[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
ELECTRONIC HEALTH RECORD
MODERNIZATION DEEP DIVE: PHARMACY
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, MAY 9, 2023
__________
Serial No. 118-12
__________
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
52-492 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 TECHNOLOGY MODERNIZATION
MATTHEW M. ROSENDALE, SR., Montana, Chairman
NANCY MACE, South Carolina SHEILA CHERFILUS-MCCORMICK,
KEITH SELF, Texas Florida, Ranking Member
GREG LANDSMAN, Ohio
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
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TUESDAY, MAY 9, 2023
Page
OPENING STATEMENTS
The Honorable Matthew M. Rosendale, Sr., Chairman................ 1
The Honorable Sheila Cherfilus-McCormick, Ranking Member......... 2
WITNESSES
Mr. Neil Evans, M.D., Acting Program Executive Director,
Electronic Health Record Modernization Integration Office, U.S.
Department of Veterans Affairs................................. 4
Accompanied by:
Mr. Thomas Emmendorfer, Pharm.D., Executive Director,
Pharmacy Benefits Management Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
Mr. Robert Silverman, Pharm.D., Chairman, Pharmacy Council,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Mr. Mike Sicilia, Executive Vice President, Global Industries,
Oracle......................................................... 6
Accompanied by:
Mr. James Ellzy, M.D., Vice President Federal, Health
Executive, Oracle
Ms. Carol Harris, Director, Information Technology and
Cybersecurity, Government Accountability Office................ 8
APPENDIX
Prepared Statements Of Witnesses
Mr. Neil Evans, M.D. Prepared Statement.......................... 35
Mr. Mike Sicilia Prepared Statement.............................. 39
Ms. Carol Harris Prepared Statement.............................. 49
ELECTRONIC HEALTH RECORD MODERNIZATION DEEP DIVE: PHARMACY
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TUESDAY, MAY 9, 2023
U.S. House of Representatives,
Subcommittee on Technology Modernization,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 3:02 p.m., in
room 360, The Capitol, Hon. Matthew M. Rosendale, Sr. (chairman
of the subcommittee) presiding.
Present: Representatives Rosendale, Mace, Self, and
Cherfilus-McCormick.
Also present: Representatives Balderson and Carey.
OPENING STATEMENT OF MATTHEW M. ROSENDALE, CHAIRMAN
Mr. Rosendale. Good afternoon. I would like to bring this
subcommittee to order. A great deal has changed since our last
hearing. The VA is finally acknowledging that the Oracle Cerner
electronic health record system is not fully functional and is
not suitable to any other facility.
After nearly 3 years of pressing forward, despite the
mounting consequences to veterans' safety, staff burnout and
billions of dollars wasted, Secretary McDonough and Dr. Evans
have become realistic about the future of this ill-conceived
project. That is encouraging. It has been painful and very
expensive to watch this disaster unfold. It has been
frustrating to argue and plead with VA not to march off the
cliff, only to be ignored or stonewalled.
Thankfully, the Department is now listening to what
veterans, it is on employees, and this committee have been
saying for so long. It is far past time to look under the hood
of the Electronic Health Record (EHR) and see if it can be
fixed and whether progress is even being made. Be assured, that
is exactly what we are about to do. We are here today to take
an in-depth look at one particularly dysfunctional aspect of
the EHR and that is pharmacy.
Pharmacy is crucial to veterans' health and well-being.
Unfortunately, it is one the most error ridden and dangerous
parts of the system. First and foremost, we need to listen to
the VA pharmacists who use it every day. To that end, the
subcommittee sent questionnaires to each of the five medical
centers using Oracle Cerner. We received responses from
Spokane, Walla Walla, Columbus and Roseburg.
The situation they describe is outrageous and dangerous.
The pharmacists cannot trust the system so they have to work in
a constant State of hypervigilance. The Spokane medical center
has been live on Oracle Cerner EHR for 2-1/2 years. Yet, they
continue to discover new problems every week.
Across these sites patient safety reports are up over 300
percent since the EHR went live. About a quarter of these
incidents are directly related to pharmacy. The medical centers
have added on average of 20 percent more pharmacy employees to
perform the same workload on top of relying on support from
remote pharmacists.
Columbus even had to dedicate a pharmacist to manage the
Cerner help desk tickets full time. They created a management
position in the pharmacy just to deal with the EHR. All
together the pharmacy operations at Spokane, Walla Walla and
Columbus have seen a more than $9 million deficit from
increased staffing costs and lost copays and collections. On
average, the staff's struggles with the EHR have shaved about
22 points off of these medical center scores in the best places
to work survey.
The pharmacists are in distress and they do not feel their
concerns are being taken seriously. That is deeply unfortunate
because they, not the VA central office, not Cerner, have been
doing the crucial work to document the system's flaws since the
very beginning. It was the Spokane pharmacists who wrote the
initial 57-page patient safety domain report in August 2021.
It was the pharmacists at these medical centers who
identified the 79 business requirement change requests and
continue to track them. Some of their findings went into the
improvement sprint report that Dr. Evans' office released in
March but appears that much more was excluded.
Oracle Cerner released pharmacy updates in February and
late April and another one is slated for August. The
pharmacists believe some of these updates have been successful
and produced incremental improvements. As for the more
significant updates, they seem to have created as many new
complications as they even resolved.
VA and Oracle Cerner are barely scratching the surface,
tackling only a handful the high priority issues from a list
that is approaching 100.
I appreciate all of our witnesses joining us today so we
can dig into these pharmacy updates and their trajectory for
improvement. We expect the VA pharmacists to give our veterans
world class service and we owe them fully functional technology
to do that.
With that, I would yield 5 minutes to Ranking Member
Cherfilus-McCormick for her opening statement.
OPENING STATEMENT OF SHEILA CHERFILUS-MCCORMICK, RANKING MEMBER
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman. Thank you
to our witnesses for being here today to discuss the critical
project at the Department of Veterans Affairs. I want to start
off by saying that I wholeheartedly support the VA's decision
to delay any further go lives while they fix the issue at five
sites currently live on he Cerner system.
I am a cosponsor along with Chairman Bost and Ranking
Member Takano on the Electronic Health Record Program
Restructure, Enhance, Strengthen, and Empower Technology (EHR
RESET) Act. I look forward to working with my colleagues to
ensure that we do not go live at any future sites until we fix
the issue in this system. These sites have born the brunt VA's
to properly manage this project from the very beginning and we
owe them our focus.
