me that you are two years too late, I do not mean
    to offend but I am thinking you are probably five years off.

    ------------------------------------------------------------------------

    -------------------------------------------------------------------------
    VA Response: Based on deployment timelines produced in 2018, it was
     projected that the EHR would be deployed at 39 sites by July 2022. VA
     executed a re-baseline of the program schedule in June 2022 (https://
     www.ehrm.va.gov/deployment-schedule).
    ------------------------------------------------------------------------

        My folks back home are telling me it is going to be 2025
    before they are scheduled to get it in southeast Louisiana. Now
    maybe they were always on the tail end of when they were going
    to get deployed, but the fact is that seems, bumping up, you
    know, you are pretty far along by then.
        Why has the Coast Guard and DoD done so well and VA done
    poorly, because the pandemic affected all three.
        Dr. Adirim. Right. The difference is that DoD--and I recall
    speaking to my colleagues, even though I was not working for
    the government at the time--they already had that core EHR that
    they were doing----
        Senator Cassidy. We had a core EHR within the VA.
        Dr. Adirim. No, no.
        Senator Cassidy. We had the VistA system, which had
    variations, but nonetheless is a core EHR that VA physicians
    have been using for quite some time.
        Dr. Adirim. Right. I misspoke. DoD was further along by the
    time the pandemic came. They were able to do wave after wave.
    And so when the pandemic hit they were not just starting their
    journey. VA was.
        I believe, in hindsight, that decisions were made about
    where to deploy, how to deploy were perhaps not the best
    decisions, not decisions I would have made.
        Senator Cassidy. So what is the current means of
    communication between DoD, at what level? Because I learned at
    some point long ago that unless it is at a secretarial level we
    would not expect the sort of cooperation between DoD and VA
    that would be necessary in order to have complete integration
    of the two systems. I am concerned about that because a lot of
    health issues occur within six months of separation, and the
    average time to get an appointment at the VA is six months. So
    you would obviously want better communication along those
    lines.
        So my question is, at what level of authority is the
    communication between DoD and VA occurring as regards to
    integration of the two systems?
        Dr. Adirim. That is at the Deputy Secretary level. The
    leadership of the Federal EHR Modernization Program report
    directly to the two Deputy Secretaries.
        Senator Cassidy. So for what it is worth I am told by a
    previous DoD Secretary and separately by a previous VA
    Secretary, if it is not at the secretary level you do not have
    the same authority to make things work.
        So let me ask, maybe they were wrong. How is it progressing
    in terms of the integration between the VA and DoD for record
    interchange?
        Dr. Adirim. There are two different ways that records are
    interchanged. There is the Joint Longitudinal Viewer, so our
    practitioners in VA have access to----
        Senator Cassidy. But they are looking at a PDF of the
    records.
        Dr. Adirim. Right. That is exactly right.
        Senator Cassidy. That is a cumbersome system----
        Dr. Adirim. Yep.
        Senator Cassidy [continuing]. Which is a system you have to
    log into separately. Correct?
        Dr. Adirim. Yes. Well----
        Senator Cassidy. We were told that there was going to be
    seamless integration so that I am on my Cerner and without
    logging into another system I would be able to access DoD
    records, or vice versa.
        Dr. Adirim. Right. When we deploy to more sites that is
    definitely going to happen.
        Senator Cassidy. At the sites where you are now how is that
    going?
        Dr. Adirim. They have access to DoD records. All their
    dated information----
        Senator Cassidy. Through the legacy system, not through----
        Dr. Adirim [continuing]. Has been migrated into the----
        Senator Cassidy. It is the legacy system, not the Cerner
    system.
        Dr. Adirim. Into the Cerner system. It is pretty unique.
    All the data has been migrated.
        Senator Cassidy. So let me ask because I am almost out of
    time. In fact, I am but he is being forbearing. Of the four or
    five places you have deployed, they can log in through Cerner
    and see a patient's record while she or he was in the DoD.
        Dr. Adirim. Correct. Yes.
        Senator Cassidy. You were going to say something, sir?
        Mr. DelBene. Yes. We may miss the fact that underlying the
    system, the records are in the same database. So, at that point
    just moving that particular site to the Cerner system allows
    that kind of transparency as well, and those systems are
    connected at the beginning of that deployment.
        Senator Cassidy. So, I can see insulin dose given over time
    longitudinally, whether or not it started in DoD and it is
    completed in VA.
        Mr. DelBene. Correct.
        Senator Cassidy. Thank you very much. I yield. Thank you,
    sir.
        Chairman Tester. Thank you, Senator Cassidy. I have got one
    really quick one and then we will get to the next panel, and it
    goes to you, Kurt DelBene. You know very well that I thought,
    and I still do think, that you are an incredibly talented
    person when it comes to IT. But, the truth is that with this
    new analysis that has come out it shows that this is going to
    cost $50.8 billion over 28 years.
        It would seem to me, as a layman, that most of the money
    and most of the cost should be up front, Okay? In other words,
    the money you are spending right now, getting the records
    straight, by the time they get to southeast Louisiana it should
    be pretty well tricked out and it should not cost that much to
    get there, or to Montana. Pick your spot.
        So, tell me if that is correct, and tell me if, in this
    analysis that was put out by the Institute of Defense Analysis,
    if this $50.8 billion over 28 years, what percentage of it is
    over the next 3 years, number one, or next 10 years, and what
    percentage goes in the last 18, and is there any way we can
    bring down costs?
        Mr. DelBene. It is a great question. I do not necessarily
    think I am in a position to defend the specific analysis that
    was done by IDA. What I would say----
        Chairman Tester. But, you are in a position of knowing IT
    like I know the back of my hand.
        Mr. DelBene. Yes, I know IT fairly well. I do think there
    is a lot of up front cost. I think you get to a point where--
    first I would say we do not have the up front cost as much on
    the development of the system from scratch. There are a bunch
    of integrations we had to do which have a cost associated with
    them. Once those are established, we will go into a
    stabilization and a sustainment mode for those. So, I do think
    you are right that the costs will be higher up front and then
    will tail down.
        I think eventually we will get to a point where we will be
    able to reduce the costs on the existing system. I think people
    have tended to think that is earlier than it will be because
    there are a lot of systems connected to the old VistA system
    and CPRS that will have to be sustained and connected in. But,
    I think you are generally right.
        As far as what they put in their estimate there is a bunch
    of risk analysis. There is an estimate that is pretty far out
    there about what the long-term sustainment cost will be. But, I
    do think you are absolutely right. They are going to have an up
    front cost, it is going to tail down, and our deployments will
    get better.
        In terms of how we reduce the cost, I think it is about
    patterning and getting a pattern established so that the sites
    that are longer or farther out there in the schedule, they are
    using equipment that we already have integrations for. The
    training we get honed into a more repeatable process.
    Everything we do we get more repeatable and it will just become
    rote for us to deploy to additional VISNs and additional sites.
        Chairman Tester. Thank you all for being here. I appreciate
    it. This conversation will continue, and I hope it is both
    directions so that we can help you do your job and we can
    ultimately help the veterans who need help. So thank you very
    much. You are dismissed. You are certainly welcome to stay for
    the second panel.
        And I will introduce the second panel as we are getting set
    up here. First David Case, who is Deputy Inspector General from
    the VA's Office of Inspector General, who is going to discuss
    the oversight efforts related to VA's EHRM. And I would like to
    commend the IG and the entire staff for their tireless work
    examining these issues over the last several years.
        Then there is also Mike Sicilia, who is Executive Vice
    President at Oracle. It is important we have Oracle at the
    table because Oracle is the company that recently acquired
    Cerner, and we look forward to hearing from you. We will start
    out with Mr. Case. David, the floor is yours.

