[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
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                 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.]

                            A P P E N D I X

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