That being said, I have a number of concerns with the
delay. VA has not provided the committee a timeline for when
they expect the work to be completed at the live sites. I am
also very concerned that the VA has still not established a
baseline EHR. Without a baseline, every future go live will
bring more changes to the system.
Constant change requests have and will continue to have
major impact on the cost and timeline the project and will
force staff at the active sites to continually adjust their
workflows. I have already heard from the staff that they feel
like they are being repeatedly bashed into rocks by the waves
of change. The change fatigue associated with constant
adjustment is detrimental to staff morale and will have lasting
effects on the VA's ability to recruit and retain high quality
staff and by extension on the veterans' access to health care.
The VA much shore up its governance process to ensure that
any changes to the system are both necessary and the best
interest of our veterans and VA providers. Electronic Health
Record Modernization (EHRM) cannot be allowed to go the way of
Veterans Health Information Systems and Technology Architecture
(VistA) where every faculty is operating a different system.
We hear frequently from the VA employees and they continue
to feel like their concerns are not being addressed and are
bothered by the lack of information on the path forward.
Communication with frontline staff must improve in VA if VA
expects them to adopt the change.
Also, there must be more emphasis on empowering employees
in the decisionmaking process and having their issues fixed
faster. There is an entire workforce at VA informatics that are
being underutilized.
In this project that could be empowered to manage local
configuration changes which would drastically improve the
timeline of these needs. I think this would also go a long way
toward improving user satisfaction.
Finally, I want to address recent reports of patient harm
caused by the new EHR. I have spent much of my career in
healthcare and I understand that it is not as simple as saying
Cerner hurts veterans. However, the fact is that the EHR did
play at least some role in these tragic incidences. I hope that
both the VA and Oracle Cerner are looking at the system and the
work flows and the policy of proactively identifying areas
where there is potential for patient harm instead of reactively
patching these places where harm has already occurred.
On a more positive note, I am cautiously optimistic that
the new leadership team has made progress in the short time
that they have been in place.
The attitude and experience of Dr. Evans has brought to his
role is refreshing. I am encouraged that the VA has chosen a
practicing physician from the system to help turn the system
around. Dr. Evans, your work--Dr. Evans, you and your work are
cut out for you. I look forward today to that conversation. I
am encouraged to hear from everybody on how we can help make
this EHR a reality for all of our VAs. Thank you so much.
I yield back to you, Mr. Chairman.
Mr. Rosendale. Thank you so much, Ranking Member Cherfilus-
McCormick.
I will now introduce the witnesses on our first and only
panel today. First from the Department of Veterans' Affairs we
have Dr. Neil Evans, acting executive director of the
Electronic Health Record Modernization Integration Office. We
also have Dr. Thomas Emmendorfer, the executive director of the
pharmacy benefits management services and Dr. Robert Silverman,
the chairman of the EHRM pharmacy council.
Next we have from Oracle Mr. Sicilia, executive vice
president for global industries and Dr. James Ellzy, vice
president for Federal Health. Finally we have Ms. Carol Harris,
the director of information technology and cybersecurity at the
Government Accountability Office.
I ask the witnesses to please stand and raise your right-
hands.
[Witnesses sworn.]
Mr. Rosendale. Thank you. Let the record reflect that all
the witnesses have answered in the affirmative.
Dr. Evans, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF NEIL EVANS
Dr. Evans. Chairman Rosendale, Ranking Member Cherfilus-
McCormick, and distinguished members of the subcommittee, thank
you for the opportunity to testify in support of the VA's
initiative to modernize its electronic health record system.
Today, as mentioned, I am accompanied by my VA colleagues,
Dr. Thomas Emmendorfer, executive director of pharmacy benefits
management, and Dr. Robert Silverman the pharmacy co-chair of
the council, the pharmacy council for Electronic Health Record
Modernization.
Before I speak about the impact of our electronic health
record modernization efforts and the intersection with VA's
pharmacy services, I would like to first spend a few moments
discussing our recent decision to halt deployment activities of
the Federal electronic health record in VA, as part of the
larger program reset. We have been listening to veterans and
the VA staff who are using the new electronic health record a
the medical centers, VA clinics, and remote supporting
locations associated with our health system in Spokane and
Walla Walla, Washington, Roseburg and White City, Oregon and
Columbus, Ohio.
We have also been listening to Congress, including this
subcommittee. The new electronic health record is not meeting
our expectations. VA is electing to take the time to get things
right.
The program we set follows an extended pause and
deployments that began in July 2022, culminating in an effort
to assess and address a more narrow set of issues deemed to be
the most impactful selected through the lens of patient safety.
The VA is already working with Oracle to address the issues
identified. Together with Oracle during this reset we will be
able to more comprehensively address both these issues and a
broader set of changes necessary for program success.
Additional deployments will not be scheduled until the VA
is confident the new EHR is highly functioning at current sites
and is ready to deliver for veterans and VA clinicians at
future sites. This readiness will be demonstrated by clear
improvements in clinician and veteran experience. Sustained
high performance and high reliability of the system itself,
improved levels of productivity at sites where the EHR in use
and more.
When the reset period concludes, the VA plans to release a
new deployment schedule. The only exception to the full stop
deployment activities is at the capital James A. Lovell Federal
Health Care Center in north Chicago, a fully integrated VA and
Department of Defense facility. To ensure that all veterans and
servicemembers who are cared for at this facility are covered
by one her system deployment activities there will continue
with at planned deployment in 2024. That deployment will of
course also leverage the improvements made during the
concurrent program reset.
I would like to now turn to the focus area of the this
hearing, a deep dive into pharmacy and the new electronic
health record. The top priority of our pharmacy program at VA
is to serve and honor the men and women who are America's
veterans by delivering pharmacy programs founded on pillars of
safety, quality and value.
In addition, customer service is a hallmark of VA pharmacy
services. One example is the consolidated mail out patient
pharmacy program that VA runs that provides prescription
fulfill to over 350,000 veterans every day. He leads the mail
order pharmacy business was validated externally by the annual
J.D. Power & Associates national pharmacy studies and has
achieved the highest customer satisfaction score in 10 of the
last 14 years.