                                PANEL II

                                  ----------

                        STATEMENT OF DAVID CASE

        Mr. Case. 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 EHRM program.
    Our oversight is focused on helping improve the program so
    veterans receive the highest-quality health care and providers
    are not having to do extra work to minimize the impacts on
    veterans.
        When I appeared before this Committee in July 2021, we had
    issued five reports examining the new system. Today, we have 14
    reports. This year, we released reports about the experiences
    at Mann-Grandstaff. We found significant issues with medication
    management, patient care coordination, the trouble ticket
    process, and an absence of EHR metrics. We also found VA and
    DoD must do more to develop an interoperable health record and
    that VA lacks a reliable and comprehensive integrated master
    schedule.
        I want to turn to the two reports we published last week.
    First, the unknown queue report addresses orders that providers
    write for patients to receive tests or other services. This EHR
    requires a provider writing an order to match the order to a
    certain delivery location. But, if a provider selected an
    option that did not match the order to the correct delivery
    location, then the order would go to the unknown queue. Most
    problematically, the provider was never informed the order was
    not delivered.
        Cerner leaders told they had no knowledge that VA was told
    about the unknown queue before go live. During our exit
    conference, we were provided Cerner documents noting a VA
    leader had approved of its use, but that official told us they
    had no awareness of it. This is reinforced by the fact that
    there was no training on the unknown queue, no planning for it,
    and its existence was unknown at Mann-Grandstaff. As one VA
    clinician noted, ``We stumbled on the unknown queue.''
        In 2021, VHA patient safety experts identified 60 safety
    concerns with the new system and the unknown queue was one of
    the three highest risks. During 2021 and 2022, Cerner and VA
    took actions to minimize the unknown queue, but every site that
    goes live will need to monitor and manage their unknown queue,
    and we have concerns about the adequacy of the current
    mitigation plan.
        Unfortunately, VHA patient safety experts identified nearly
    150 veterans at Mann-Grandstaff who suffered harm due to the
    unknown queue from go live through June 2021.
        We are concerned with the VA Deputy Secretary's response to
    our report that is essentially silent about those harms.
    Acknowledging harm is critical for VA as a learning
    organization, and patient safety must anchor all health care
    activities.
        Second, we published the administrative investigation
    resulting from our 2021 review of deficiencies in training on
    the new EHR. This administrative investigation found OEHRM
    Change Management leaders provided inaccurate information about
    training evaluation to us. We concluded this happened due to
    inadequate care and diligence, not from an intent to deceive.
        When we reviewed the training program, VA provided a
    document entitled ``Training Evaluation Plan,'' but we later
    learned it had not been reviewed, approved, or implemented.
    After go live, we asked VA for the raw data they collected, but
    instead, VA sent us bullet points, saying 89 percent of checks
    were passed in three attempts or less. We later found a VA
    email showing a 44 percent pass rate. VA told us they moved
    from 44 percent to 89 percent by just removing some outliers,
    but after receiving the data we found VA had removed anyone who
    had failed the test.
        Transparency would have made all the difference. First, VA
    should have told us how undeveloped their training strategy
    was. Second, they should have just provided the raw data we
    requested. This episode is concerning because if we had not dug
    into their data, it is likely that you, VA leaders, and the
    public would not have had access to the truth.
        In general, we remain concerned by the number of open
    recommendations from older reports and what appears to be
    continued challenges with being transparent with stakeholders.
    There must be considerable attention focused on ensuring VA is
    ready and resourced for deployments next year at its most
    complex facilities.
        Chairman Tester, this concludes my statement. I would be
    happy to answer any questions you or other members may have.

