[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON
H.R. 592; H.R. 608; H.R. 1658; H.R. 1659; AND H.R. 2499
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, APRIL 19, 2023
__________
Serial No. 118-10
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
52-207 WASHINGTON : 2023
COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
JENNIFER A. KIGGANS, Virginia, Chairwoman
AUMUA AMATA COLEMAN RADEWAGEN, FRANK J. MRVAN, Indiana, Ranking
American Samoa Member
JACK BERGMAN, Michigan CHRIS PAPPAS, New Hampshire
MATTHEW M. ROSENDALE, SR., Montana SHEILA CHERFILUS-MCCORMICK,
Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
WEDNESDAY, APRIL 19, 2023
Page
OPENING STATEMENTS
The Honorable Jennifer A. Kiggans, Chairwoman.................... 1
The Honorable Frank J. Mrvan, Ranking Member..................... 2
The Honorable Mark Takano, Ranking Member, Full Committee........ 3
The Honorable Matthew M. Rosendale, U.S. House of
Representatives, (MT-2)........................................ 8
WITNESSES
Mr. Phillip Christy, Deputy Executive Director, Office of
Acquisition, Logistics, and Construction, Department of
Veterans Affairs............................................... 4
Accompanied by:
Ms. Catherine Cravens, Chief of Staff, Office of Information
Technology, Department of Veterans Affairs
Dr. Leslie Sofocleous, Executive Director, Program Management
Office, Electronic Health Record Modernization
Integration Office, Department of Veterans Affairs
Ms. Shana Love-Holmon, Acting Assistant Secretary, Office of
Enterprise Integration, Department of Veterans Affairs
Ms. Shelby Oakley, Director, Contracting and National Security
Acquisitions, Government Accountability Office................. 6
APPENDIX
Prepared Statements Of Witnesses
Mr. Phillip Christy Prepared Statement........................... 23
Ms. Shelby Oakley Prepared Statement............................. 30
Statements For The Record
The American Legion.............................................. 49
Fleet Reserve Association........................................ 51
LEGISLATIVE HEARING ON
H.R. 592; H.R. 608; H.R. 1658; H.R. 1659; AND H.R. 2499
----------
WEDNESDAY, APRIL 19, 2023
U.S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 9:30 a.m., in
room 390, Cannon House Office Building, Hon. Jen Kiggans
[chairwoman of the subcommittee] presiding.
Present: Representatives Kiggans, Rosendale, Mrvan, Pappas,
and Cherfilus-McCormick.
Also present: Representative Takano.
OPENING STATEMENT OF JENNIFER A. KIGGANS, CHAIRWOMAN
Ms. Kiggans. Good morning. Thank you to our witnesses for
being here today. In today's hearing, we will examine
legislative options to check the struggling Electronic Health
Record (EHR) modernization effort to address VA management
concerns, and to authorize VA's newest effort to modernize its
supply chain. I will begin with my bill, which is H.R. 2499,
the Supply Chain Management System Authorization Act.
Though I have been in Congress a short time, I have learned
that the VA's major modern modernization efforts over the past
decade have been plagued by some challenges. Government
Accountability Office's (GAO's) written testimony highlights
one of the roots of this problem, and to quote them, ``the VA
often puts actions ahead of planning.''
This reality at the Department is precisely why Congress
must be involved in VA's major programs and why I believe we
need to specifically authorize VA's supply chain effort.
My bill would give Congress the ability to have more
control over the scope, planning, and spending of this major
project by authorizing the VA to purchase and implement a
system for Veterans Health Administration (VHA) focused
specifically on inventory management, requiring the system to
be implemented in 3 years, and directing VA to begin with a
pilot of the system at one location to make sure it really
works for the VA before implementing it across the country.
I appreciate that the Department still has some concerns
with the bill but considering the VA's struggle with a number
of major projects like the EHR Modernization Program, which is
the subject of the next two bills, I am convinced that H.R.
2499 is vitally important.
Now, I will turn to H.R. 592, the Department of Veteran
Affairs Electronic Health Record Modernization Improvement Act
introduced by Chairman Bost. Congress never authorized the EHR
Modernization Program, and it has struggled from the very
beginning. The program is live at only five medical centers
after 5 years, and over $5 billion have been spent. It has
faced issue after issue, and providers and veterans at these
five sites are not getting the support and care they need. That
is why H.R. 592 would require medical center and Veterans
Integrated Services Network (VISN) leadership to certify the
EHRs ready for their hospital before it can be installed. It
would also require the Secretary to certify the EHRs running
without issue 99.9 percent of the time, which is a requirement
in the contract before the EHR can be installed anywhere else.
VA must take these steps to make sure it does not repeat
mistakes made at the first five sites. I look forward to
hearing from our witnesses about this bill.
Also on the agenda today is H.R. 608, to terminate the
Electronic Health Record Modernization Program of the
Department of Veteran Affairs. This bill was introduced by Mr.
Rosendale, the Chairman of the Subcommittee on Technology
Modernization. I will let him speak to the details of this
bill.
Another bill on today's agenda that would impact the EHR
Modernization Program is H.R. 1659, the Department of Veteran
Affairs IT Modernization Improvement Act. This bill was
introduced by Ranking Member Takano and would require VA to
contract for an independent verification and validation
assessment of five major IT modernization efforts to include
the EHR Modernization Program and the Supply Chain Program.
Last, we have H.R. 1658, the Manage VA Act. Also introduced
by Ranking Member Takano, this bill would create an
undersecretary for management. The position would be
responsible for VA's budget, accounting, procurement, human
resources, information technology, and other VA central office
functions. I will recognize Ranking Member Takano in a few
minutes to speak to his bills.
Again, thank you all for being here today and I look
forward to our discussion. I now recognize Ranking Member Mrvan
for his opening remarks.
OPENING STATEMENT OF FRANK J. MRVAN, RANKING MEMBER
Mr. Mrvan. Thank you, Chair Kiggans. I am looking forward
to discussing two bills that I have co-sponsored with Ranking
Member Takano at our hearing today. As the Chair of Technology
Modernization Subcommittee last Congress, I have seen firsthand
the impacts of failures to improve VA's large IT systems. The
Department of Veterans Affairs IT Modernization Improvement Act
is a strong first step to introducing a higher level of support
and accountability for the VA and for Congress.
Independent verification and validation is not a new
concept and has been successfully utilized at the Department of
Defense to ensure that the Department and the taxpayers get
what they pay for. I am very pleased to see that VA supports
this effort and I look forward to hearing their testimony on
this bill today.
A second broader and more aspirational bill we will discuss
today is the Manage VA Act, which would create an
undersecretary of management at the VA and consolidate
acquisition and business functions at the Department. Creating
one management position is not going to fix every issue that VA
has had with managing acquisitions, budget, and IT across the
Department, but it is a start. I feel it is time to provide a
position that has the authority and weight to ensure that we do
not keep making the same mistakes over and over and over again.
We found out last Congress that it took a decision from the
Secretary to end the failed supply chain modernization attempt
with Defense Medical Logistics Standard Support (DMLSS). As we
move toward yet another attempt at modernizing supply chain
management, I want to ensure we are providing VA with every
resource possible to get a successful program at this time.
I would also like to acknowledge my colleagues' bills
concerning the Electronic Health Record Modernization (EHRM)
program. I was happy to lead the EHRM Transparency law with
Chairman Bost and Ranking Member Takano on a bipartisan basis
last Congress. I look forward to continuing to work on a
bipartisan basis on this program and get a system and result
that will benefit veterans and employees.
I am happy to say that we will be introducing and I will
cosponsor the EHRM Reset Act introduced by Senator Tester. This
bill is an ideal platform for negotiating a long-term
bipartisan fix to the program. This bill will address a number
of issues, including in Chairman Bost's legislation today. I
look forward to collaborating across the aisle, as we
successfully accomplished last Congress. I look forward to
hearing from our witnesses today, and I yield back my time.
Ms. Kiggans. Thank you, Ranking Member Mrvan. I now
recognize the ranking member for the full committee, Mr.
Takano, to speak on his bills H.R. 1658 and H.R. 1659.
STATEMENT OF MARK TAKANO, RANKING MEMBER, FULL COMMITTEE
Mr. Takano. Well, thank you, Chair Kiggans. I am happy to
discuss two bills today that I have introduced in this
Congress. I am also happy to say that Chairman Bost and I will
be working together on a bipartisan basis on a long-term
solution to the EHRM program with our planned introduction of
Senator Tester's EHRM Reset Act this week. We have had a lot of
success working together on a bipartisan basis, and I look
forward to continuing to work across the aisle to fix this
problem.
The Department of Veterans Affairs IT Modernization
Improvement Act will require VA to contract for independent
verification and validation of the EHRM, Financial Management
Business Transformation (FMBT), supply chain, and Veterans
Benefits Management System (VBMS) modernization programs. The
key word there being independent. For too long, Congress has
not had the visibility into these large IT modernization
programs that we need to provide necessary oversight. This will
also be an invaluable tool for VA to ensure that the
government, veterans, and taxpayers are getting what they pay
for. This is a long-standing best practice of Department of
Defense (DoD). Given the ever-increasing size of the VA, the
time is now to create this capacity.
My second bill, the Manage VA Act, will create an
undersecretary for management at the VA and consolidate
acquisition and business functions at the Department. With the
continued appearances of acquisition management and management
IT acquisitions and operations on the GAO high risk list, it is
past time that we designated an undersecretary whose expertise
will be the business of government.
The failures to modernize VA's financial systems, supply
chain management, health records, et cetera, has had a direct
impact on the care and benefits we provide to veterans. VA has
not been provided with the management and acquisition resources
commensurate with their responsibilities. Leadership is needed
on these business functions so that our VA employees can do
what they do best, which is provide exceptional care and
benefits to our veterans.
I hope both bills can get bipartisan support. It is in
everyone's best interest to ensure that we are managing the
business of VA wisely. I encourage all my colleagues to support
these bills and I yield back.
Ms. Kiggans. Thank you, Ranking Member Takano. We will now
turn to witness testimony. Testifying before us today we have
Mr. Phillip Christy, who is the Deputy Executive Director for
the Office of Acquisition, Logistics, and Construction at the
Department of Veteran Affairs. He is accompanied by Ms.
Catherine Cravens, who is the Chief of Staff for the Office of
Information Technology at the Department of Veteran Affairs. We
have Dr. Leslie Sofocleous, who is Executive Director of the
Program Management Office for the Electronic Health Record
Modernization Integration Office at the Department of Veteran
Affairs. We have Ms. Shannon Love-Holmon, who is Acting
Assistant Secretary for the Office of Enterprise Integration at
the Department of Veteran Affairs. Last but not least, we have
Ms. Shelby Oakley, who is Director for Contracting and National
Security Acquisition at the Government Accountability Office.
Ms. Oakley, you appear outnumbered by Veteran Affairs members,
but I trust you are not outgunned.
Now I would like to swear in our witnesses. I will ask all
witnesses to please stand and raise your right hand.