Managing over 146 million total prescriptions a year at VA,
pharmacists and pharmacy staff are fully integrated into our
care teams as first-class members of the team. The division
that exists between the health system and retail pharmacies in
the private sector does not exist in VA.
Our pharmacy achieve success by cultivating a culture of
continuous improvement. I want to acknowledge and thank our
pharmacy community for using the same approach to identify the
improvements that are needed in the Oracle Cerner pharmacy
system and the electronic health report.
The main concerns identified by our pharmacy community have
been related to select acts aspects of an Oracle Cerner
pharmacy application called Med Manager retail, as well as its
interaction with a core Cerner electronic health record, Cerner
Millennium and specifically PowerChart.
A series of development efforts underway by Oracle to
improve the visualization of medications for both pharmacists
and ordering provider to improve synchronization between Med
Manager retail and PowerChart and to improve the efficiency of
the work flow for pharmacy staff as they process prescriptions
and refills.
Some improvements are recently delivered in a series of
software updates over the past few months and the remainder are
planned for delivery between now and February 2024. The
feedback from or pharmacy community on the recently deployed
enhancements is that the improvements have been small and
incremental.
Although these improvements are appreciated, VA pharmacy
staff and providers need an accelerated delivery of upgrades to
eliminate the burden of the more labor intensive human
mitigation strategies that are currently in place. Furthermore,
the current pace the new requests for upgrades and enhancements
exceeds the delivery schedule of changes to address those
requests. This way one of our focus areas during the months to
come as we work with Oracle Cerner to optimize and accelerate
efforts where possible.
Chairman Rosendale, Ranking Member Cherfilus-McCormick and
members of the committee, I thank you again for this
opportunity to testify today and for all your continued support
of our Nation's veterans and their caregivers.
[The Prepared Statement Of Neil Evans Appears In The
Appendix]
Mr. Rosendale. Thank you, Dr. Evans. The written statement
of Dr. Evans will be entered into the hearing record.
Mr. Sicilia, you are now recognized for 5 minutes to
deliver your opening statement.
STATEMENT OF MIKE SICILIA
Dr. Sicilia. Chairman Rosendale, Ranking Member Cherfilus-
McCormick and members of the subcommittee, thank you for
inviting us here today. I am joined by Dr. James Ellzy from our
Federal EHRM team and we look forward to this discussion about
pharmacy capabilities for the new VA EHR.
First, with VA's announcement on April 21 of the reset for
the EHRM program I want to State again that Oracle is proud to
continue to work together with VA to modernize its EHR system.
We support VA's plan to improve the operation of the EHR at the
current sites and take the necessary time to institute
governance, change management, and standardization changes to
ensure the success of future VA deployments, similar to what
Department of Defense (DOD) did a few years ago. DOD's
modernization is now nearly complete, on time and on budget. We
will continue to closely coordinate with VA to provide
enhancements and updates to the EHR as we have since we closed
our acquisition of Cerner last June. Since then we have made
significant progress on many critical issues that were
impacting the EHR system, including its pharmacy capabilities.
Overall the system performance has significantly improved from
where it was last summer.
At the five currently live sites on average more than
200,000 prescriptions are being filled each month. To date 2.8
million prescriptions have been filled through the mail system
Consolidated Mail Outpatient Pharmacy (CMOP). When a veteran
can send to get a prescription the average window turnaround
time across the currently live sites is 25 minutes, which is
below the 30-minute key performance metric set by the VA.
The VA's pharmacy system does not operate the same as
commercial healthcare systems, as Dr. Evans noted, where the
EHR enables a provider to order a prescription but the
receiving pharmacy then utilizes its own software for the
dispensing of the medication. In the VA healthcare system VA is
both the ordering party and the dispensing party through its
own VA pharmacy whether outpatient or by mail. Therefor the her
needs to support the supplying components to fill
prescriptions. Its fundamental difference is the reason that
pharmacy enhancements were needed to tighten the integration
between the outpatient pharmacy application and the provider
ordering application.
Shortly after the acquisition closed I came to the Hill and
met with many Members who were interested in this program. In
every single meeting I heard about pharmacy and the need for
these enhancements. Members were unhappy that Cerner had
provided a timeline of up to 3 years to do the work once VA
finally settled on it requirements. That was clearly
unacceptable. Once the requirements for the enhancements were
delivered to us in VA, by VA in August we built and deployed
the top three enhancements to VA in 4 months. There are seven
total enhancements and their order was prioritized by the VA.
The remaining four enhancements will be delivered this year
for deployment in 2023 and early 2024. That is a significantly
faster overall timeframe--timeline. We hope it shows you that
the Oracle is a highly, capable partner for VA and whether it
is pharmacy enhancements or other fixes we have put tremendous
engineering rigor and resources into getting the work done well
and quickly.
We have also read the survey results around the recently
delivered pharmacy enhancements. We are not completely
surprised given the first three enhancements delivered as
prioritized by the VA were focused more on improving--ordering
provider experience. The next set of enhancements are focused
more on improving the pharmacist experience. We believe that
once delivered and implemented then pharmacists will be in a
position to provide very variable feedback.
One other point about the pharmacy system I would like to
highlight is the new opioid adviser tool included with the EHR.
This tool allows clinicians to simultaneously check data from
47 State prescription and drug monitoring programs and
Department of Defense facilities to prevent improper
prescribing in controlled substance.
The opioid adviser tool has automatically alerted providers
to avoid prescribing opioids to high-risk patients nearly 1,800
times since November 2020. With the opioid adviser the other
modern features of the EHR and the enhancements completed and
in process we believe that the pharmacy system will provide a
high degree of safety for veterans as they received their
medications.
However, we will continue to review it together with VA,
especially given the reset period that we are now in. We will
continue to work with VA to make sure that enhancements which
are forthcoming are delivered on or ahead of schedule. We
continue to prioritize our work in pharmacy so that we are
confident veterans will receive the cases they need when
needed.
Thank you.
[The Prepared Statement Of Mike Sicilia Appears In The
Appendix]
Mr. Rosendale. Thank you, Mr. Sicilia.
The written statement of Mr. Sicilia will be entered into
the hearing record.
Ms. Harris, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF CAROL HARRIS
Ms. Harris. Chairman Rosendale, Ranking Member Cherfilus-
McCormick, and members of the subcommittee, I am pleased to
participate in today's hearing on the pharmacy-related
functions of VA's new EHR system.