        [The prepared statement of Mr. Case appears on page 53 of
    the Appendix.]

        Chairman Tester. Thank you, Mr. Case, and there will be
    questions.
        Mike, would you tell me how you pronounce your last name?
        Mr. Sicilia. Si-CEEL-ya.
        Chairman Tester. Si-CEEL-ya. Mike Sicilia, you are up.

                       STATEMENT OF MIKE SICILIA

        Mr. Sicilia. Thank you, Chairman Tester, Ranking Member
    Moran, and members of the Committee. Thank you for the
    opportunity to speak with you today.
        As you know, approximately six weeks ago Oracle completed
    its acquisition of Cerner and assumed its EHRM contract with
    the VA as well as those with the DoD and the Coast Guard. We
    are excited about this opportunity and we believe strongly in
    this mission. We consider the EHRM not only a contractual
    obligation but a moral one to improve health care for our
    Nation's veterans and their caregivers. We intend to exceed
    expectations.
        In my recent meetings with many of you and other
    congressional stakeholders your frustration with the current
    situation was clear. I spent the last six weeks reviewing the
    issue and working through engineering plans, and I have
    concluded that there is nothing here that cannot be materially
    improved in short order.
        I want you to understand that Oracle brings an order of
    magnitude, more resources, and a substantially larger
    engineering team than Cerner alone. We have already shifted
    Oracle's top talent to working on the VA and DoD EHR system as
    the company's combined number one priority.
        A war room has been established, led by a team of very
    senior Oracle engineers. Our war room is conducting a top-to-
    bottom analysis of the entire system and is already hard at
    work making a number of improvements that previously were not
    possible. If something is not working for caregivers or
    patients, we plan to fix it first and work out the economics
    later. Patients and providers will always come first and we
    will not let contract wrangling get in the way.
        Oracle's goals are twofold and in this priority order:
    first, to ensure patient safety above and beyond anything else,
    and second, to deliver to the VA and DoD the most modern,
    intuitive, performant, and secure EHR in the world. We intend
    for this system to be the gold standard.
        As we focus on these goals, we know there are undeniable
    issues that cannot be sugarcoated or ignored. Examining the
    list of 36, provided to us by the Committee, leads me to bucket
    these issues into three categories: performance, design, and
    functionality.
        With regard to performance, this is not unusual with
    commercial EHR systems. The Cerner EHR system is currently
    running on a dated architecture and technology. Today I am
    announcing our intention to move the Cerner application to a
    modern cloud data center within the next six to nine months
    which will deliver far better performance and stability for the
    end user. We will do that once we have permission, of course,
    from the VA and the DoD in parallel to that effort.
        This is the same Generation 2 Cloud infrastructure that
    underpins Oracle's customers' most critical workloads in
    sectors like financial services and utilities. Candidly, we
    anticipate that this alone will be the single most important
    change we make in terms of the current system reliability.
    Moving to a new, state-of-the-art, federally certified and
    secure Oracle data center will be completed at no extra cost to
    either the DoD or the VA.
        As to design, applications are largely processes and
    workflows. If the workflow is not intuitive, if it has too many
    steps or clicks, or if it does not quite meet the needs of end
    users, let's change those processes and change the design. The
    case in point is the so-called unknown queue that the Deputy
    Inspector General just spoke about. We take this report very
    seriously and agree that further changes are required.
        Cerner and VA worked in the recent past to reduce the
    number of orders going into the unknown queue and to better
    address those orders that were sent into it. However, we can do
    even better. We intend to make this process work for the end
    users and the patients with increased automation and alerts and
    a workflow designed largely to prevent orders from ever
    entering the unknown queue in the first place. We believe these
    changes can be implemented within weeks.
        The third category of items on the list are areas where
    functionality is not yet developed or not yet ready for prime
    time. Maybe the best example here is pharmacy. My inclination
    with the pharmacy module is to start over and make pharmacy an
    example, a showpiece of what is to come. Today, I am announcing
    that we believe we can have a beta version of the new pharmacy
    module built and delivered within six to nine months from
    today.
        In conclusion, we recognize this list of 36 could grow as
    quickly as it shrinks, and other issues will come up that need
    to be addressed. You can be assured we are triaging all of the
    issues that we have been made aware of to date and working
    through them with appropriate clinical and engineering
    expertise, where needed.
        Oracle is excited to be the VA's new partner on the EHRM
    project. With a little time, we can deliver a world-class EHR
    for all of the veterans who served our Nation and deserve
    nothing but the best.
        Thank you.