[Witnesses sworn]
Ms. Kiggans. Thank you so much. Let the record reflect that
all witnesses answered in the affirmative. Mr. Christy, we will
start with you. You are recognized for 5 minutes to provide
your testimony.
STATEMENT OF PHILLIP CHRISTY
Mr. Christy. Good morning, Chairman Kiggans, Ranking Member
Mrvan, and other members of the subcommittee. Thank you for the
opportunity to appear before you to discuss the pending
legislation that would affect VA programs and services. Today,
I am blessed and flanked by some incredible talent. Joining me
are Dr. Leslie Sofocleous, Executive Director of Electronic
Health Record and Modernization and Program Management Office,
Ms. Shana Love-Holmon, the Acting Assistant Secretary, Office
of Enterprise Integration, and Catherine Cravens, the Chief of
Staff for the Office of Information and Technology.
Madam Chairwoman, in my oral testimony, I will highlight
the Department's views concerning the five bills on the agenda.
Regarding the five bills we are here to discuss, the VA
supports certain provisions of the proposed bills and would
like to highlight areas of concern and certain provisions we
oppose. VA appreciates the intent behind the bills and looks
forward to discussing the opportunities to continue to improve
program management, accountability, and jointness within the
Department. The rationale for our VA's position is outlined in
our written statement.
First, the VA Electronic Health Record Modernization
Improvement Act, H.R. 592, which VA supports, in part. VA
supports the bill's requirement that VA continue to partner
with the Department of Defense and the Federal Electronic
Health Record Modernization Office to improve overall
performance within the EHR and the systems connected to it.
However, VA does not fully support some of the specific
prohibitions and certification requirements. As currently
written, the proposed limitations would pause program
activities and cause significant cost impacts. We suggest
modifications to the bill text to ameliorate these concerns,
and we believe the modifications would work toward facilitating
the intent of the bill.
The second bill focused on EHR, H.R. 608, would require the
Secretary to terminate the program, abolish the EHR Integration
Office, and revert facilities where the new EHR is deployed
back to Veterans Health Information Systems and Technology
Architecture (VistA). VA opposes this bill, as it would
frustrate VA's ability to have an interoperable and
longitudinal record with the Department of Defense. Modernizing
VA's EHR is critical for providing the best care for our
veterans and facilitates advancements in the delivery of that
care. We believe terminating the program would work against
those goals.
As for H.R. 1659, the IT Modernization Improvement Act, the
VA supports the bill if amended and with appropriations. This
bill would direct VA to contract for independent verification
and validation of certain modernization efforts of the
Department. Ideally, VA would have in-house team with the
expertise to conduct Independent Verification and Validation
(IV&V) of its major modernization efforts. Contracting IV&V
support while VA builds internal capacity, makes practical
sense, and will help expedite the resulting delivery of
benefits and services to veterans, their caregivers and family
members. VA anticipates an IV&V contract of this size would be
extremely expensive. Appropriate and timely funding of this
bill is critical.
Regarding H.R. 1658, the Manage VA Act, the VA does not
support. This bill would create a new undersecretary for
management as the chief management officer of the Department.
Integrating the Department's efforts in creating operational
jointness in our support of veterans, their families,
caregivers, and survivors is essential to veterans choosing VA
for care, benefits, and services. VA has implemented robust
governance to drive jointness and integration in support of the
Secretary and the Deputy Secretary who serves as VA's Chief
Operating Officer. This framework enables evidence-based risk
informed decisionmaking that advances the mission of the VA.
Currently, the Assistant Secretary for Enterprise
Integration serves as the VA accountable executive for
enterprise management and governance in support of the Office
of the Secretary. In addition, VA has one of the most
outstanding customer experience offices in the Federal
Government, which serves as a key partner within our enterprise
governance framework to ensure we continue to put veterans
first in all of our decisions and all of our program execution.
The VA already has in place many of the functions this bill
prescribes.
Finally, VA cites concerns with a draft bill that would
authorize the Secretary to carry out an IT system and
prioritize certain requirements to manage supply chains for
medical facilities. As written, the bill may impede ongoing
efforts toward an enterprise supply chain solution. We are
concerned about the timeline for implementation does not
accurately reflect the complexities involved in successful
procurement and execution. VA welcomes the opportunity to
continue working with the committee to provide additional
technical assistance that will create the flexibility and the
scope and timing needed to ensure the success of the supply
chain mission.
Madam Chairwoman, before I close, I wanted to share our
deepest appreciation to the committee and all of the staff that
have worked with us regarding these bills. This concludes my
statement, and we would be happy to answer any questions you or
other members of the subcommittee may have.
[The Prepared Statement Of Phillip Christy Appears In The
Appendix]
Ms. Kiggans. Thank you so much, Mr. Christy. Ms. Oakley,
you are now recognized for 5 minutes to provide your testimony.
STATEMENT OF SHELBY OAKLEY
Ms. Oakley. Chairwoman Kiggans, Ranking Member Mrvan, and
members of the subcommittee, I am pleased to be here today to
assist you with your consideration of the legislative proposals
to improve VA management and key modernization programs. While
Congress provides VA with hundreds of billions of dollars each
year, we are all aware of the opportunities VA has wasted
because it has not followed disciplined management approaches
when planning and executing its programs. EHRM is just one
example, but a critical one.
We added VA acquisition, management, and healthcare to our
high-risk list because VA lacks a disciplined management
approach, among other challenges. Our updated assessment of
these high-risk areas will be issued tomorrow.
The five bills the committee is considering reflect the
underlying theme that change is needed. As I laid out in my
written statement, we have issued an expansive body of work on
effective management practices and made prior recommendations
in line with aspects of the proposed legislation. Today, I will
discuss ways in which this work could help Congress and VA as
you seek lasting and transformative change.
For example, we identified key strategies for implementing
chief management officer positions, like the proposed VA
undersecretary for management. These include ensuring that the
Chief Marketing Officer (CMO) responsibilities are clearly
defined and documented, and that the CMO have a high and
sustained level of authority. We have also recommended CMO
positions be established by other departments, such as DoD and
Department of Homeland Security (DHS). Each department followed
or identified key strategies to different degrees, and, as a
result, have experienced varied success in integrating this
position.
Leadership is essential, but so is good information for
decisionmaking. We have long recognized independent
verification and validation as a best practice. When agencies
are developing or acquiring a system IV&V can help reduce risk
by having a knowledgeable independent party determine that the
system meets users' needs and fulfills its intended purpose.
We have identified key elements of effective IV&V plans
that may be helpful to Congress as it considers this proposed
legislation. These include risk-based criteria for determining
which programs or aspects of programs require IV&V and
establishing standards for independence. We recently
recommended that VA reinstitute plans to conduct an EHRM
independent operational assessment, which could be an element
of an overall IV&V review. IV&V is a specific solution to one
of the challenges the EHRM program faces.
As the draft legislation indicates, the subcommittee is
greatly concerned with broader program challenges. Our reported
findings and those of the Inspector General (IG) over many
years validate your concerns. For instance, we recently
reported to Congress that the overwhelming majority of users
are not satisfied with the system. Whichever approach Congress
chooses for this program, heeding the numerous GAO and IG
recommendations and lessons learned from the current effort
could help ensure that VA uses a more disciplined management
approach in pursuit of programmatic success.
Finally, as VA pursues a new supply chain management
system, our recommendations and our leading practices for
effective pilot programs could come in handy. For instance, 2
years ago, we recommended that VA develop a comprehensive
supply chain management strategy to guide its multiple
interrelated efforts. This strategy should drive the
development of whatever system VA requires, not vice versa. VA
is moving forward with its system acquisition despite still
developing this strategy.
Additionally, our prior work, consistent with the draft
legislation, indicates that effective pilots can inform and
facilitate program and policy decisions, especially for
significant modernization programs. These practices for pilot
programs call for having clear, well-defined, appropriate, and
measurable objectives, among other things.
In conclusion, the challenges these bills are trying to fix
are complex, and there are really no easy solutions. However,
consistently applying leading practices and strategies
summarized in my testimony will better position VA to fulfill
its mission in the years ahead. Your continued oversight will
be essential to holding VA accountable for delivering what it
has promised to our veterans. Thank you again for having me
here this morning. This concludes my statement, and I look
forward to any questions you have.
[The Prepared Statement Of Shelby Oakley Appears In The
Appendix]
Ms. Kiggans. Thank you so much, Ms. Oakley. Now I would
like to recognize Mr. Rosendale to speak on his bill H.R. 608.
STATEMENT OF MATTHEW M. ROSENDALE
Mr. Rosendale. Thank you, Chairwoman Kiggans, for holding
this hearing and to Chairman Bost for making oversight of
electronic health record modernization project a major priority
for this committee. We owe it to our Nation's veterans to have
a safe, fully functioning electronic records system. Quite
frankly, I feel sorry for the witnesses that are here trying to
defend a demonstrably failed system.
The Oracle Cerner electronic health record system operates
at five of the 171 VA medical centers. The VA acknowledges the
system has created unacceptable levels of productivity losses,
patient safety risks, and stay at burnout at these five small
to medium-sized facilities. Veterans at these five facility
centers have complained about lost medication in the mail,
receiving other veterans' medication, delayed specialist
appointments and diagnostic tests, confusion with the patient
portal, and generally increased wait times, widespread errors
in their personal information.
We are also seeing experienced employees at these five
medical centers leaving their jobs because of frustrations with
the system. In a survey, 60 percent of the staff at one of the
centers said the system has made them question whether to
continue working there. I was pleased with Secretary
McDonough's recent decision to continue the pause on
implementing the disastrous system at other VA sites. While
Secretary McDonough deserves credit for this decision, I think
it is unwise to delay the inevitable. This system and this
project have simply not worked out and are bleeding critical
resources from the VA at astronomical rates, and there is no
reason to believe that that is going to change.
It is not just bad execution. It is flawed concept. The VA
is not ready to accomplish a massive EHR replacement. The VA's
cost estimate was initially $16.1 billion over 10 years. Now,
the Institute for Defense Analysis is estimating up to $38.9
billion for implementation over 13 years. Our Nation is over
$31 trillion in debt, yet we are throwing billions of dollars
at a failed EHR system that is compromising veterans' safety.
This is unacceptable.
I introduced the EHR Termination Act to put a stop to this
madness before the VA spends billions of dollars more of
taxpayers' money. My legislation would abolish the Electronic
Health Record Modernization Integration Office and transfer any
functions to the Veterans Health Administration or the Office
of Information and Technology at the VA. It would also revert
all five medical centers using the Oracle Cerner EHR system
back to VistA and Computerized Patient Record System (CPRS).
Moreover, it would prevent the VA from exercising any options
on Oracle Cerner's contract, causing it to expire within 1
year.
The Congressional Budget Office estimated my legislation
would reduce discretionary costs by about $8 billion over 5
years. The taxpayer has already shelled out over $5 billion for
this project, and the only thing we have to show for it is
worse care for our veterans. Money that the taxpayer expended
should be returned because of this poor performance. The job of
the VA should be providing veterans the world class benefits
and services that they have earned, not doling out billions of
dollars to Silicon Valley companies. It is time to put our
Nation's veterans first by terminating the Oracle Cerner
electronic health record system. Thank you, Madam Chair, and I
yield back.