As requested, I will briefly summarize the findings from
our recently completed review of this mission critical system.
The results are applicable to the EHRM program as a whole
including to the pharmacy-related concerns discussed today. As
you know, VA provides healthcare services to roughly 9 million
veterans and their families and relies on a legacy system
called VistA to do so.
In June 2017, the Department initiated the EHRM program to
replace VistA and has obligated at least $9.4 billion on this
program to date. This is also VA's fourth attempt at replacing
the legacy system and the implementation thus far has been just
as challenging as the last three attempts, if not even more so.
As such we support VA's recent decision to pause future
deployments in order to focus on making improvements at the
five sights where the system is currently in use.
In our most recent work, we detailed VA's gaps to
effectively manage organizational change as well as the extreme
dissatisfaction among users and system issues. This afternoon I
will highlight three key points that VA should address during
this reset period.
The first is more needs to be done to adequately address
VA's organizational change management challenges. Our recent
review detailed eight leading practices for change management.
VA had partially implemented seven and did not implement one.
These gaps occurred for a number of reasons. Most notably, the
Department lacked a VA driven strategy for how its efforts
would supplement the contractor-led change management
activities. As such the activities focused on system
deployment, not on user challenges with transitioning to new
work flows.
The results of VA's own post-deployment questionnaires
highlight the need for more attention for this area. On a scale
of zero to 100 with 68 being average, users rated their
abilities to use a new EHR system somewhere between 23 and 32.
We made seven recommendations to VA to address the gaps in
their change management activities.
Now to my second point, users of the new EHR system are
generally dissatisfied and this needs to be fully addressed
before deployments resume. The VA is well aware that its users
are unhappy with the system. Their 2021 and 2022 user
satisfaction survey showed this. For example, about 6 percent
of users agreed that the system enabled quality care.
Roughly 4 percent of users agreed that the system made them
as efficient as possible. I have been auditing for over 20
years now across the Federal Government, these are the lowest
scores that I have seen in government, hands down.
With regard to the pharmacy module, users told us
processing prescriptions took much longer in the new system,
leading to increased backlogs and decreased efficiency which
led to patient safety concerns because the pharmacy could not
full prescriptions in a timely fashion.
The pharmacy Department at one facility increased from 15
to 60 staff to manage increased workloads associated with the
system. There were also multiple instances of double
prescriptions and incorrect medication orders and the list goes
on.
Furthermore, VA has not established goals to assess user
satisfaction. Having such goals in place would provide the
department with a basis for determining when satisfaction has
improved and also help ensure that the system is not
prematurely deployed to additional sites which could risk
patient safety. Accordingly, we recommended that VA set these
goals and also demonstrate improvement toward meeting them in
prior to future system deployments.
Now to my final point. The VA did not adequately identify
and address EHRM system issues. The VA has not conducted an
independent operational assessment of the new system and as of
January did not plan to do so. This critical evaluation
performed by a third party would enable VA to systemically
catalogue, report on and track resolution of assessment
findings with greater rigor transparency and accountability. We
recommended that VA make plans to have the independent
assessment done.
In summary, the successful implementation of a new system
across VA will require a level of program management,
adaptability to change and sustained system performance that
the department and contractor have yet to demonstrate.
Continuance of the EHRM is not without risk but with strong
oversight from this committee in addition to improved VA
program management and contractor system performance we can
increase the odds for success.
Mr. Chairman, that concludes my statement. I look forward
to your questions.
[The Prepared Statement Of Carol Harris Appears In The
Appendix]
Mr. Rosendale. Thank you very much, Ms. Harris. The
statement of Ms. Harris will be entered into the hearing
record.
Before we proceed to questioning I ask unanimous consent
from Representative Mike Carey and Troy Balderson to
participate when they are able to get here.
Hearing no objection, so ordered.
I now recognize myself for 5 minutes for questioning.
Dr. Evans, are you committed to making the Oracle Cerner
pharmacy software and the EHR as a whole fully, functional
before restarting any go lives?
Dr. Evans. Yes. I mean that is--the purpose of our program
reset at the highest level is no have a single minded focus on
the system improvements. Frankly also the process improvements
that are necessary for us to have the confidence that we can
move forward with further deployments.
Mr. Rosendale. Are you willing to rely upon the input from
the directors of the facilities that the system is fully
functional in order to account for that recognition.
Dr. Evans. Yes, absolutely. I just was in Columbus last
week meeting with facility leadership in Columbus and I look
forward to meeting with the facility leadership of all the
facilities that are currently using EHR.
Mr. Rosendale. Pharmacy is just one aspect of EHR's
problems, but its very important because it directly affects
veterans. What is necessary to make the system fully
functional?
Dr. Evans. As was mentioned by Mr. Sicilia, we talk about
pharmacy, there are three main stakeholders. There is the
ordering provider who is ordering the prescription. There is
the pharmacist and pharmacy staff who need to process that
prescription and interact with the ordering provider. Then of
course there is the veteran who is receiving the prescription.
When we talk about the health information technologies that
support and effective pharmacy operation, we need to take into
account all of those stakeholders.
One of the areas that you heard discussion about in some of
the opening remarks here was around supporting the efficiency
of pharmacists themselves to be able to safety and effectively
do their work, whether that be communicating with the ordering
provider or processing prescriptions and refills. At the top
level it is that efficiency and quality of processing
prescriptions and engaging with veterans that we are measuring
the success of this technology to meet our needs in the VA.
Mr. Rosendale. Thank you very much.
Mr. Sicilia, you testified to the Senate Veterans' Affairs
Committee in March. ``We believe from a performance and
scalability standpoint the system is ready for the resumption
of deployments.'' 5 weeks later Secretary McDonough halted all
future implementations. What is your definition of ready?
Mr. Sicilia. I was referring the to technical readiness of
the performance scalability of time. The clinical decisions
course belong to the VA.
Mr. Rosendale. Clearly you and Secretary McDonough have a
different definition of ready could we say?
Mr. Sicilia. I do not believe that the clinical areas of
the system are my responsibility. I am not a provider, I am not
a doctor. I do not make those decisions.
Mr. Rosendale. Okay. The VA has requested budgeted $1.8
billion for Fiscal Year 2024 based upon the old scheduled
rollout, which included facilities--10 more facilities. That is
been frozen and the original five are not fully functional
under the terms of the agreement. I have heard a lot of pledges
from Oracle over the last 6, 7 months about standing by their
product and being this large institution that is prepared to
take this on. The project has never performed as advertised. It
has caused so many problems the Secretary has delayed further
implementation. You cannot blame that on staff.