        [The prepared statement of Mr. Sicilia appears on page 86
    of the Appendix.]

        Chairman Tester. Yes, thank you, Mr. Sicilia. I will tell
    you, I do not think there is anybody on this Committee that is
    not rooting for you, if you get this done and get it done
    right. I do not think anybody on this Committee has been overly
    impressed with what has happened up to date, and so we have
    great hopes for Oracle. But as you well know, talk is cheap.
    Production is what we want to see.
        And so I am going to start with you, Mr. Case. For
    starters, could you just very clearly and simply explain what
    the IG's unknown queue report found?
        Mr. Case. Senator, this EHR requires a provider writing an
    order to match that order to a certain delivery location, but
    if a provider selects an option that did not match the order to
    the correct delivery location, then the order would go to this
    unknown queue. Providers did not know this was happening, and
    we found that Cerner and VA leaders did not train staff about
    the unknown queue. They did not plan for the unknown queue
    prior to go live. So four days after go live, at Mann-
    Grandstaff, someone submitted a trouble ticket, and all of a
    sudden it started to be revealed to Mann-Grandstaff staff that
    this unknown queue existed.
        We found that VHA patient safety experts identified that
    one of the most severe safety risks is the unknown queue. It
    was in the top three. And, in part, that was because it was not
    easily detectable by the staff. VHA later identified that
    nearly 150 veterans were harmed by delays in care resulting
    from this unknown queue.
        So, it is the combination of the unknown queue and then the
    harm that resulted that our report addresses.
        Chairman Tester. And I am going to have you respond to that
    very similar question about what Oracle has done to help solve
    this situation in a minute, but I just want to get the timeline
    down right. Who knew about the unknown queue and when, and how
    long was that information before it became public so that
    senior officials in the VA could do something about it?
        Mr. Case. Right. So the first ticket that raised this was
    four days after go live, October 2020.
        Chairman Tester. October 2020. Okay.
        Mr. Case. Yes, sir. And then, at that point, people at the
    facility started trying to figure out what the issue was, what
    went wrong. They discovered, as I recall, 2,000 orders in the
    unknown queue. At that point, it started to be raised within
    VA, and a patient safety team went out there in May 2021,
    meeting Mann-Grandstaff staff.
        In June 2021, the patient safety team started to evaluate
    the potential problems with the unknown queue in terms of
    patient harm. By November 2021, the Deputy Secretary had
    received a report about patient harm at Mann-Grandstaff in
    connection with the EHRM. In December 2021, that same report
    and that information was provided to Dr. Adirim. So that gives
    you the timeline of who knew what, when, where.
        Chairman Tester. On November 2021, the Deputy Secretary,
    was that Remy?
        Mr. Case. Yes, sir.
        Chairman Tester. Okay. And in December 2021 it was Dr.
    Adirim.
        Mr. Case. Right. She had just joined December 20, I
    believe.
        Chairman Tester. And you said there were 2,000 orders. I
    believe I heard--and you will have to correct me, Janko, but
    there were 150 veterans that were potentially harmed?
        Mr. Mitric. Incidents of harm.
        Chairman Tester. When did they know about that?
        Mr. Case. Yes. So that information was being developed by
    the patient safety experts. It was available to Deputy
    Secretary Remy, and also available to Dr. Adirim in 2021,
    November and December, respectively.
        Chairman Tester. So when they found out about the unknown
    queue they also found out about the veterans that were
    potentially harmed.
        Mr. Case. Right. Well, the unknown queue, that information
    was coming up earlier, Senator. The patient safety team went
    out there in May 2021. At that time they were already taking
    steps at the facility to try to address the unknown queue.
        Chairman Tester. Okay. Thank you. Mike Sicilia, what is
    Oracle's response to this unknown queue bit?
        Mr. Sicilia. Well, the situation, as is, is, of course,
    unacceptable. So what we have done initially is to reduce the
    number of items that appear in the list. The list is the pull-
    down that the doctor would select for a place for the order to
    go. Frankly, there are just too many items in the list and it
    is not intuitive when most of the items in the list are not
    relevant to that particular physician. So that has been
    reduced.
        What we are also developing right now is an automatic
    trigger, and that should greatly reduce the number of orders
    that show up in the unknown queue to begin with. But we are
    also developing a trigger to say if something does come into
    the unknown queue, which we think will be greatly reduced, that
    physician will be alerted immediately that there is an order
    that is unassigned. That alert will continue to persist. They
    will continue to be reminded of this until they rectify the
    order and assign it to the proper location.
        I would say the other thing, just thinking about it
    logically, the name of the unknown queue is not so great. It
    should really be the ``look here queue,'' right away because
    something does not belong here. And these are the types of
    things, from a system intuitive standpoint that are not very
    difficult for us to address. And as I said, we plan to turn
    that trigger functionality over to the VA for testing by August
    1st.
        Chairman Tester. Perfect. Coach?
        Senator Tuberville. Thank you, Mr. Chair. Thank you all for
    being here today. I am new at this job. My phone rings off the
    wall about the VA. My goodness. You know, of course in Alabama
    we are loaded with veterans and we have got some good VAs, and