Ms. Kiggans. Thank you, Mr. Rosendale. Now we will turn to
questions, and I would like to yield myself 5 minutes. Starting
with Mr. Christy, H.R. 2499 would authorize a VA supply chain
management system. I know the VA is pursuing a massive
enterprise-wide VA supply chain management system under its own
authority, but what is the VA's independent lifecycle cost
estimate for that effort?
Mr. Christy. Ma'am, as we are working through the concepts
of the supply chain and the overarching strategy, we still do
not have a finalized cost estimate for what that will be in its
total. It is something that is under development. Understand
that when that number is arrived at that we could share it with
you and the committee.
Ms. Kiggans. Do you think you could get it to us by the end
of the week? Could you commit to that or?
Mr. Christy. I cannot commit to the end of the week that we
will have that number. It is still under development.
Ms. Kiggans. Do you know approximately how long it will
take?
Mr. Christy. Two components here. There is the internal
estimate that the program office will be working up. As part of
the acquisition strategy, we are using a statement of
objectives for the actual procurement. What that means is we
are going to lay out the objectives and industry will come back
to us with their solutions and their cost to deliver on those
solutions. Depending who wins through that procurement
competition, that would be the cost of the procurement itself.
Now, obviously, a program is just more than the contract
with all the ancillary and overhead costs with that. That will
be a key component into what is the cost of this program. Yes,
the program is taking its stab at what will this cost through a
lifecycle. A big, really important step to this, though, is
what will be the procurement cost? That is where a lot of the
money will go, frankly. Until we have those numbers, we are not
able to provide that to you. We still do not have the
procurement out on the street, right? That is still under
development along with the strategy.
Ms. Kiggans. Are we talking weeks or months or is this
going to take another year? I am just wondering what the
timeline looks like for that cost estimate.
Mr. Christy. Just for as a working concept, I would say
about 6 months before we could have that number ratcheted down.
Ms. Kiggans. Okay. We would like that number as soon as you
have that available, please.
Mr. Christy. We will try to.
Ms. Kiggans. We just need that before going forward, I will
say that. Ms. Oakley, you testified that just to quote your
statement, ``a recurring theme from our findings has been that
the VA often puts action ahead of planning.'' Would you please
explain why this finding is so important when we are talking
about starting major projects like the supply chain management
system?
Ms. Oakley. Absolutely. Thank you for your question. Yes,
it has been a recurring theme that we have seen, especially
with regard to the supply chain management approaches that VA
has attempted over the years in terms of putting action ahead
of strategy. I think, you know, a perfect example of this is
the fact that 2 years ago we made a recommendation about
instituting or developing a comprehensive supply chain
management strategy that would guide acquisition of the
individual technical solutions that VA is seeking for the
system itself. Unfortunately, that strategy is not finished,
but the acquisition is proceeding.
To comment on the lifecycle cost estimate issue, having a
lifecycle cost estimate before committing to a program is super
important. Our work in other agencies has validated having that
as a key piece of the business case information for committing
to a program is essential to understanding if you are going to
get what you are saying for the cost and within the timeframes
that you are anticipating.
Ms. Kiggans. I agree, and it is hard to do much without
having that before we can go forward. Mr. Christy, do you agree
with the GAO's testimony that the VA has often or has in the
past acted before it is sufficiently planned?
Mr. Christy. Yes, I do concur with that. There are numerous
GAO findings and IG findings. This is what we are trying to
correct through the----
Ms. Kiggans. Yes.
Mr. Christy [continuing]. supply chain and I know it is
probably frustrating to say, hey, when are you going to give me
the number? It is----
Ms. Kiggans. Yes.
Mr. Christy [continuing]. wanting to make sure that we do
not repeat the sins that GAO, and IG, and others have
identified. We want to get this right and not go out the door
and repeat the same things that we have been doing for years.
Ms. Kiggans. Agree very much. Ms. Oakley, my bill would
esquire the VA to pilot the new supply chain platforms function
prior to wider deployment. Can you explain why it is important
to pilot a program like this before rolling it out VA-wide?
Ms. Oakley. Absolutely. Piloting a program can provide you
with valuable information on whether it is going to meet its
intended purpose and whether it is even scalable across the
enterprise. When you consider an organization like VA as big
and complex with medical centers with different needs and
different, you know, configurations and whatnot, a pilot would
allow you to understand those pain points, get feedback from
users, people who are actually going to be implementing the
system, and incorporate that feedback to make changes to the
program, to be able to then scale it and distribute it across
the organization.
You know, it is not, you know, as my testimony stated, and
as my written testimony stated, it is not just as simple as
putting in place a pilot. It has to be structured effectively
such that you can collect data from that pilot to be able to
use going forward. Our leading practices would indicate ways in
which that can happen for VA.
Ms. Kiggans. Out of curiosity, did we pilot the EHR program
then as well before moving forward?
Ms. Oakley. I am not certain of that answer. Maybe VA can
answer that question. I am not sure I have been around long
enough to know that.
Ms. Kiggans. Mr. Christy, do you know?
Mr. Christy. I am going to pass to Dr. Leslie Sofocleous.
Ms. Sofocleous. Ma'am, I would say based off of the
conversation here, it is probably not the same type of pilot.
We were in Integrated Operations Center (IOC), and we had some
initial sites, but I can say that, you know, there was an
ability for us to probably have some lessons learned from the
approach that was just referenced.
Ms. Kiggans. Yes, I would agree with that. Just and
agreeing with the value of piloting a program, I think going
forward, and hindsight is always 2020, and lessons learned, but
that probably would have been a great idea.
Ms. Oakley, the VA's healthcare and acquisition management
are on GAO's high-risk list. Could a supply chain management
system focused on the VHA and with clear metrics help fix the
VA's healthcare and acquisition management issues?
Ms. Oakley. I think it would go a long way. It is certainly
a driver of many of the challenges that we have identified in
that area for VA over the years. I think one thing that you
mentioned that is important to note is, you know, our work for
product development, system development would indicate that
kind of taking an incremental approach to developing a system
as critical as the supply chain management system would give VA
an opportunity to release initial capabilities, understand how
those are working, and then continue to build on those
capabilities going forward. I think your bill advocates for
limiting the scope of the effort, at least initially, to then
be able to understand how it could be expanded to VA's
enterprise-wide supply chain. We think that that is a good,
measured approach.
Ms. Kiggans. Thank you. Thank you, and I concur. I look
forward to seeing bill to fruition. Next, I will turn to
Ranking Member Mrvan for his questions.
Mr. Mrvan. Thank you, Chairwoman. Ms. Oakley, my first
question for you is regarding H.R. 1659, Ranking Member
Takano's IT Modernization Improvement Act. Specifically, from
your experience with independent verification and validation,
is there any major IT program that VA that you think would not
benefit from the IV&V?
Ms. Oakley. I definitely do not think I can think of any
program that would be considered under this bill that could not
benefit from additional quality information to support
decisionmaking. In fact, one of the criteria that we have, one
of our best practices for IV&V would focus on risk-based
criteria for determining which programs are suitable for IV&V,
or which aspects of programs are suitable for IV&V. That would
be things like the maturity of the technology, the criticality
of the system to the mission, things like that, that would
drive the decisions. I think the programs that you mentioned
are all pretty critical to VA. I can not think of one that
would not benefit.
Mr. Mrvan. Specifically for a program like EHRM, do you
feel like the program is too far along for the IV&V to be a
benefit going forward?
Ms. Oakley. I do not think it is ever too late to do the
right thing. You know, the program is in the pretty early
stages with only five sites rolled out. There is a lot more
work that needs to be done from a development perspective. I
think it is also important to note that each location has
different needs, and so there might be different requirements
for each location. Having a concerted IV&V effort for a program
like EHRM as it continues to roll out, I think is critically
important to provide that really good quality information to
make those go-no-go decisions, and the certifications that are
outlined in the bill.
Mr. Mrvan. Mr. Christy, from your testimony, I see that you
have some good constructive technical amendments to the bill,
which we will definitely consider. From your perspective
overall, I would really like to hear your opinion of this bill
and the IV&V overall as it relates to these large IT
modernization programs at VA.
Mr. Christy. Yes, I think through the identification of
what we talked about earlier with many GAO reports, an IV&V
support of those modernization efforts or any large programs is
extremely helpful to the VA. Fully support this.
Back to the comments by Ms. Oakley. You know, I think the
key thing there is I wanted to kind of lock in, is that we
believe in all the best practices that were put out into those
different reports, you know, the criteria when you are using
the independents, the upfront rules, making sure what we are
paying for, and that there is oversight of itself of the IV&V
program. From an acquisition and a VA perspective, this is a
good thing for the VA and veterans. We are going to start
getting help with making sure the money that is spent we are
getting the buck--getting the money that we are--getting the
value from the money we are spending on veterans. Again, fully
support this.
Mr. Mrvan. I appreciate those comments and appreciate your
attention to helping to increase accountability and results
from these programs. I want to give you the opportunity as well
right now to offer any thoughts you may have on the support
outside of IV&V that you need in the Office of Acquisitions,
Logistics and Construction (OALC). I realize that Congress has
put an enormous burden on your office in executing these large
acquisitions, and I want to give you the opportunity to let us
know what else you need from us to help increase effective
acquisitions at VA.
Mr. Christy. Yes, I am going to pull a line from GAO's
testimony. If you saw in there, there was 147 percent increase
in procurement in the last 10 years. That is just the
procurement piece, not the program management. I am using that
to kind of highlight how much work has come to the VA, how much
responsibility that is laid on acquisition officials. Both
contracting folks but also program folks.
I will share with you the steady State of how many
acquisition folks we have at the VA has not grown with that 147
percent spike in 10 years. You got a huge workload on the
acquisition workforce here. We would welcome opportunities to
discuss how can we approach that, streamline, you know,
procurements, program oversight, et cetera. As the IV&V, now,
that is another great example of help the VA needs to improve
acquisition and program management accountability and
jointness.
Some of this gets down to resources that I think, you know,
maybe an offline TA or discussion would be really helpful to
that conversation. Generally speaking, the acquisition
workforce has a huge workload on it and the requirements are
growing without corresponding growth of the workforce.
Mr. Mrvan. With that, I yield back. Thank you.
Ms. Kiggans. Thank you very much, Mr. Mrvan. Now, the chair
would like to recognize Mr. Rosendale for 5 minutes.
Mr. Rosendale. Thank you, Madam Chair. I appreciate it.
While it was not designated as such, unfortunately, the Oracle
Cerner EHR system has been a multibillion-dollar pilot project
that has not even vaguely worked out and stands to consume
billions of valuable resources in the future with no
foreseeable improvement if not stopped.