Do you think $1.8 billion for Fiscal Year 2024 is fair
compensation to Oracle for an EHR system that is not fully
functional in the five facilities that it is located in and in
the elimination of the 10 that were scrubbed.
Mr. Sicilia. Well. The total amount of money contemplated
includes lots of different things, software, plus go live
services. Obviously if the system is not going live we are not
going to be compensated for those services.
Mr. Rosendale. You would say that the $1.8 billion would be
excessive for Oracle to receive for compensation in Fiscal Year
2024 based upon the ten facilities that are not going to be
brought on and the five that are not functioning now.
Mr. Sicilia. If we are not going to resume go lives, then
sure, that is not going to be--that is not going to be the----
Mr. Rosendale. Okay. Do you think it is fair to enter into
a new contract and hold taxpayers responsible for a failing
system and sites that were never even added onto?
Mr. Sicilia. I would say that the system was core and
fundamentally flawed it would not be live at Walter Reed or Ft.
Belvoir. By the way we went live at the same time in parallel
at sites and the Department of Defense runs the same exact
system.
Mr. Rosendale. We are not talking about the Department of
Defense. In case you did not see the sign on the door--excuse
me, Mr. Sicilia. This is the House Veterans' Affairs Committee.
Do you think the taxpayers should pay $1.8 billion, which was
scheduled for 2024 a bill for 10 facilities that are not even
going to be utilized and for the five that are not fully
functional?
Mr. Sicilia. No, I do not think that they should because
the systems are obviously not going to go live.
Mr. Rosendale. Okay. That is fine. Thank you.
I will turn it over to Representative Cherfilus-McCormick
for 5 minutes of questioning.
Ms. Cherfilus-McCormick. Thank you so much, Mr. Chair.
My question is for Dr. Evans. Dr. Evans, how are pharmacy-
related patient safety events reported and investigated at the
sites using Oracle Cerner?
Dr. Evans. Any patient safety related concern is reported
in the same way, regardless of whether it is really the
pharmacy or any other part of care delivery. It is--these are
reported by--they can be reported when a user is calling in and
reporting a ticket or entering a ticket. They are entered into
something called the Joint Patient Safety Reporting system.
Our National Center for Patient Safety, as well as within
VA, as well as patient safety experts within the Electronic
Health Record Modernization Integration Office, as well as
informatics patient safety experts and the Veterans Health
Administration take every one of those reports seriously,
evaluate what has been reported, investigate the issue and
identified solutions to address any findings that are there.
One of the things that is very important is we encourage
our end users to report concerns. We would rather have an over
reporting of concerns so that we can evaluate the possibility
and address items that do prove to have patient safety risk.
The second thing I would say is that--and I think there was
a mention of this in comments earlier--a prospective, forward-
leaning approach to patient safety is also an important part of
this program. That is that as we are configuring the record and
improving the record that we are thinking about and evaluating
where there might be risk to patient safety in making those
decisions on the front end to mitigate or lessen the risk of
challenges down the line.
Ms. Cherfilus-McCormick. Specifically how does the VA
leadership receive the results of these investigations?
Dr. Evans. With regard to if--this is part of our routine
management of the system. With regard to--if we are talking
about patient safety reports or patient safety concerns there
are the changes we need to make to the system, but then there
are also if there is a concern that there might have been
patient harm our national center for patient safety will do a
root cause analysis and we have very regular discussions and
meetings with that group to identify what has been fond so that
we can take action to improve anything that is necessary within
the record.
Ms. Cherfilus-McCormick. How many actual patient harm
events have occurred at the Columbus center that you are aware
of?
Dr. Evans. I would have to take that for the record to give
you an exact number.
Ms. Cherfilus-McCormick. Do you know if any of them or how
many if you break it down in ratios were from pharmacy or
medical related?
Dr. Evans. I think when we talk about patient harm, patient
harm healthcare can be complicated. It is a complicated--we are
orchestrating delivery--a team of individuals taking care of
the veteran, imaging studies, orders getting placed,
medication. There is a lot that is happening in healthcare. In
general, when we look at patient harm, patient harm is almost
never singly attributed to an electronic health record. A
electronic health record can have a role in patient harm, but
it is often one of many facets.
When we think about patient harm, it is hard to say--to
answer your question to say how many--how many events of
potential patient harm, that is near misses or actual patient
harms can be directly and solely attributed to the electronic
health record.
Ms. Cherfilus-McCormick. I guess what I am trying to get at
is trying to identify are we really getting the numbers from VA
leadership of how many patients are harmed? How can we improve
it? That is the specificity that we are looking for. Do you
feel like you are getting the real number?
Dr. Evans. Yes.
Ms. Cherfilus-McCormick. Have you put together a pathway
for improvement?
Dr. Evans. Yes. I mean, I am seeing the real numbers on a
weekly if not daily basis. I am able to review the numbers that
are being evaluated. We have a process by which we take the
findings of what we learned to make the changes in the system
that are necessary to enhance safety.
Ms. Cherfilus-McCormick. Thank you so much, Dr. Evans. I
yield back.
Mr. Rosendale. Thank you, Representative Cherfilus-
McCormick. I now yield to Representative Self from Texas for 5
minutes.
Mr. Self. Thank you, Mr. Chairman.
I brought this up in hearings before with the VA, that
currently it is not in my district but it is certainly in my
area--the Dallas Veterans Integrated Services Networks
(VISN),--which I think is the second largest in the system.
Even under the VistA system, I hear from veterans all the time
that their pharmacy prescriptions do not arrive, they arrive
infrequently, or they have to request them again. It is very
interesting to hear the Government Accountability Office (GAO)
brief that this is a human factor issue. My question is how
does--and we will get to VistA in just a second--this may be
for Dr. Emmendorfer, how do prescriptions get filled
differently under Oracle Cerner than they do under VistA,
because I assume you are using the same pharmacy human factors.
Dr. Emmendorfer. Thank you, Congressman Self.
Oracle Cerner, there are five Cerner sites the vast
majority of the prescriptions are filled with the same pathway
as our VA medical facilities. Across the Nation, 84 percent of
all our prescriptions go through our mail order pharmacy
system.