    I appreciate you all's work and your thoughts on this. There
    will be a lot of people who will be listening and wanting to
    know what is going on.
        We just heard from the VA group and how they plan on
    staying online and staying within budget and all that. You
    know, we are talking about a lot of money. We are talking about
    modernization. And now that Oracle has acquired Cerner you all
    now own this contract, and I would hope that you would come
    back quite often and give us some oversight on what is going on
    and how we can make it better, you know, stay on time and help
    our veterans.
        You know, we have got a lot of people out there, and a lot
    of the burn pit people are starting to get in line, ready to
    go. So it is going to be interesting.
        Mr. Sicilia, will you commit to providing timely, honest,
    comprehensive updates to this Committee about what is getting
    ready to happen and what is going to happen in the future and
    the problems? You know, we need to hear about the problems
    instead of after they have happened.
        Mr. Sicilia. Sure. Absolutely. I commit to be here myself,
    in person, at every hearing going forward. At both the Senate
    and House hearings as well. I will be here. I am ultimately
    responsible for this at Oracle, and it is my job to make sure
    that this is successful. So you will hear from me early and
    often, as you said, I think more importantly to hear from us
    proactively rather than after something has already happened is
    the better course of action.
        We will also take a look through, you mentioned, the costs
    and the budgets. I have not had a chance to review the overruns
    that were potentially presented this morning in great detail,
    but I do think that moving to a more modern cloud architecture
    gives us economies of scale that we potentially, at least on
    the infrastructure side of things, that Oracle would control,
    have some cost savings that can be realized.
        Right now, I would assume that the assumptions are that the
    technology remains static for a certain period of time, which I
    frankly do not think is the right approach. We need to continue
    to evolve this technology, because technology, by default,
    usually becomes cheaper to operate, not more expensive to
    operate. And we want to make sure that we can pass those
    savings on to the government.
        So by moving these to modern cloud data centers, of course
    we will do all of this in coordination with the VA and the DoD,
    and by looking at modern, stateless web applications, which is
    how I described the pharmacy application that will roll out, I
    do think that we will get compressions on the Oracle Cerner
    cost side of this as we go forward.
        Senator Tuberville. Yes. What conversations have you had
    with the VA on maintaining a timeline, you know, of the cost
    commitments and of the electronic health records? Have you had
    good conversations with them?
        Mr. Sicilia. We have not yet. I mean, in the first six
    weeks here I have been focused on making sure that all of the
    patient safety issues are our first priority, to make sure that
    the system is meeting the needs of the caregivers and
    providers. We have not yet gone deep on the timeline.
        I will be meeting with both VA leadership and DoD
    leadership on August 4th in Kansas City, at the former Cerner
    headquarters, to go through the timelines for moving to modern
    cloud architectures and to look at the overall deployment scope
    of both of these things.
        So primary focus in my first six weeks has been on patient
    safety issues and system reliability issues and now we will
    move into the overall program.
        Senator Tuberville. Do you and the VA believe that the
    current timeline and budget is still manageable?
        Mr. Sicilia. I do not have telemetry into the entire VA
    budget. I can tell you that from an Oracle Cerner perspective
    we are prepared to deliver on the contractual obligations at
    the current costs that have been appropriated to Oracle Cerner.
        Senator Tuberville. Mr. Case, the OIG testimony describes
    certain VA leadership having careless disregard for the
    accuracy and completeness of the information they provided to
    the IG team and the leaders, lack of care and due diligence
    resulting in misinformation being submitted to the OIG staff.
    And, by the way, one was fired for this uncooperative behavior,
    and failure of leadership, he was not fired but he was just
    moved to another position. Is that how we do things?
        Mr. Case. Senator, the actions that are going to be taken
    with regard to these two individuals--and you are correct, our
    finding was there was no intent, which means there is no crime
    here--but we did find a careless disregard for----
        Senator Tuberville. Was it lack of knowledge?
        Mr. Case. It was a whole mix, a lack of communication, a
    lack of checking what the data was, a lack of even
    understanding what data was being produced by the consultant
    who was working on this. So there were a lot of problems. We
    wrote our report. Our recommendations were turned over to VA.
    It is within their purview to decide how they want to hold
    these folks accountable or whatever actions they want to take.
    We have no purview or authority to take action or really to
    recommend action.
        So, we have given them the facts, and it is up to the
    Secretary and those he has designated to take action on this,
    what action they are going to take.
        Senator Tuberville. I got great advice from one of my old
    mentors years ago, Tom Landry. He said, ``Coach, in your
    business now you are getting ready to move on up. Organization
    and communication is the key to winning, and if you can't do
    that you will never make it.'' And it sounds like we had a
    little communication and organization problem here.
        Mr. Case. That was certainly a significant part of it, sir.
        Senator Tuberville. Yes. Thank you.
        Chairman Tester. Senator Sinema.