Ms. Sofocleous, 2 weeks ago, the VA announced through an
email from the Director of VISN 10 that implementation of the
Oracle Cerner EHR will be postponed in Saginaw, Michigan. That
announcement left a lot of things unsaid. I will not allow you
to set the record straight today. Are there other upcoming
sites also postponed, including Battle Creek, Detroit,
Chillicothe, Dayton, and elsewhere in Michigan, Ohio, Indiana,
and Wisconsin?
Ms. Sofocleous. Sir, thank you for the question. We have
said that we would evaluate the sites as we move forward to
ensure that we do not have any of the additional patient safety
issues we have talked about. We make the improvements in terms
of system uptime and performance and then we also address some
of the change management and adoption issues. We will continue
to do that and make informed decisions moving forward on those
additional sites. We can see that veterans and the clinicians
need to have a system that works for them and we will continue
to do that as we move forward, sir.
Mr. Rosendale. Will you be setting another go-live date for
any of these sites?
Ms. Sofocleous. Sir----
Mr. Rosendale. How much lead time will you be giving this
committee in advance of going live in those additional sites?
Ms. Sofocleous. Sir, we will inform this committee of any
decisions we will make and we will assure that there is
informed time so that there are questions and that the sites
are aware of our plans moving forward. Obviously, we want to
make sure that we have all stakeholder involvement in any
decisions we make moving forward.
Mr. Rosendale. Before we are announcing, I am trying to
narrow down some timeframes so I know what I am going to be
dealing with, okay? Are we looking at 30 days' notice, 60 days'
notice, 180 days' notice? What kind of notice do you commit to
this committee giving us before we go live on any additional
sites?
Ms. Sofocleous. Sir, I will take that of record to come
back with a timeframe on that.
Mr. Rosendale. Thank you very much.
Ms. Sofocleous. You are welcome, sir.
Mr. Rosendale. Appreciate it. Thank you. Ms. Sofocleous,
tell me about the decision not to proceed with implementing the
Oracle Cerner system in Ann Arbor, Saginaw, and elsewhere. Who
made the decisions, how were they made, and what was the role
of the medical center directors from each of these VISNs?
Ms. Sofocleous. Yes, sir. In other sites, we have--I think
we have briefed before previously, we have the site readiness,
which we use in our previous sites, you know, albeit we have
had some issues after our previous deployments that look at key
categories in terms of, you know, training, adoption, whether
or not we have technology in place, interfaces in place. Those
are all decisions that we use to evaluate. We have, based off
of the Sprint Report and assess and address, come up with
additional operational metrics that we want to incorporate. As
we use that, we will use that to inform decisions, in terms of
joint decisions, I might say in terms of whether or not we want
to proceed with any deployments at the site. That framework was
used for Ann Arbor and Saginaw. Ann Arbor, we did reference
that that had pharmacy tied to it--sorry, research tied to it.
We wanted to make sure that we had that effectively addressed.
Then for Saginaw, we still had additional work that had to be
performed in terms of the site readiness.
Those decisions are collaborative decision. They are not
made in a vacuum. We do involve the VISN and site leadership.
VHA is involved and Office Of Information and Technology (OIT),
and then obviously, the Deputy Secretary is informed and
provides the final viewpoint and a vote on us to proceed. It is
a collaborative process under governance.
Mr. Rosendale. This local decisionmaking process sounds
like a lot like H.R. 592, the EHR Improvement Act, would
require. Would you agree with that?
Ms. Sofocleous. Yes, sir, it does, in a sense. Yes, sir.
Mr. Rosendale. Okay. When you go through this analysis and
this collaboration, are you deferring to the directors of those
facilities to give them any type of veto power whatsoever?
Ms. Sofocleous. I think we allow them----
Mr. Rosendale. I mean, if they identify deficiencies, they
identify areas that they just are not ready, are we going to
defer to the people on the ground?
Ms. Sofocleous. We make informed decisions. I think the key
part here is mitigations that we have in place, and that is a
conversation that we would have. Like, hypothetically, we would
have to talk about whether or not the mitigations are in place,
the mitigations are effective, and also whether or not they are
going to impact operations at the ground to make that decision.
I think that is the approach we would take and what we have
made previously in terms of whether or not the mitigations are
the effective mitigations to allow the sites to continue to
perform effectively.
Mr. Rosendale. Okay. Not to put words in your mouth, but it
still sounds to me like what we have is a discussion, a
collaboration. At the end of the day, the heavy hand of the
Veterans Administration is going to make the decision about
whether something is going to be implemented or not.
Ms. Sofocleous. Sir----
Mr. Rosendale. Thank you, I yield back, Madam Chair.
Ms. Kiggans. Thank you, Mr. Rosendale. The chair now
recognizes Ms. McCormick for 5 minutes.
Ms. Cherfilus-McCormick. Thank you. Ms. Love-Holmon, I
realize that the VA feels that they do not need an
undersecretary for management and that the Deputy Secretary has
had this authority previously. Unfortunately, I think that we
all know that proficiency in the business of government is not
a prerequisite for the Deputy Secretary. I know that in your
current position, you are performing some of the governance
that we are looking for. I would like to hear from you the
opportunity to answer these questions. The current governance
structure for the management of the VA, what is your view on
it? Two, what improvements would you recommend?
Ms. Love-Holmon. Thank you very much for the opportunity to
speak. I would first like to start off by just saying this is
an organization that I am very proud to work for VA, and we
have an amazing mission. Specifically with regard to the
current structure, I have had the pleasure of being there from
the ground up in creating the enterprise governance framework
that we have now. We have the VA Operations Board that is
chaired by the Deputy Secretary, who serves as our chief
operating Officer. We have the VA Executive Board that is
chaired by the Secretary of Veterans Affairs.
As we have put these two boards together, we were very
thoughtful about who needs to participate in these boards.
There is a mix of participants from the political staff, the
career staff, participants from VA Central Office, as well as
field leadership to ensure that we have representation from
across the organization. Also, the chief executive officers
participate as well, the chief acquisition officer, information
officer, et cetera, to ensure that everyone has a seat at the
table.
There are really three parts to these boards that I am very
proud of, and we really did look also at the GAO report and try
to understand the intent there and those comments and the
criteria for what it looks like to create a good Chief
Operating Officer (COO). The governance framework is around
transparency, making sure that all folks that are going to be
impacted by a decision are brought to the table. Going back to
a previous comment, that means that if there is something that
is happening about you, we are bringing you there to the table
to have an opportunity to talk about it.
Also, about accountability in terms of making sure that we
have accountable officials for the various projects or programs
that are there at the table, but there is also accountability
across the table, meaning even if you are not the chief for a
particular program, what is my responsibility as the Acting
Assistant Secretary in supporting this initiative? What is the
Chief Information Officer's (CIO's) responsibility in
supporting it, in supporting the various initiatives?
Last, we have also tried to be grounded in evidence-based
and principle-based decisionmaking in terms of as decisions are
coming through governance, really understanding what is the
data telling us about the decisions and the recommendations
that are coming. Also, from a principles-based perspective,
ensuring that we are really looking at is this the best
decision for veterans and our employees as we are moving
forward.
In terms of opportunities for improvement, I think I would
agree with my colleagues and the comments that have been made
with regard to our opportunity to put in more disciplined
management framework, particularly around some of our program
management. We have already begun that for several of our
strategic initiatives, many of which are being discussed here
today. We have bringing those projects through the governance
framework where we are asking those hard questions. Sometimes
the hard question is what is the problem we are trying to solve
and making sure that everyone at the table understands what the
problem is, understands what the plan is to move forward so
that we are moving forward and creating strategy into action.
Again, I think that is my response.
Ms. Cherfilus-McCormick. Thank you. My next question is for
Ms. Christy--Mr. Christy. I know in your position you are under
tremendous pressure to execute a giant acquisition program. I
know you have had issues with resources. Would it be beneficial
to have an advocate in upper management for the VA to champion
your needs?
Mr. Christy. We will always welcome advocates, no matter
where we are and what we are doing. I think to have somebody
above the chief acquisition officer, so at the VA, that is the
political appointed person for the acquisition. If it is even
higher than that, obviously that helps with, you know, being at
the table and communicating those risks and where we can get
help within acquisition programs. Absolutely would welcome
that.
Now, back to the point of what Ms. Love-Holmon said, we do
have governance, right? There are those avenues when there are
concerns to bring those up. Those go to both the Deputy
Secretary, and depending on what the issue is, it could go up
to the executive board, which is chaired by the Secretary
himself. I think we have those advocates through our governance
process but would always welcome more voices at the table in
support of acquisition.
Ms. Cherfilus-McCormick. Thank you so much. I just want to
emphasize that as the Ranking Member of Technology and
Modernization Subcommittee, I am interested in finding ways I
can support the VA to modernize its IT program. I think Ranking
Member Takano's bills are a great start to get us back on track
in delivering better healthcare benefits to our veterans and
supporting the VA. Madam Chair, I yield back.
Ms. Kiggans. Thank you very much for your comments. Just to
wrap up and close, I just had a couple of extra questions for
really just for personal knowledge. Mr. Christy and maybe Dr.
Sofocleous, when looking at how we are assessing our electronic
charting implementation in the five facilities that have begun
that process, specifically, we have an outside group, this
IV&V, coming in to do some just overarching critique, I guess,
of how that is going. How long do we expect that this IV&V to
be in place for?
Ms. Sofocleous. You are talking about the new IV&V. I guess
the new IV&V, based off of what was proposed, I would think we
would want to have that in for long term for the program in
order to be able to help assist with some of the program
management and technical pieces of it. There are multiple
components of that. I think, you know, Mr. Christy said we are
already open into. It is probably not a one or done. I think we
would be open to that.
Ms. Kiggans. It is a long-term commitment?
Mr. Christy. Yes, absolutely. I am sorry if I might have
misunderstood. I was not sure, because there are some current
IV&V efforts that are going on in the EHR program today. It is
not as formalized as the bill talks about. If the question is
geared toward the bill, yes. You will see in there, we are
talking over the period of this and to follow the GAO
recommendations, right? Risk-based, so there might be parts up
front really heavy into many topics and areas. As you get to
the back part of the acquisition of it, you might taper down on
the risk of that. I would see IV&V going through the total
lifecycle of an acquisition.
Ms. Kiggans. I know it is a huge expense.
Mr. Christy. Yes.
Ms. Kiggans. I am wondering what other resources are out
there for us to maybe do the same job. Does, for example, does
Cerner Oracle now do they play any role in this transition
process? Just as a nurse practitioner thinking through when we
have gone to electronic charting systems, transition to that on
a much smaller scale than what the VA is trying to do, we had
the team come in from, you know, the company who owned the
program. They sat there in a trailer next to the facility and
they made sure every patient was, their records got
transferred, that their current notes were getting transferred,
that all the test results, and whatnot were getting
transferred. What role is Cerner Oracle playing in this whole
process?
Mr. Christy. Yes, so, I think Dr. Sofocleous will answer
this in a second, but I just want to quickly add, you know, we
are in current negotiations with the Oracle Cerner team. A lot
of these new standards are being negotiated. In a public
hearing, we can not disclose them. I think we can get you that
information.