The difference with our Cerner sites is what you heard from
the different folks at the panel today is the increase in
staffing for our Cerner sites. For example, in a Cerner site
from visiting with our staff it takes approximately three times
as long to process a prescription in Cerner. It is our staff's
dedication to the mission to care for our Nation's veterans
that still insurers we are delivering high quality pharmacy
services to our veterans.
To my knowledge, I do not believe that there are
significant delays coming from prescription delivery services
from our CMOP from our mail order pharmacy whether it is Cerner
or from a VistA site. The big issue for our staff, our pharmacy
staff is the amount of time it takes to process a prescription
to get the medication to the veterans.
Mr. Self. If there is no difference in method then what is
the advantage and what is the value added from Cerner?
Dr. Emmendorfer. The value added to Cerner is if you look
globally at our pharmacy system, we do have elements of our
electronic health record system that do need to be modernized.
Just to give one example is we do - we have had a requirement
going back to the early 2000's where we do need a perpetual
inventory system.
A perpetual inventory system would be highly advantageous
to our enterprise because that would allow us the ability to
have--I could be sitting here in my office and be able to look
at the inventory that is on hand across the enterprise.
That would be one advantage regardless of modernization of
our electronic health record and how that happens that would be
one advantage that we would see in pharmacy.
Mr. Self. Wow, your testimonies have taken me to a higher
level than my questions. I guess I want to drop down to one of
my last questions. Is this a matter of will to make this
happen, because again, the human factors to me are fascinating.
If Oracle says the system itself is ready to go and yet the
human factors are not there, that is where we are failing. Is
this a matter of the will, because we have heard that its
incredibly more expensive to do this system and yet the VA, if
I heard the Oracle representative right, is where the human
factors have not been taken into account. Is this feasible
long-term? Does the VA want to do this?
Dr. Evans. I think I can help answer that. As Dr.
Emmendorfer would say, there are capabilities in the Oracle set
of capabilities that have been on our list of things we need to
modernize for a long time, perpetual inventory system as an
example. A graphical user interface with a modern graphical
user interface for pharmacists to use. Right now pharmacy
prescriptions are still processed in what we call a roll-and-
scroll interface in VistA.
One of issues that you have heard laid out here is that
processing those prescriptions right now is not as efficient
for our pharmacy staff in part because we are--there are system
improvements that you have heard mentioned that need to be put
in place to allow us to deliver that more efficient operation.
Right, for the pharmacist. There is a human factor element, but
there are--but I would say the majority of this is that we need
to adapt the work flows, the how the system works for our
frontline pharmacists in processing prescriptions to be more
efficient to allow them to return to the same level of workload
that they were able to achieve in the VistA system.
Mr. Self. I yield back, Mr. Chairman.
Mr. Rosendale. Thank you, Representative Self. I appreciate
that.
Ms. Harris, we heard some testimony about the problem with
the clinicians, not the actual software itself and what is
going on is clinically related, if you will. We need to look at
that a little bit because we are coming up on the renewal
period for this contract and I have got major concerns about
how that is going to be addressed. If mechanically you have a
system that is functioning but the people that are supposed to
implement it are not able to do so and it requires additional
staffing, it requires workarounds, it has decreased morale
because of utilizing this new system to deliver the exact same
number of units. While it might be functioning, it clearly is
not the people who are delivering the work, if you will.
It is their problem because of something new that has been
addressed to them. How do we know if the EHR is fully
functional? How are we going to know when it is ready, in your
opinion.
Ms. Harris. What you just described is not a functioning
system. Yes, technically if the system were to work if the
users are extremely dissatisfied which is what we are seeing
now the system is doing to fail, because it is not sustainable
to have workarounds and, you know, ad hoc processes outside of
the system it is just not a sustainable solution. There will be
increased patient safety risk as a result.
What we have identified through or work is VA lacks set
goals for what constitutes a user satisfaction and that is what
we need to see. We need to see very clear objective measures
for what constitutes adequate user satisfaction. We need to
have that defined before and VA needs to demonstrate progress
against that before the reset period closes and before they
move forward with any future deployments. That is a major
issue. Changed management is also another significant issue.
VA lacks a VA-driven strategy for changed management.
Oracle Cerner has been doing quite a bit of work in training
users in the system itself, but users are not prepared to
change their business work flows because they just have not
been adequately trained and that is a major issue. The VA needs
to take a leadership role in leading that change management
effort so that users fully understand the expectations around
what--how they are business processes will change.
Mr. Rosendale. A real simple question, do you think that
this new EHR system that Oracle has rolled out offers either
safety, quality or value at this current time?
Ms. Harris. No.
Mr. Rosendale. Thank you very much.
Dr. Evans, in order to ever have confidence in Oracle
Cerner EHR we need to see that it is working well in Spokane,
Walla Walla, Columbus, Roseburg and White City. We are a long
way from that today. Maybe even more importantly the system has
to demonstrate some sort of value to justify the enormous
expense. It is not enough to merely swap EHR systems. How are
you reevaluating your strategic goal? How will this project
ever demonstrate a value proposition?
Dr. Evans. I wholeheartedly agree that simply changing from
one electronic health record to another electronic health
record is not strategy for value realization.
The electronic health record is an absolutely critical
element of the functioning of the modern healthcare system. It
is how one uses the electronic health record, how one
configures it, how one enhances its ability to meet your
business goals and frankly your customer service goals that
delivers the real value.
You know, and example of that is that we operate as an
enterprise healthcare system. You know, there are elements of
this transition that are actually frankly quite critical for us
to meet our strategic goals.
Mr. Rosendale. If they are functioning properly.
Dr. Evans. That is correct.
Mr. Rosendale. Okay.
Dr. Evans. If one of our strategic goals is for us to be
able to deliver care across the enterprise. Right now there are
tele critical care physicians. There are tele critical hubs
that are caring for patients remotely at 20, 30 different VA
medical centers. Using VistA they have 20 to 30 instances of
VistA open to do that. It would be great for them to have one
instance of the electronic health record open to be able to
deliver care.
To your point this is where we need to understand what we
are trying to achieve strategically to make sure that our
investment in the electronic health record is allowing us to
achieve those needs.
Mr. Rosendale. Thank you, Dr. Evans.