                         SENATOR KYRSTEN SINEMA

        Senator Sinema. Thank you, Chairman Tester, for holding
    this hearing, and thank you to our panelists for being here and
    for the service that you provide for America's veterans.
        Electronic health record modernization is more than just
    digitizing paper copies. It is about supporting the military
    community to ensure they are getting first-class health care.
    It means that servicemembers no longer have to hand-carry
    stacks of paper PCS or lose their prescription history. And it
    prevents forcing veterans to undergo duplicative and invasive
    procedures. And finally, it helps collect data for research and
    longitudinal studies to better predict health concerns and get
    faster treatment. We need to make sure we get this right, and
    we need to do so in a way that is responsible to the taxpayer.
        So my first question is for Mr. Sicilia. I have been told
    that at one VAMC in Arizona the VA paid more than $2 million
    for repeat and unnecessary imaging procedures because the
    electronic records were not compatible. What is the rate of
    repeat advanced imaging veterans must undergo due to VA
    clinicians not having digital access to prior images from a
    private community provider?
        Mr. Sicilia. Well, having been involved in this project for
    six weeks I do not yet have the exact details on specific cases
    like that. I am certainly happy to submit a formal reply to you
    in writing as I work on that with the team.
        Senator Sinema. Thank you. In places such as Phoenix and
    the Tucson VAMC and the other VISNs where they have a tool for
    electronic radiology image transmissions, do you have any
    information about how the rate of repeat imaging and number of
    unnecessary imaging such as mammograms change?
        Mr. Sicilia. Again, I do not have specifics into imaging
    functionality at this point but certainly happy to provide that
    to you in writing in a very timely manner.
        Senator Sinema. Thank you. And finally, what are the VA's
    plans for providing all of the access to electronic radiology
    image transmission capabilities?
        Mr. Sicilia. I can tell you from a system perspective I
    would defer some of that question to the VA. But the images are
    part of the electronic medical record and this is a
    longitudinal system where there is a common database between
    and among the Coast Guard, the DoD, and the VA. So to the
    extent that those images are part of the electronic medical
    record they will travel with that person as they traverse the
    system.
        Senator Sinema. And to that end, what are the VA's plans
    for integrating this capability into the electronic health
    record management system?
        Mr. Sicilia. Well, the electronic health record system is
    integrated with imaging systems. There are a bunch of different
    imaging systems that are in use throughout the world. I am sure
    the VA is no exception. But obviously imaging is a big part of
    electronic health records.
        Senator Sinema. Thank you. I will look forward to that
    follow up.

        [Oracle response to Senator Sinema appears on page 99 of
    the Appendix.]