It is to the point you are asking it is like, hey, what is
their involvement, and what are the standards, and how is that
being wrapped back into the program office? You just do not get
us to do all the work. You own the contract, deliver the
results----
Ms. Kiggans. Right.
Mr. Christy [continuing]. that are expected of you----
Ms. Kiggans. Right.
Mr. Christy [continuing]. in that contract. Those things
are ongoing, but I am going to have Les pile on to what I am
saying here.
Ms. Sofocleous. Ma'am, I think, you know, we have talked
about like change management, some of the areas you were
talking about change management, training, adoption issues, and
we are talking about from the technical standpoint, which we do
have IV&V already for testing. Obviously, Oracle Cerner is
involved in that. I think if we are talking about independent,
then obviously we want to take their input and then have a
separate validation to ensure what they are providing is a
service that we are paying for, it is effective, and it is of
use to the sites and to VA. There are two components of that, I
would say.
Ms. Kiggans. I do not want too many cooks in the kitchen,
you know. Sometimes we get so convoluted, like how many people
and the most important people we need to be talking to are the
providers, right? The people that are the end users of this
program. Those are the people who have the responsibility to
make sure that continuity of care piece and patient safety, all
of those really big issues are the ones that we hear about in
our offices, we want to make sure that end product is
accomplished. Making sure the providers, the healthcare
provider, the physicians, the nurses, those guys who are
already busy and already hard to get in a room, and to say, we
are going to have an hour meeting about how you feel about this
electronic charting. Those should be the loudest voices at that
table. I do not want all of us to get not only does it cost a
lot of money to have all these outside groups looking at that,
but just, you know, tightening that up and making sure we can
make the best product possible for the end user, I think, is
where I would like to see just to pass my priority along.
Thank you. I know it is a work in progress and I am
finished with my questioning. Ranking member Mrvan, do you have
one?
Mr. Mrvan. Just 5 minutes, yes.
Ms. Kiggans. Yes, go ahead.
Mr. Mrvan. For Mr. Christy, I am going to follow on that.
What is the timeline do you believe for the negotiations to be
complete and what are the outcomes that you are looking for
from those negotiations?
Mr. Christy. Right, and I will ask Les to assist me again.
There is an option period that comes to May 16 that we have to
get past those negotiations so we can move forward to the next
options. For the initial, it was a 5-year period. We are coming
up on that 5-year period, May 16, and we are negotiating the
next 5 years currently. I will turn it over to Les a little bit
more about the details of the outcomes of that.
Ms. Sofocleous. Yes, sir. We are in negotiations. As Mr.
Christy said, May 16 is the period. I think we had some
productive negotiation conversations. Obviously, we are
focusing on some of the areas we have talked about. Obviously,
system performance is one of the big issues. Our ability to
hold Oracle Center accountable, which we tend to continue to
enforce in our negotiations. We do have backup strategies in
place and we will be more than happy to provide updates as we
move forward with the negotiations.
Mr. Mrvan. Okay. I guess why I bring that up is because the
disconnect between the pharmacy and the different type of
results that we were talking about in past meetings, just
making sure that those errors are being fixed. You are to kind
of focus on what the chairwoman was saying, making sure that
the providers are included and have a seat at the table is so
vitally important. That is why I followed up with that question
and just wanted to make sure I understand you do not want to
negotiate here at the table, and so, your answer. The outcomes,
making sure that the providers have a seat at the table seem to
be one of the priorities through the past meetings, along with
accountability. I thank you very much.
Ms. Kiggans. Thank you, ranking member. Thank you to all of
our witnesses for being here today. I ask unanimous consent
that all members shall have 5 legislative days in which to
revise and extend their remarks and include any extraneous
material. Hearing no objections, so ordered. This hearing is
now adjourned. Thank you.
[Whereupon, at 10:28 a.m., the subcommittee was adjourned.]
=======================================================================
A P P E N D I X
=======================================================================
Prepared Statement of Witnesses
----------
Prepared Statement of Phillip Christy
Chairwoman Kiggans, Ranking Member Mrvan and other Members of the
Subcommittee: thank you for inviting us here today to present our views
on several bills that would affect VA programs and services. Joining me
today is Dr. Leslie Sofocleous, Executive Director, Electronic Health
Record Modernization (EHRM) Integration Office's (IO) Program
Management Office (PMO), Ms. Shana Love-Holmon, Acting Assistant
Secretary, Office of Enterprise Integration (OEI), and Catherine
Cravens, Chief of Staff, Office of Information and Technology.
H.R. 592 - Electronic Health Record Modernization Improvement Act
Section 2(a) of the bill would prohibit the Secretary of Veterans
Affairs from commencing a program activity at a Veterans Health
Administration (VHA) facility where such activity is not being carried
out as of the date of enactment until the Secretary of VA submits to
the House and Senate Committees on Veterans' Affairs written
certification that the electronic health record (EHR) system has met
each of the following improvement objectives prior to implementation:
(A) a monthly uptime for the electronic health record system of 99.9
percent for 4 sequential months, and (B) the completion of all
improvements or modifications of the EHR system required to be
completed pursuant to a contract, task order, modification or other
similar instrument, entered into before the date of the enactment of
this Act.
VA does not fully support section 2(a) of this bill. Specifically,
VA does not support the prohibition of commencing program activities
until the completion of section 2(a), which would pause program
activities and cause significant cost impacts. However, adjustment to
the ``program activities'' definitions outlined in section 2(c) would
address this issue by allowing certain activities that support early
pre-deployment to start, while limiting the commencement of full
deployment.
VA suggests the following:
Modification: Update section 2(a)(1) to read: ``(1)
Prohibition.--The Secretary of Veterans Affairs may not deploy the
electronic health record system at a facility of the Veterans Health
Administration until the date on which the Secretary of Veterans
Affairs...''
VA supports section 2(a)(2)(A) of this bill, in part. Improving
system reliability and availability remains a VA focus. Corrective
actions within the Cerner data base configuration have resulted in more
than 6 months of system uptime above 99.9 percent without a complete
outage. As written in section 2(a)(2)(A), if the 99.9 percent metric
dropped the month prior to deployment then VA would not have the 4
sequential months prior to deployment.
VA suggests the following:
Modification: Update section 2(a)(2)(A) to read: ``(A)
monthly uptime for the electronic health record system of 99.9 percent
for four sequential months or documented risk mitigation and
certification for deployment under 99.9 percent.
VA does not support section 2(a)(2)(B) of this bill. The Electronic
Health Record Modernization Integration Office (EHRM-IO), VHA and
Office of Information Technology have worked collaboratively to assess
and remediate a subset of identified system challenges and continue
work to expediently resolve all identified and validated issues.
There are many improvements and proposed modifications that are
already on task orders. These are all in flight, with varying dates of
completion - some of which extend beyond 2023. Many of these
improvements are important, but not essential, for a future go-live. To
require all system modifications to be completed in their entirety
before allowing resumption of any program activities would introduce
significant delay. Additionally, given the complexity of heath care and
potential policy changes it is anticipated that ongoing additional
changes will be required. While all system modifications may not be
completed prior to deployment, mitigations should be in place.
VA suggests the following:
Modification: Update section 2(a)(2)(B) to read: ``The
completion of improvements or modifications of the electronic health
record system as agreed upon by the VA Deputy Secretary, VA Under
Secretary for Health, EHRM-IO and VISN leadership.''
Section 2(b) would require the VHA facility director, the facility
chief of staff, and the director of the VISN in which such facility is
located to each submit written certification that: (1) the build and
configuration of the EHR system, as proposed to be carried out at such
facility, are accurate and complete; (2) the staff and infrastructure
of such facility are adequately prepared to receive such system; and
(3) the implementation of such system will not have significant,
sustained adverse effects on patient safety, patient wait-times for
medical care, or health care quality at such facility.
VA supports section 2(b) of this bill, with amendments. VA uses a
consistent process for each deployment of the EHR system to approve the
decision to go-live. Infrastructure readiness is assessed through the
current State review (CSR) process and addressed before deployment
operations begin. Deployment kickoff starts 13 months prior to go-live,
and there are weekly working deployment meetings with the facility,
Change Leadership Team and change sponsor to walk through outstanding
issues. Approximately 4-8 weeks before go-live, VHA, EHRM-IO, Veterans
Integrated Service Network (VISN) and site leadership begin to meet
weekly to review the readiness checklist and areas of concern. Last, a
go/no-go decision meeting with VHA, EHRM-IO, the VISN and the facility
is held no later than the week before go-live based on the elements of
the readiness checklist, along with the people, process and technology
elements of readiness for personnel at the site. The written
certification outlined by the bill would support the existing
concurrence process.
VA suggests the following:
Modification: Update section 2(b)(1) to read: ``(1) the
build and configuration of the EHR system, as proposed to be carried
out at such facility, are accurate and complete based on the approved
enterprise standard.''
Modification: Update section 2(b)(3) to read: ``(3) the
implementation of such system will not have known significant,
sustained adverse effects on patient safety, patient wait-times for
medical care, or health care quality at such facility.''
Section 2(c) includes definitions for EHR and program activity. VA
supports this section with amendments.
Modification: Update section 2(c)(2) to read: ``(2) The
term ``program activity'' means any local or national workshop and/or
training activities under the Electronic Health Record Modernization
Program before the certification of the electronic health record
system.''
H.R. 608 - Terminate VA's EHRM Program
Section 1(a) of the bill would require the Secretary of Veterans
Affairs to terminate the Electronic Health Record Modernization (EHRM)
program. VA opposes section 1(a) of this bill. Without a modern EHRM
program, VA would not have an interoperable, longitudinal record with
the Department of Defense and community care partners; therefore, VA
could not provide the Veterans with an electronic health record (EHR)
that tracks the first day of service delivery with DoD to through the
transition to VA, thereby limiting care and services to the Veteran.
Modernizing the electronic health record (EHR) system is critical
to providing the best care for Veterans and facilitates advancements in
delivery of care in the following ways:
1. Increased access to new technologies both now and in the future.
2. Standardized workflows and systems across VA and to automate and
integrate manual processes, resulting in efficiencies and better
service and care to Veterans.
3. Standardized EHR system reducing training and delivers a more
integrated and skilled workforce.
4. Facilities use of telehealth services to share clinical
expertise across VA's expansive health care delivery network.
5. Improved scheduling and smarter clinical decision support,
driven by a comprehensive view of a Veteran's medical history and
service record.
6. Reduced sustainment costs of an enterprise EHR system.
If enacted, section 1(a) would have additional costs. VA may need
to initiate ``stop work'' and/or termination activities depending on
timing of enactment Claims resulting from government stop work and/or
termination activities could vary by a wide range, are contract
dependent, and would need to be evaluated on a case-by-case basis to
determine the costs to the government.