Representative Cherfilus-McCormick. I yield.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
My question is for Mr. Sicilia. We understand that an issue
has arisen with certain medication and allergy information from
Oracle sites not transmitting correctly to VistA, VistA
providers are receiving a warning to check through the joint
longitudinal view whether their patients has received the
medication and Oracle site.
If so the provider must check for all allergies and drug
interaction problems before prescribing any new medication. Are
you aware of this issue.
Mr. Sicilia. I am not personally aware of this issue but I
will ask Dr. Ellzy who is a clinician.
Dr. Ellzy. Yes, ma'am. I am aware of the situation and we
have actually rectified it for anything going forward. We have
come up with a remapping to make sure that what is going back
to the VistA sites is correct. We are still working with the VA
to do the retroactive work that needs to be done for thing that
were already transmitted.
Ms. Cherfilus-McCormick. When did you discover that and
what was the root cause?
Dr. Ellzy. Ma'am, unfortunately I would have to take that
for the record. Thank you.
Ms. Cherfilus-McCormick. Thank you. My any question is
going to be for Dr. Evans. Are you aware of this issue or were
you aware of this issue?
Dr. Evans. I am aware of the issue.
Ms. Cherfilus-McCormick. What was the mitigation plans that
you guys quickly went to before Cerner corrected their plan?
Dr. Evans. This is an issue that has to do with again I
actually would highlight this, it follows on with the theme
from Chairman Rosendale, it is important for VA that we operate
as an enterprise healthcare system. It is our expectation that
if an order--if a medication is ordered at any site that
regardless of what site it is ordered at we are doing drug
interaction checks, checking for allergies, that we are doing
the safe things for the prescription of that medication. With
this issue there was an interface bill between the Oracle
system and what we call our health data repository, which is
where we keep track of prescriptions that have been written
from across the enterprise.
When we realized there walls an issue there, we again gave
instructions to our end users at our VistA sites for how to
find the information they need and we have been working very
closely with Oracle to execute the technical fix, which has
already been done and now to fix the data that needs to be
adjusted in follow up to this event. Again, when we find an
issue like this, the answer to your question is it is all hands
on deck, all hands on deck to fix it.
Ms. Cherfilus-McCormick. Well, thank you. I wanted to
ensure that we had that communication in the lag time if we can
actually make sure that there is not a big lag time because
medications with allergies and intermixing is a deadly
combination which I am sure everyone here is aware of.
Issues like these have been a concern in the past and of
course are going to be a concern going forward for the
committee.
The EHR RESET Act would require VA to contract for
independent verification and validation of the EHR program. I
feel like this is the perfect example of why something like
this is needed.
My next question is for Dr. Evans. We understand that these
continue to be a problem with veterans addressing reverting to
their address in D-E-E-R-S. The question is this issue with
Defense Enrollment Eligibility Reporting System (DEERS) was
identified shortly after the first go lives, why does it
continue to be an issue?
Dr. Evans. As you are aware, the electronic health record
is a Federal electronic health record that is being used by
both the Department of Defense and the Department of Veterans
Affairs, the United States Coast Guard and soon National
Oceanic and Atmospheric Administration (NOAA) as well. DEERS is
the identify system used by the Department of Defense.
The system is architected with the dependency on DEERS
before VA was an involved with this project. This is an area
where we are continuing to work closely with the Department of
Defense. In fact, we have meetings scheduled even within the
next week and a half at a very senior level addressing issues
around some of these points of intersection to include DEERS
and its dependency on the system itself.
Ms. Cherfilus-McCormick. How has this affected the mailing
of medication? Are you aware instances where medication was
delivered to an incorrect address?
Dr. Evans. I am not personally aware of that. I will--I do
not know whether my pharmacy colleagues can speak to that.
Mr. Silverman. Thank you, Dr. Evans.
Ranking Member Cherfilus-McCormick, I am aware of some the
incidents in which medications was mailed to incorrect address
as a result of DEERS information being overwritten. It is my
understanding that with block 8, which was installed February
of this year, the ability for that to overwrite any VA data has
been addressed such that if the employees working on the EHR
are recognized by the system as VA that it will no longer take
DEERS information to overwrite the VA information.
Thank you.
Ms. Cherfilus-McCormick. Mr. Chairman, I yield back.
Mr. Rosendale. Representative Self, I recognize you for 5
minutes of questioning.
Mr. Self. Thank you, Mr. Chairman.
I want to go to the drop in average scores of best places
to work. These are dramatic as the GAO briefed. Did you see
similar drops in locations that were VistA only? What I am
trying to get at is that are there other factors or can we
point to Cerner alone?
Dr. Evans. I have not done that analysis with the level of
detail where I feel confident that I could answer that
question. However, I have read the reports from the pharmacy
and those numbers with regard to what the process are reporting
at these sites are compelling. I would agree.
Mr. Self. Okay. Then the next question is once something
gets engrained in a psyche of your organization, it is going to
be hard to overturn. Are you confident that you can overturn
these numbers, because believe you me across the VA system
people knows these numbers as well as we do. Will you be able
to recover regardless of how well you do in your human factor
advantages now that you are assuring us that you are going to
put this into place? Can you recover from the deep engrained
dissatisfaction in your five Cerner sites?
Dr. Evans. As Ms. Harris testified, it is not without risk
as we move forward, but I think so. When we----
Mr. Self. Why?
Dr. Evans. Well, when we think about what motivates VA
healthcare providers, I am one, I am a primary care provider,
what matters to me is not the EHR but how the EHR let is me
take care of my patients. What drives the heart and motivation
of VA healthcare providers and pharmacists who are healthcare
providers, but really all of those of us who come to work every
day to take care of patients in VA is taking care of the
veteran.
It is the delivery of healthcare, that is what we do. The
EHR needs to enable that. When, you know, I believe that if the
EHR is performing technically at the level that it should, that
is it is consistently up with the capabilities are working in
the system and that it is performing quickly from a reliability
standpoint, there are no hangs, crashes, lags.
When users see changes in the system that start to increase
their confidence that the system is going to be there. Frankly
it is going to get out of the way and let them take care of the
veterans that come to work to take care of that day. When they
start to see improved efficiency in using that EHR to get back
to talking to the veteran, they--that is what will drive
change, that is what drives using confidence. Confidence in a
tool occurs when that tool is something that is fit for
purpose, when it does what I want it to do.