        Mr. Case, in 2020, 46,000 veterans had their personal
    information compromised after a cyberattack against the VA. As
    the VA transitions to its new electronic health record system
    even more of our veterans' sensitive information will depend on
    the VA's strict adherence to cybersecurity best practices.
        What lessons has the VA learned from previous cyberattacks
    against its networks as well as attacks against other Federal
    agencies, and what are you going to do to ensure similar
    incidents do not compromise the new electronic health record
    system?
        Mr. Case. Yes. You could look at that issue and it is a
    significant issue as you have identified, Senator. I think
    right now we are doing routine inspections at facilities of
    their cybersecurity and reporting on that in formal reports. We
    inspect on other compliance by VA with cybersecurity questions.
    And as this moves forward, VA will be working with the DoD in
    protecting the records of both veterans and active-duty
    military personnel.
        And, I noted in the testimony from Oracle Cerner that they
    have plans to make moves into the cloud and into systems that
    will enhance the cybersecurity of the process and the system.
        Senator Sinema. Thank you. Mr. Case, in the course of
    investing issues relating to the electronic health records
    management at the VA did you come across any information
    indicating that the DoD electronic health record system is
    limiting health care capacity?
        Mr. Case. We have not looked specifically at that question
    with regard to DoD. We did do a joint project with the DoD IG
    but did not address that issue. I really cannot address
    concerns within the DoD effort.
        Senator Sinema. I would like to follow up on that and find
    out if there is something that the two agencies can learn from
    each other as they go through similar transformations.
        Do you anticipate an issue arising with cross-communication
    medical records between the DoD and the VA for transitioning
    servicemembers?
        Mr. Case. The whole intent of this is to eliminate those
    problems, and as the system is successfully deployed, we think
    it will eliminate those problems. But that is the intent of the
    system. We will monitor that. We do monitor that period of time
    in other aspects as well. That is a period of time, that six-
    month window, which is so important that we monitor in a lot of
    different ways in terms of handoff and efforts to make sure
    that the transition is done in a way that protects the
    servicemember turning to a veteran.
        Senator Sinema. Thank you, Mr. Chair.
        Chairman Tester. Senator Moran.
        Senator Moran. Chairman, thank you. Mr. Sicilia, I am
    testing what you said to Senator Tuberville. I just want to
    have a better understanding. The cost to implement the Cerner
    EHR have risen by about $23 billion. The sustainment estimate
    is $17 billion on top of that, and you expressed previous and
    again today Oracle's willingness to absorb costs. And so if
    that is true maybe my question is poorly worded, but how much
    of this enormous increase is Oracle willing to pick up?
        Mr. Sicilia. Well, it is my understanding that the cost
    estimates are for an overall program implementation, so
    obviously a piece of that would be a portion. What we are
    willing to absorb, the cost, and certainly we will work
    together with VA and DoD, is to move these to modern cloud
    architectures, FedRAMP, high-certified data centers that are in
    place for our other government customers today, and to enhance
    functionality that is within the scope of the current contract.
    And certainly, if there are things that I think would be minor
    enhancements or even moderate enhancements that are a benefit
    to all customers, we are certainly willing to do those at our
    expense.
        I do not believe that going back for a task order or a
    change order for every little bit of functionality is a way
    that we should be operating. Obviously, we need to operate here
    with a far greater level of velocity, and we need to do that
    across the board in good faith with the VA and the DoD.
        As far as exactly how much cost compression there is, I
    would appreciate if I can get back to you in writing on that as
    we have a chance to digest this report, which I just received
    this morning, on these potential cost overruns. So I have not
    had a chance to go through that with the team and assess if we
    can work together with VA/DoD to get permission to move to
    modern cloud data centers, how much infrastructure compression
    that brings to the table as well as we rewrite individual
    modules like pharmacy and how much less expensive that will be
    to operate the software.
        So my intention is to move any potential cost overrun that
    is associated with Oracle Cerner as close to zero as I can
    possibly get it.
        Senator Moran. Was Oracle aware of the magnitude of these
    challenges prior to the purchase of Cerner?
        Mr. Sicilia. That is a good question. I would say there are
    always things that you discover after the fact. You know, we
    certainly had read the press and we certainly had read things
    that were publicly disclosed, but there is nothing like owning
    something to fully understand what is going on.
        That said, I will repeat what I said in my opening
    statement. I firmly believe that everything here is fixable and
    addressable, and we see it as an opportunity, certainly a
    challenge, but we also see it as an opportunity to do a much
    better job for our veterans and their caregivers.
        Senator Moran. And the outcome you believe you can achieve
    is well worth the pain of getting there.
        Mr. Sicilia. I believe so.
        Senator Moran. For the veterans and for the----
        Mr. Sicilia. I believe that the VA implementation can
    become the gold standard for electronic medical record
    implementations worldwide. We deal with organizations, medical
    organizations and governments throughout the world, and I can
    tell you that everybody at this point is far from perfect.
    However, the vision here, the longitudinal health record, the
    fact that it is implemented on a common database--which means
    these records do not have to go anywhere; they all live inside
    the same house, if you will--gives us a tremendous economy of
    scale.
        The difficulties have been closer to the edge. The
    difficulties have been with the systems that interact with the
    providers and their caregivers, and they are easier to address
    than it is to fundamentally have to rearchitect a program and a
    system.
        Senator Moran. By the nature of Oracle's business and by
    your experience is Oracle an appropriate, the right company to
    make this work?
        Mr. Sicilia. Well, we supply infrastructure, large-scale
    infrastructure systems to the systems that power our Nation's
    financial services organizations and utilities. Eighteen of the
    20 top pharmaceutical companies in the world use our clinical
    trials management software, and at the height of the COVID
    pandemic, for example, we had 121 clinical trials running in
    our clinical trial system for either COVID vaccines or
    therapeutics.
        During the COVID period we built and donated multiple
    systems to HHS, specifically to CDC and NIH, for COVID vaccine
    management, for the V-safe post-vaccination safety surveillance
    system. We built and delivered those systems with stateless web
    applications at scale, and frankly, they rarely, if ever, had