Section 1(b) would require the Secretary to carry out the following
activities within 180 days of enactment: (1) Abolish the Electronic
Health Record Modernization Integration Office (EHRM-IO); (2) Transfer
any activities or functions carried out under such office that are not
terminated pursuant to this section to the Veterans Health
Administration or the Office of Information and Technology of the
Department of Veterans Affairs; (3) With respect to each facility of
the Veterans Health Administration that uses the EHR system implemented
pursuant to the EHRM Program, revert the facility to instead use the
Veterans Health Information Systems and Technology Architecture (VistA)
and the Computerized Patient Record System (CPRS) of the Department.
VA opposes section 1(b) of this bill. VA's existing EHR system,
VistA, is almost 40 years old. In its current State, however, VistA is
comprised of 130 distinct instances and cannot deliver the benefits of
a modern, enterprise system or provide a seamless health record system
from military service to Veteran status. Previous attempts to upgrade
VistA have been unsuccessful; there is potential risk in repeated
efforts.
Integration with DoD would not be as strong on separate platforms
and there would be decreased access to innovations being driven by a
commercial provider. Moreover, critical solutions that have been
deployed to enhance interoperability between VA and DoD, such as the
Joint Health Information Exchange (JHIE), are reliant on the joint
platform and do not have a replacement. Previous solutions that enabled
interoperability have been sunsetted. Significant resources and funding
would be required to develop a replacement platform that could
effectively and efficiently handle the clinical data exchange volumes
and adheres to current and upcoming regulatory requirements.
Connections with national health care organizations that enable health
information exchange with community providers would also have to be
reestablished.
Lastly, section 1(b) would have significant personnel impacts
across the enterprise. EHRM-IO alone has approximately 300 Federal
staff, in addition to contractors, nonpermanent staff and staff hired
to VHA, OIT and EHRM in support of the EHRM program. The timeframe for
this change in personnel is extremely narrow and will not afford VA the
time needed to ensure personnel are appropriately relocated to
positions elsewhere within the Department and would result in
significant loss in institutional knowledge and subject matter
expertise.
Given the breadth and complexity of the impacts of EHRM
termination, VA does not have an estimate for section 1(b) of this
bill. However, VA anticipates cost considerations to include (1)
resources required to sustain the existing EHR solution at deployed
sites; (2) additional costs for VA to execute a plan to revert back to
VistA, which would not be feasible within the specified 180-day
timeframe; and (3) significant additional costs and resourcing required
to modernize VistA. Appropriations language would also need to be
updated, since the EHRM program is funded as a separate appropriation.
H.R. 1659 - VA IT Modernization Improvement Act of 2023
This bill would direct the VA Chief Acquisition Officer (CAO) to
contract for the independent verification and validation (IV&V) of
certain modernization efforts of the Department within 90 days of
enactment. It prescribes the characteristics and experience (linked to
the Department of Defense Acquisition Program) required of entities
eligible to compete and details the oversight functions to be
accomplished under the IV&V contract.
The bill defines ``covered programs'' to include ongoing VA
modernization efforts, e.g., EHRM, Supply Chain Modernization,
Financial Management Business Transformation (FMBT), Human Resources
(HR) Systems and Veterans Benefits Management Systems (VBMS) and
excludes any entity currently performing or having performed on a
contract for VA within the 5 years preceding issuance of the
solicitation, including contracts or subcontract related to a covered
program. The bill also institutes a new annual reporting requirement
and directs the CFO to work with heads of department offices to ensure
the amount of the IV&V contract awarded is paid proportionately from
respective appropriations.
VA supports this bill if amended, and subject to the availability
of appropriations. Section 2(a) of the bill directs VA's CAO not later
than 90 days after the date of the enactment of this Act to enter into
a contract with an eligible entity under subsection (b) to carry out
the oversight functions described in subsection (c). VA strongly
supports the importance of and need for IV&V for VA modernization
programs. Although VA does not object to the direction given to the
CAO, it may be more appropriate ``to direct the Secretary of Veterans
Affairs'' given that ``covered programs'' defined in the bill, e.g.,
EHRM, FMBT, SC Modernization and H.R. Systems, have major IT components
and impact across the enterprise.
The requirement in section 2(a) to, ``enter into a contract within
90 days,'' is not sufficient time to conduct market research, identify
qualified entities and award a contract. VA proposes the following for
section 2(a): ``conduct market research to identify one or more
eligible entities as described in subsection (b).'' Initiation of
market research within 90 days is feasible; awarding a large and
comprehensive IV&V contract or contracts within a 90-day timeframe is
not realistic.
Alternatively, VA suggest the language and format of Public Law
114-286, The Faster Care for Veterans Act of 2016. Specifically,
2(a) CONTRACTS-
(1) AUTHORITY. -Not later than 120 days after the date of
enactment of this Act, the Secretary of Veterans Affairs shall
enter into a contract with an eligible entity under subsection
(b) to carry out the oversight functions described in
subsection (c).
(2) NOTICE OF COMPETITION.--Not later than 60 days after
the date of the enactment of this Act, the Secretary shall
issue a request for proposals for the contract described in
paragraph (1). Such request shall be full and open to any
eligible entity as described in subsection (b) and has the
capacity detailed in subsection (c).
(3) SELECTION.--Not later than 120 days after the date of
the enactment of the Act, the Secretary shall award a contract
to one or more contractors pursuant to the request for
proposals under paragraph (2).
Section 2(b) ELIGIBILITY. - describes the characteristics of an
eligible entity.
VA supports section 2(b) of this bill, with amendments. VA notes
the criteria in paragraph (1) coupled with the exclusion in paragraph
(2) may severely limit the pool of eligible entities and potentially
frustrate VA's ability to award a contract. Paragraph (2) as written,
will likely exclude many vendors and could result in legal challenges.
VA suggests replacing the proposed text with the following:
``(2) performed the work at a satisfactory or better level as
indicated by the past performance information in the Contractor
Performance Assessment Reporting System for any contract used
to demonstrate eligibility under subsection (b)(1).''
Section 2(c) FUNCTIONS. - describes the oversight functions to be
carried out by the contract awardee. Paragraph (3) of subsection 2(c)
currently reads - (3) Conducting continuous oversight of the activities
carried out under, and the system associated with each covered program,
including oversight of the status, compliance, performance, and
implementation of recommendations...
VA supports section 2(c) of this bill, with amendments. VA
recommends revising paragraph (3) of subsection 2(c) to acknowledges
the need for a VA adjudication process regarding the IV&V findings and
recommendations. VA recommends revision as follows:
``Conducting periodic oversight of the activities carried out
under, and the system associated with each covered program,
including oversight of the status, compliance, performance,
`and adjudication' and implementation of recommendations...''
VA recommends amending subsection 2(c) (3) subparagraph (A) to
read:
``(A) Program management, including but not limited to,
management of the governance of the program...A comprehensive
IV&V assessment would incorporate a broader range of assessment
areas than stated in the proposed text.
Subparagraph (F) of subsection 2(c) (3) lists several items
with respect to associated systems for evaluation. However,
validation of the measurable benefit of the system (i.e.,
business impact, outcomes, value, return on investment...) is
not listed. These measures of benefit would be a subset of the
overall set of measures of effectiveness for the program.
VA recommends adding ``vi'' validation of measurable benefit of the
system at the end of subparagraph (F) and following that a subparagraph
(G) Change management approach. Change management and realization of
program value must be tightly connected, i.e., the connection to the
proposed value/impact/business-functional outcomes of the program. The
revised paragraph (3) would appear as follows:
``(3) Conducting continuous oversight of the activities carried
out under, and the systems associated with, each covered
program, including oversight of the status, compliance,
performance, and implementation of recommendations with respect
to, for each covered program, the following:
(A) Management, including governance, costs, and
implementation milestones and timelines.
(B) Contracts for implementation, including financial metrics
and performance benchmarks for contractors.
(C) Effect on the functions, business operations, or clinical
organizational structure of the health care system of the
Department of Veterans Affairs.
(D) Supply chain risk management, controls, and compliance.
(E) Data management.
(F) With respect to such systems, the following:
(i) Technical architectural design, development, and
stability of the systems.
(ii) System interoperability and integration with related
information technology systems.
(iii) System testing.
(iv) Functional system training pro-vided to users.
(v) System adoption and use.
(vi) Measurable benefit of the system as measured by the
program's approved base line Objective Key Results (OKR) and
Key Performance Indicators (KPI), (i.e., business impact,
outcomes, value, ROI''
(G) Change Management approach effectiveness''
VA believes these amendments, if adopted, would strengthen the bill
consistent with congressional intent.
Subsection 2(e) AWARDED AMOUNTS.--Not later than 90 days after the
date on which the Chief Acquisition Officer of the Department enters
into the contract under subsection (a), the Chief Financial Officer of
the Department, in coordination with the heads of such office of the
Department responsible for the management of a covered program, shall
ensure that amounts awarded to an eligible entity under such contract
are derived, in proportionate amounts, from amounts otherwise
authorized to be appropriated for each such office of the Department,
respectively. VA supports subsection 2 (2e) of this bill and has no
objection to this provision.
Subsection 2(f) DEFINITIONS - list key terms and authorities that
are referenced throughout the bill, e.g., ``covered program.'' The bill
identifies the Electronic Health Record Modernization Program (EHRM),
the Financial Management and Business Transformation Program (FBMT),
the Veterans Benefits Management system (VBMS), any program related to
supply chain modernization, and any program related to the
modernization of information technology systems associated with human
resources as the ``covered programs''.
VA offers for consideration that the scope of this undertaking is
likely going to create Organizational Conflicts of Interest (OCI) at a
level which will dissuade many vendors. VA currently has IV&V contracts
in place for EHRM and FMBT. It is unclear how enactment of this law
would affect existing contracts. Ideally, VA would have an in-house
team with the expertise to conduct IV&V of its major modernization
efforts.
Contracting for those services as VA builds internal capacity makes
practical sense and will help to expedite the resulting delivery of
benefits and services to Veterans, their caregivers and family members.
VA does not have cost estimates for this bill but anticipates an IV&V
contract of this size would be extremely expensive. Appropriate and
timely funding of this bill is critical.
H.R. 1658 Manage VA Act
H.R. 1658 would add 38 U.S.C. Sec. 307A which would establish in
the Department of Veterans Affairs (VA) an Under Secretary for
Management (USM). The new subsection would establish a new USM to serve
as the Chief Management Officer of the Department, reporting directly
to the Deputy Secretary and as a principal advisor to the Secretary on
matters related to the management of the Department, including
management integration and transformation in support of Veterans
operations and programs. The USM responsibilities would include budget
and finance, procurement, human resources, information technology,
management integration and transformation, development of transition
and succession plans, certain GAO reporting, management of the Office
of Enterprise Integration, and the supervision of the Director of
Construction and Facilities.
VA does not support this bill. Integrating the Department's efforts
and creating operational jointness in our support for Veterans, their
families, caregivers and survivors is essential to Veterans choosing VA
for care, benefits and services. VA appreciates that this bill
generally seeks to address management, integration, and transformation
issues within the Department, however, VA already has established and
continues to mature its joint oversight and decisionmaking roles and
processes, focused on the integrated customer journey it needs to work
toward these outcomes. Together these are successfully driving the
integration envisioned by this legislation without the need for a new
position such as an Undersecretary for Management.
Oversight and Accountability. The VA Deputy Secretary serves as the
Department's Chief Operating Officer, supported by a robust governance
structure that ensures the Chief Executive Officer (CXO) roles (i.e.,
Chief Acquisition Officer, Chief Information Officer, Chief Financial
Officer, Chief Human Capital Officer, and Chief Experience Officer) are
brought together regularly for joint decisionmaking. The Deputy
Secretary chairs the VA Operations Board, which serves as the most
senior operations implementation management body for the Department
providing oversight of the implementation and execution of the
Secretary's strategic direction. Its purpose is to enable the Deputy
Secretary to critically evaluate evidence-based, risk-informed
recommendations about the operational implementation and execution of
the Department's Strategic Plan and provide Department-level oversight
and operational direction of key enterprise programs (e.g., Electronic
Health Record Modernization (EHRM), Financial Management Business
Transformation (FBMT), Supply Chain transformation), to support well
integrated operational plans and impactful outcomes. Department of
Veterans Affairs Operations Board (VAOB) membership includes all the
CXO roles as well as the Administrations and other key VA leaders.
Robust Governance with Integrated Customer Focus. VA already has
implemented robust governance to drive jointness and integration, as
outlined in VA Notice 22-15 (September 15, 2022). The purpose of the VA
Governance is to enable evidence-based, risk-informed decisionmaking
that advances the mission of VA and enables VA to meet its promise to
provide timely access to world-class health care and earned benefits
and services to all Veterans.
Departmental governance includes the VA Executive Board chaired by
the Secretary and the VA Operations Board chaired by the Deputy
Secretary that ensure critical risks and opportunities are discussed by
all leaders from across VA and result in well-integrated decisions that
matter to Veterans. These two boards are supported by the Evidence
Based Policy Council, which ensures policy options are developed
jointly and founded on rigorous evidence, and the Investment Review
Council, which ensures investment decisions reflect an enterprise-wide
view of what will make the biggest impact for Veterans.
Likewise, VA has one of the most outstanding customer experience
offices in the Federal Government, the Veterans Experience Office
(VEO). Our Chief Experience Officer is a key partner within our
enterprise governance framework, facilitating human centered design
efforts that ensure the Veteran's journey through VA is seamless and
that each policy and operational decision impacting one of VA's
components naturally contributes to a well-integrated customer
experience. The Assistant Secretary for Enterprise Integration serves
as the VA accountable executive for enterprise management and
governance in support of the Office of the Secretary. Serving as the
Governance Executive Secretariat for these four principal Department-
level Governance bodies.
VA does not have a cost estimate for this bill.
H.R. XXX - VA Supply Chain Management System Authorization Act
This bill would authorize the Secretary of Veterans Affairs to
carry out an information technology (IT) system and prioritize certain
requirements to manage supply chains for medical facilities of the
Department of Veterans Affairs. Specifically, it would give VA
discretion to procure an IT System to manage the supply chains for the
Veterans Health Administration (VHA). It details the desirable
functions and capabilities of such a system and lists specific items to
be included or excluded. It requires the prioritization of inventory
management capability and specifies, that should the Secretary choose
to carry out such a system, it must first be piloted at a VHA facility,
and that full implementation be completed within three (3) years of
enactment of this Act. The bill also provides for the system to apply
across the enterprise, e.g., to the Veterans Benefits Administration
(VBA) and the National Cemetery Administration (NCA) to the extent
items VBA and NCA procure can be accommodated by VHA processes.
VA cites concerns with this bill. The reason for VA's concern is
twofold. First, as written, the bill may impede ongoing efforts toward
an enterprise supply chain solution. Second, the timeline does not
accurately reflect the complexities involved in successful procurement
and execution. As such, VA welcomes the opportunity to continue working
with the Committee to provide additional technical assistance that will
create the flexibility and scope of timing needed to ensure success of
the mission.
VA began an enterprise-wide supply chain assessment in October
2021. Leveraging previous internal and external investigations,
assessments and reports, VA mapped and validated all current supply
chain processes including, facilities, High Tech medical equipment, IT,
medical supplies, the National Cemetery Administration,
pharmaceuticals, prosthetics, and the Veterans Benefits Administration.
VA also completed a detailed gap analysis comparing the ``as-is'' State
with the desired objective of an Easy to Use, Integrated and
Intelligent Supply Chain system.
VA is far along in the process that will culminate in the
identification and eventual selection of an IT system or systems that
will provide a modernized enterprise-wide solution for the supply chain
and logistics management. VA has engaged with industry on multiple
occasions for feedback and to gain a better perspective on what best
practices can be leveraged in our efforts to modernize. We recognize
that the most critical aspect of this endeavor is to ensure the
continued and consistent delivery of high-quality health care products
and services for our providers, Veterans, Caregivers, and their
families. VA is committed to an approach focused on lessons learned,
end-user input and phased implementation.
Although VA expected to solicit proposals and complete evaluations
in January 2023, that timeline has shifted to the right as we learn
more from internal and industry feedback. VA continues to socialize the
anticipated organizational and staff changes needed to properly execute
the mission. This methodical approach enables VA to better understand
the issues to be solved, effect change management, and refine and
revise our requirements before determining which potential technical
solutions will be needed.
VA is nearing completion of the acquisition strategy for the
enterprise supply chain modernization effort which will enable VA to
develop an Independent Lifecycle Cost Estimate for the overall
enterprise supply chain modernization effort. Currently, VA is
preparing to issue a Request for Proposals and expects to issue the
solicitation by late April or early May. VA does not currently have a
cost estimate for this bill.
Conclusion
This concludes my statement. We would be happy to answer any
questions you or other members of the Subcommittee may have.
______
Prepared Statement of Shelby Oakley
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Statements for the Record
----------
Prepared Statement of The American Legion
Chairwoman Kiggans, Ranking Member Mrvan, and distinguished members
of the subcommittee, on behalf of National Commander Vincent J. ``Jim''
Troiola and more than 1.6 million dues-paying members of The American
Legion, we thank you for the opportunity to comment on H.R. 592 -
Department of Veterans Affairs Electronic Health Record Modernization
Improvement Act.
The American Legion is directed by active Legionnaires who dedicate
their time and resources to serve veterans and their families. As a
resolution-based organization, our positions are guided by more than
104 years of advocacy and resolutions that originate at the grassroots
level of our organization. Every time The American Legion testifies, we
offer a direct voice from the veteran community to Congress.
H.R. 592 - Department of Veterans Affairs Electronic Health Record
Modernization Improvement Act
To prohibit the Secretary of Veterans Affairs from carrying out certain
activities under the Electronic Health Record Modernization Program
until certification of system improvements and facility readiness.
In 2018, the Department of Veterans Affairs (VA) began its
Electronic Health Record Modernization (EHRM) program to replace its
current operating system, Veterans Health Information Systems and
Technology Architecture (VistA), which originally dates to 1977.\1\ The
VA's new EHR system, Oracle Cerner Millennium, is intended to bring new
capabilities to VA, such as a more efficient process for identifying
potential health risks, scheduling features that would improve wait
times, and a seamless experience across VA, Department of Defense
(DOD), and civilian healthcare facilities and their departments.\2\ The
EHRM program aims to provide veterans with an easily updated health
record that follows a veteran for life, from when the service member
joins the military to their time in VA healthcare. The American Legion
strongly supports these goals.\3\
---------------------------------------------------------------------------
\1\ Allen, Arthur. n.d. ``A 40-Year `Conspiracy' at the VA.'' The
Agenda. Politico.com. https://www.politico.com/agenda/story/2017/03/
vista-computer-history-va-conspiracy-000367/.Unless otherwise noted,
all cited hyperlinks accessed March 28, 2023.
\2\ Communication, IT Strategic. 2022. ``What Veterans Need to Know
about How VA's Health Record System Is Changing--VA EHR
Modernization.'' Digital.va.gov. July 21, 2022. https://digital.va.gov/
ehr-modernization/resources/fact-sheets/what-veterans-need-to-know-
about-how-vas-health-record-system-is-changing/.
\3\ ``Resolution No. 83: Virtual Lifetime Electronic Record.''
2016. https://archive.legion.org/node/329.; ``Resolution No. 12:
Implementation of the MISSION Act.'' 2022. https://archive.legion.org/
node/14050.
---------------------------------------------------------------------------
The first deployment of Oracle Cerner Millennium began in 2020 at
Mann-Grandstaff VA Medical Center in Spokane, Washington. It
immediately faced problems with transferring medical records to the new
system.\4\ For example, it imported outdated emergency contact
information and eliminated essential prescription histories. As
detailed in two VA Office of Inspector General (OIG) reports, the
rollout also had training and reporting issues, and caused multiple
incidents where veterans were harmed.\5\ On one occasion, the Oracle
Cerner Millennium system shut down for over 4 hours at Mann-Grandstaff,
causing medical center staff to rely on outdated paper records and
leaving veterans at risk of medical error.\6\
---------------------------------------------------------------------------
\4\ VA OIG Details Continued Deficiencies with VA's EHRM.'' n.d.
www.meritalk.com. https://www.meritalk.com/articles/va-oig-details-
continued-deficiencies-with-vas-ehrm/.
\5\ Department of Veterans Affairs Office of Inspector General.
``The New Electronic Health Record's Unknown Queue Caused Multiple
Events of Patient Harm.'' 2022. va.gov https://www.va.gov/oig/pubs/
VAOIG-22-01137-204.pdf.
\6\ Krishan, Nihal. ``VA Cerner Ehr System Goes down for over 4
Hours Due to Patient Data base Corruption Issue .'' FedScoop,
August 5, 2022. https://fedscoop.com/va-cerner-ehr-system-goes-down-
for-3-hours-due-to-patient-data base-corruption-issue/.
---------------------------------------------------------------------------
After several more deployments, the system continued to experience
installment and operational issues, eventually leading to VA's decision
to put the rollout on hold. The most recent pause started in October
2022 and was indefinitely extended in April 2023. During this time, VA
established an EHRM Sprint Project Team to identify the solutions
necessary to move forward. \7\ After reviewing more than 450 issues,
the Sprint Project Team released a report focusing on 30 current
critical issue areas in the EHRM implementation.
---------------------------------------------------------------------------
\7\ Department of Veterans Affairs Veterans Health Administration.
``EHRM Sprint Report.'' 2023. veterans.senate.gov. https://
www.veterans.senate.gov/services/files/5B5776E7-8765-4303-9B93-
D2BCBF8D5A33.