    problems.
        So I do believe that based upon our years of experience in
    clinical systems, our over 44 years of experience in dealing
    with large-scale, hyper-scale type problems and extremely
    complicated datasets, that we are well positioned to deliver.
        Senator Moran. Within the chain of command at the VA do you
    know who your primary contact will be who is leading the
    governance of this EHRM moving forward?
        Mr. Sicilia. My primary contact is Deputy Secretary Remy,
    who I have met with and will meet with again tomorrow as well.
    I am also in contact with Dr. Adirim and Mr. DelBene as well,
    as we go forward.
        Senator Moran. And those are the appropriate people for you
    to be in touch with----
        Mr. Sicilia. Absolutely.
        Senator Moran [continuing]. For resolving this?
        Mr. Sicilia. Absolutely.
        Senator Moran. And I guess that answers my question.
        Mr. Case, my final question. Fourteen reports, 6
    recommendations that have been open for longer than 2 years,
    with 24 total recommendations open for more than 1 year. What
    in those reports or open recommendations concerns you the most
    and therefore should concern us the most?
        Mr. Case. Senator, I think the recommendations that flow
    out of our recent report in March of this year, addressing
    issues that impact patient safety, medication management, and
    care coordination are important. I think the recommendations
    that flow into the training questions are important. We issued
    a report in November of last year on the lack of training and
    problematic training in the scheduling system, and last July,
    we issued a report on training overall at Mann-Grandstaff,
    which found it to be insufficient. And, those have to be
    addressed.
        So you have patient safety questions, you have training
    questions, and finally I think there are programmatic issues
    that have to be addressed. There is no integrated master
    schedule that will show how this is going to be accomplished in
    10 years. And, so without that integrated master schedule and a
    risk analysis affiliated with that integrated master schedule
    it is really hard to assess can they get this done, and how
    fast they can get it done.
        Senator Moran. Thank you, Mr. Case. I always appreciate
    inspectors general, and I appreciate you and the Department of
    Veterans Affairs. In those things you just outlined, who is
    primarily responsible, the VA or Oracle, to meet those most
    important features?
        Mr. Case. The recommendations are all directed to VA,
    sometimes different components within VA. Now they will have to
    enlist, I suspect, in some of these, the efforts of Oracle and
    perhaps others. But the recommendations are to VA. This is
    their system, at the end of the day, and especially on program
    management it is something they have to follow, and they are
    the ones who have the patient safety experts in-house that can
    address some of these patient safety questions.
        Senator Moran. So it is not appropriate, it is not fair to
    suggest this is just Oracle's problems to fix.
        Mr. Case. Well, I would agree it is not just Oracle's----
        Senator Moran. That was a question. I did not ask it--my
    voice went up.
        Mr. Case. Yes. It is not just Oracle's problems to fix. As
    I said, the recommendations are directed to VA, and many of
    these are things that VA has to address, sometimes with the aid
    of others--consultants or Oracle or others--but they are
    really, at the bottom, things that VA has to address.
        Senator Moran. Thank you both for your presence today.
        Chairman Tester. Mr. Sicilia, I want just a quick follow up
    on the Ranking Member's questions today. You said your point of
    contact with Remy and Dr. Adirim. How often do you meet?
        Mr. Sicilia. We have a monthly standing meeting and
    certainly lots more conversations in between as well. That is
    with Secretary Remy.
        Chairman Tester. Do you see it as being adequate?
        Mr. Sicilia. I think that is the minimum. I would say we
    will probably move to a more regular cadence. After August 4th,
    when I meet with VA and DoD leadership combined, I plan to
    suggest perhaps a different cadence.
        Chairman Tester. Okay. I want to thank you both for your
    testimony. I do want to close with a statement, assuming the
    coach does not have more questions.
        Senator Tuberville. I would like to ask Mr. Sicilia, what
    is a good timeline to get you to come back, once you have got
    your foot in the door, to really give us an idea of what is
    going on and what we need to do to help you.
        Mr. Sicilia. I think we will show significant improvements
    in the system over the next six months. I think I will be
    prepared to talk about them in more detail in three to four
    months.
        Senator Tuberville. Thank you.
        Chairman Tester. So there are a lot of things on this
    Committee we do together, Democrats and Republicans. I would
    tell you that all the things we do in this Committee pale in
    comparison by our belief that the inspector general
    recommendations need to be followed through and taken
    seriously. And I say that not for this panel but for the
    previous ones, and I appreciate you guys staying here.
        The fact that we have six recommendations that have gone
    out two years, as the Ranking Member pointed out, and 24 one
    year, I will be quite frank with you that that is completely
    unacceptable and needs to be addressed.
        The IG are our eyes on agencies. We are not able to go in
    and do the kind of in-depth investigations that they are, and
    when they come forward with those recommendations, if they are
    not followed through there better be a damn good reason why
    they are not followed through with.
        And so I say that saying today was a pretty calm hearing.
    It is going to get a lot rougher if these issues are not
    addressed, or if they are not addressed there better be a
    really good reason why they are not addressed, because quite
    frankly, it does not matter if it is this area, it does not
    matter if it is on some other committee--and by the way,
    Senator Moran and I serve on all the same committees together,
    and we have the same opinion about IGs, whether it is on this
    Committee or any other committee, that their recommendations
    need to be taken seriously and followed through on, and if they
    are not there is going to be a come-to-Jesus meeting.
        So thank you all. I want to thank the previous panel and I
    want to thank them for sticking around. I appreciate that. I
    want to thank Mr. Case and Mr. Sicilia for being here today.
    The topic of this hearing is technical but it only comes down
    to one thing and that is VA's dedication to frontline employees
    who need a stable, working, cutting-edge EHR to allow them to
    effectively deliver health care on behalf of our 9.2 million
    veterans in this Nation.
        Right now the new EHR is not getting it done. I have great
    hopes that we are beyond the roughest part and we are going to
    be moving forward. Look, I will tell you that I think, I hope--
    I really do hope that the acquisition by Oracle is going to be
    a game-changer. I hope it is. And if it is then that is going
    to be good news for our veterans.
        We are going to keep this record open for a week. With that
    thank you all, and this hearing is adjourned.
        [Whereupon, at 4:54 p.m., the Committee was adjourned.]

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