---------------------------------------------------------------------------
The critical issues identified include diagnostic echocardiogram
orders being entered incorrectly, problems with home oxygen
requisition, lost prosthetic orders, medication lists disappearing, and
prescription delays and omissions. In these areas of care, patient
safety must remain a top priority - where one mistake can kill or
severely harm a veteran and their quality of life. In its current
State, the Oracle Cerner Millennium system makes these levels of care
vulnerable and potentially harm veterans in the future. Last month, on
March 21, 2023, VA informed the Senate Veterans Affairs Committee that
EHRM issues were linked to at least four veteran deaths and two
additional instances of critical harm to veterans.\8\
---------------------------------------------------------------------------
\8\ Rodriguez, Sarai. (2023, March 21). ``VA Admits Oracle Cerner
EHRM Issues Contributed to 4 Veteran Deaths.'' ehrintelligence.com. VA
Admits Oracle Cerner EHRM Issues Contributed to 4 Veteran Deaths
(ehrintelligence.com).
---------------------------------------------------------------------------
It is important to note that the report is not intended to fix
issues with the EHRM program but rather to identify and recommend
solutions, leaving VA and Oracle Cerner to further develop and
implement them. The American Legion recognizes this is a complex, time-
consuming process, and fixes will take time and effort.
H.R. 592 would address some of the major problems facing the EHRM
program rollout. The act implements reasonable recommendations and
requires two main certifications from current facilities using the
Oracle Cerner Millennium system before it is deployed to further
facilities.\9\
---------------------------------------------------------------------------
\9\ Congress.gov. ``Text--H.R. 592--118th Congress (2023-2024):
Department of Veterans Affairs Electronic Health Record Modernization
Improvement Act.'' February 16, 2023. https://www.Congress.gov/bill/
118th-congress/house-bill/592/text's=1&r=28.
---------------------------------------------------------------------------
The first such requirement is a monthly average uptime of 99.9
percent for facilities currently using the Oracle Cerner Millennium
system, which is key for any system, especially one meant to care for
veterans. The American Legion believes an average monthly uptime of
99.9 percent would allow the maximum ability for VA to deliver world-
class care to our veterans.
The second requirement is that any new EHR system will not launch
in a new facility unless the facility's director, chief of staff, and
Veterans Integrated Services Network (VISN) director certify that the
facility and its staff are prepared for system deployment and use. VISN
and facility leadership are the most qualified to assess a facility's
readiness. Furthermore, if leadership and staff are properly prepared
and ready to receive the new system, the willingness to learn and
operate the system will likely assist in a successful implementation.
Together, these requirements are sensible safeguards moving forward to
ensure the success of the EHRM program.
Through Resolution No. 83: Virtual Lifetime Electronic Record, The
American Legion supports the implementation of an electronic health
record and wants the EHRM program to succeed and serve veterans
safely.\10\ The VA and veteran service organizations, like The American
Legion, work tirelessly to improve the lives of our Nation's veterans.
H.R. 592 and the Oracle Cerner Millennium system will provide the
capabilities to ensure that American veterans receive the world-class
care they deserve.
---------------------------------------------------------------------------
\10\ The American Legion Resolution No. 83 (2016): Resolution No.
83: Virtual Lifetime Electronic Record : Digital Archive (legion.org).
---------------------------------------------------------------------------
The American Legion supports H.R. 592 as currently written.
Conclusion
Chairwoman Kiggans, Ranking Member Mrvan, and distinguished members
of the subcommittee, The American Legion thanks you for your leadership
on this matter and for allowing us the opportunity to share the
position of our more than 1.6 million members. For additional
information or questions regarding this testimony, please contact
Legislative Associate, John Kamin, at The American Legion's Legislative
Division at (202) 861-2700 or jkamin@legion.org.
______
Prepared Statement of Fleet Reserve Association
The FRA
``Heading to 1OO Years''
The Fleet Reserve Association (FRA) is the oldest and largest
organization serving enlisted men and women in the active, reserve, and
retired communities plus veterans of the Navy, Marine Corps, and Coast
Guard. The Association is congressionally Chartered, recognized by the
Department of Veterans Affairs (VA), and entrusted to serve all
veterans who seek its help.
FRA started in 1924 and its name is derived from the Navy's program
for personnel transferring to the Fleet Reserve after 20 or more years
of active duty, but less than 30 years for retirement purposes. During
the required period of service in the Fleet Reserve, assigned personnel
earn retainer pay and are subject to recall by the Secretary of the
Navy.
The Association testifies regularly before the House and Senate
Veterans' Affairs Committees, and it is actively involved in the
Veterans Affairs Voluntary Services (VAVS) program. A member of the
National Headquarters' staff serves as FRA's National Veterans Service
Officer (NVSO) and as a representative on the VAVS National Advisory
Committee (NAC). FRA's VSOs oversee the Association's Veterans Service
Officer program and represent veterans throughout the claims process
and before the Board of Veteran's Appeals.
In 2016, FRA membership overwhelmingly approved the establishment
of the Fleet Reserve Association Veterans Service Foundation (VSF). The
main strategy for the VSF is to improve and grow the FRA Veterans
Service Officers (VSO) program. The newly formed foundation has a
501(c) 3 tax exempt status and nearly 800 accredited service officers
with FRA.
FRA became a member of the Veterans Day National Committee in
2007,joining 24 other nationally recognized VSOs on this important
committee that coordinates National Veterans' Day ceremonies at
Arlington National Cemetery. FRA will host the ceremony in their
centennial year, 2024. The Association is a leading organization in The
Military Coalition (TMC), a group of 35 nationally recognized military
and veteran groups jointly representing the concerns of over five
million members.
The Association's motto is ``Loyalty, Protection, and Service.''
Introduction
The FRA welcomes this and other numerous oversight hearings because
the Association believes congressional oversight of the VA technology
program is vital to ensuring improvements to the system. The VA
healthcare structure is a hybrid system consisting of inpatient and
outpatient care, telehealth, and community care. Ensuring that the VA
is equipped to meet the unique needs of veterans requires the VA to
fully leverage all components of the VA healthcare system and create a
seamless and paperless transition from active-duty service to veterans
status. The Electronic Health Record Modernization (EHRM) is an
essential element in modernization of the VA healthcare system.
EHRM
``The VA uses the Veterans Health Information Systems and
Technology Architecture (VistA), which includes the VA's Electronic
Health Record (EHR) system to provide healthcare to patients. In June
2017 the agency initiated the EHRM program to replace VistA because it
is technically complex, costly to maintain, and does not fully support
the need to exchange health data with other organizations.'' \1\ The VA
has spent more than $9.42 billion on the EHRM program.
---------------------------------------------------------------------------
\1\ GAO report -23-106685, March 15, 2023
---------------------------------------------------------------------------
FRA appreciates the House Veterans Affairs Committee oversight
hearings on the Electronic Health Record Modernization at the VA. The
plan has been plagued with ongoing problems dating back to its initial
launch at the VA Medical Center in Spokane, Washington. Serious issues
related to patient safety, training, employee morale, and several other
deployment problems still exist, though some progress has been made.
Office of Inspector General (OIG) report revealing serious issues with
the deployment of VA's new Electronic Health Record Modernization
(EHRM) program.
The VA first launched its new electronic health record (EHR) system
more than 25 months ago. The program was scheduled in July 2022 to
expand to include the VA Medical Center in Boise, Idaho. The expansion
was delayed from October 2022 until June 2023 when VA wanted to expand
the software to new VA medical centers.
Oversight committees were told that the VA is using this pause to
make system enhancements and to perform tests to ensure the system is
stable, resilient, and provides the capability VA employees and
veterans need to improve access and quality of care. Department of
Veterans (VA) Secretary McDonough has extended the pause for
implementing the Electronic Health Record Modernization (EHRM) program.
There is growing concern on Capitol Hill about the long-term cost,
safety, and reliability of the program. This new delay did not specify
when implementation would resume. When the program started it was
estimated that the cost would be $16 billion over 10 years. However, a
more recent independent estimate predicts $33-36 billion over 13 years.
Nevertheless, progress has occurred since the VA joined with the
DoD in a joint contract to modernize its EHR system in 2017. The huge
$16 billion project raised lots of concerns with lawmakers after
decades of attempts by both departments to develop a joint
interoperable health record that never materialized.
The House and Senate passed the ``Electronic Health Record
Transparency Act'' (H.R. 4591) to require the VA to submit to Congress
quarterly reports that evaluate the performance of the EHR, and it was
signed into law in June 2022. The FRA wants to ensure adequate funding
for DoD and the VA health care resources delivering seamless, cost-
effective, quality services to personnel wounded in combat and other
veterans and their families. Some Members of Congress have expressed
concern about the cost and length of time to fully implement this
program. The cost and the long time for implementation notwithstanding,
the FRA believes there is a tremendous opportunity with the two
departments using the same Electronic Health Records.
Implementation Problems
The recent acquisition of the Cerner system by Oracle has come with
a wide variety of challenges. The VA staff has experienced difficulties
adjusting to the new system. The VA claims this is due to a lack of
proper training. The new system created an ``unknown queue,'' a
problematic feature that has caused referral orders to effectively go
missing at the VA. Additionally, an audit by the Office of Inspector
General (OIG) claims that the VA lacked a reliable integrated master
schedule consistent with scheduling standards, which increases the risk
of missing milestones and delaying the delivery of a system to provide
timely, quality care to veterans. Schedule delays that extend the
program are also likely to result in about $1.95 billion in annual cost
overruns and may determine the VA's other modernization efforts on
supply chain and financial management system. The report claims that
Cerner failed to deliver more than 11,000 orders for specialty care,
lab work and other services--without alerting health care providers the
orders had been lost. Those lost orders, resulted in delayed care and
what a VA patient safety team classified as dozens of cases of
``moderate harm'' and one case of ``major harm.'' It should be noted
that the Department of Defense (DoD) waited for roughly 2 years after
implementing the EHR at its first four sites, and the glitches DoD was
focused on fixing (primarily with its networks) were smaller than what
VA is trying to fix. As VA leadership has confirmed, they will not
deploy the new EHR system at any facility until they are certain it is
ready to deliver for veterans and VA providers. Based on recent
assessments, the VA has determined that the new EHR is not yet ready
for further deployment at this time.
Legislative Action
There have been two legislative proposals introduced in the House
that pertain to the VA's EHRM program. FRA believes congressional
oversight of VA technology is vital to ensuring improvements in the
system. Legislation introduced in the House the ``EHRM Improvement
Act'' (H.R. 592) to block further implementations of the system until
the medical centers determine they are well- equipped to receive and
use it, without hindering the delivery of care to veterans and hurting
productivity. The HVAC Chairman and sponsor of the bill, Rep. Mike Bost
(IL) believes that the Oracle Cerner system should not be implemented
at any more VA sites until the VA Medical Centers leadership certifies
that the medical center is ready.
Other legislation introduced ``the EHRM Termination Act'' (H.R.
608) which would end the project altogether if VA and Oracle Cerner are
unable to make significant improvements. FRA supports H.R. 592 and has
not taken a position on H.R. 608.
Conclusion
In closing, FRA wants to express its sincere appreciation for the
opportunity to present its views on the EHRM program to this
distinguished Subcommittee. The FRA believes there is a tremendous
opportunity with the two departments using the same Electronic Health
Records.
[all]