Mr. Self. That is great, doctor, but you now have ingrained
a deep dissatisfaction with it. I see my time is going to close
real fast here, so I will say you look for new systems, you
look at cost, time to implement and productivity. I have not
heard a single positive out of this system in the several
briefings that I have been in. I think you need to examine that
real carefully, can you recover? It is simple as that.
Mr. Chairman, I yield back.
Mr. Rosendale. Thank you, Representative Self.
I yield 5 minutes to Representative Balderson for
questioning.
Mr. Balderson. I thank you, Mr. Chairman for allowing me to
ask questions today. Thank you all for being here.
My first question is for Dr. Evans. Sir, it has been
abundantly clear for about a year that the EHR system is unsafe
and has undermined healthcare delivery operations and morale in
Columbus. I heard this from employees and veterans at Chalmers
P. Wylie Veterans Outpatient Clinic when I toured last fall.
Unfortunately, it sounds like Washington and Oregon are
experiencing the same issues.
I understand you have been there and heard the same
concerns I have heard. If your improvement efforts are
successful, what should we expect to see at Chalmers and
elsewhere?
Dr. Evans. In fact, I was there just this past Tuesday. I
am incredibly grateful for the leadership and the frontline
staff in Columbus. They are leaning forward and have been doing
what--you know, have been raising their hands and pointing out
the issues that we need to fix.
A major part of the program reset is listening to our end
users and more rapidly addressing the issues. As I mentioned
before, what is the path to improvement? System reliability,
increased efficiency in using the system, a better
configuration that will allow improvements in the
configuration, and, you know, regular close-loop communications
around improvements.
That is what we are committed to do with all of our sites
as part of this reset.
Mr. Balderson. Okay. Thank you.
The next couple of questions I have are for anybody, and if
you want me to directly ask somebody, I can do that, but if
anybody would like to speak up, it is for any witness here
today.
We have heard from pharmacists in Columbus that there have
been over 730 Cerner help desk tickets logged, averaging over
three tickets per day for each pharmacist. Just keeping track
of the help desk tickets is literally someone's full-time job.
How do you justify the sheer administrative burden that has
been placed on the facility?
Dr. Silverman. Good afternoon, Congressman Balderson.
As you heard, I am co-chair for the pharmacy council. My
co-chair, Dr. Ladue, and I are aware of the volume of tickets,
and, in fact, it is part of our recommendation for there to be
a staff member of the pharmacy who is focused on addressing
those tickets and being able to centrally be aware of them; and
part of that is how the interaction plays between the reporting
staff at the pharmacy and the help desk staff by Oracle Cerner
that receive those.
We actually find that it is advantageous to have one person
or a manager of staff that are aware of those issues in order
to avoid the undesirable impact of two people reporting a
ticket of similar issue and then having two tickets being
worked concurrently with potentially not even the same results
on that.
We would like to give some appreciation to the Electronic
Health Record Modernization -Integration Office (EHRM-IO)
office for the funds that will allow Dr. Emmendorfer and myself
to travel to Columbus tomorrow, in fact, for an ongoing
discovery visit. Their team is already in place there this week
to learn and continue to address these issues.
I have no concern about if there need to be tickets
reported, we want that. We want to be accessible. We want to be
approachable about that, and then the tickets need to be
addressed to resolution.
Thank you.
Mr. Balderson. All right. Thank you.
My next question, again, is for anybody, and it is the
pharmacy piece, too. Maybe you just want to continue on, Dr.
Silverman.
They had to increase staffing by 20 percent. I mean, this
is pretty much what you just said. I am down to 40 seconds. I
appreciate you all being here, and I thank you for answering
the last question pretty thorough.
Mr. Chairman, I yield back my remaining time.
Mr. Rosendale. Thank you very much, Representative
Balderson.
Dr. Evans, I believe, I really do believe that the
physicians and the folks that are delivering the health care to
the veterans really do have a mission, a goal, and a life's
goal of making sure they deliver top quality health care to our
veterans. I really do believe that.
To use an analogy, if you are given new tools, and somebody
comes out and gives you a chain saw, and you are a lumberjack,
and he does not give you any gas, okay, you are better off
using the handsaw that you used to have. You will actually be
able to cut more wood than to sit there and try to make that
chain drag across the log. Okay?
This question is for--we are going to start with Dr.
Silverman. I am going to read you a quote from one of the
questionnaires: The Mann-Grandstaff VA has been live on Cerner
for 2 1/2 years, yet we all continue to discover new problems
weekly. The 79 change requests referenced earlier was a
starting point; however, it is critical to note that many more
issues have been identified since that time, and a list of
change requests continues to grow at a rate outpacing that of
resolutions being implemented, end of quote.
How could there be this many problems in just one area of
the EHR? How could the software be this ill-suited for the
pharmacists' needs?
Dr. Silverman. Thank you for that question, Chairman
Rosendale.
As you heard in the opening testimony, the pharmacy
solution that is part of the Millennium software is med manager
retail. It is designed for the traditional workflow in which
the prescriptions are sent to the pharmacy. They are processed
by the pharmacy and dispensed to the patient.
Because VA pharmacy operates on this very tight-knit,
closed-circuit operation of pharmacy interaction with the
prescribers. It is important to us to have that synchronization
between the systems so that the activities of the pharmacist
are then reflected in the PowerChart, the prescribers
application.
That is among those type priorities that you have heard
referenced for what we are seeking to work with, is the ability
for our pharmacy dispensing activities to show up in the
ordering profile.
Mr. Rosendale. If they are working that closely, which is
out of the ordinary from what you see in a typical setting in
the public sector, why would not it be easier to get this
sorted out instead of it being more difficult?
Dr. Silverman. For that, I would give an opportunity for--
our partners from Oracle Cerner would like to comment as well
about what it would take to synchronize the pharmacy and
prescriber systems.
Dr. Ellzy. Chairman, if I understood your question
correctly, we had about 500 prioritized--or 500 things that
needed to be changed in the system. My pharmacist sat down with
the VA pharmacist to say: What is the top priority? They came
up with about 10 to say these are the first 10 we need to go
after.
It is not necessarily the fastest 10. These are the
prioritized 10, and that is the ones we went after that turned
into the seven projects that you have seen outlined where three
already went live. We have more--one that went in the cube, or
in block, and the next block and the block after block 10.
That was because that is what VA prioritized as the most
important to them to go after, not necessarily can you tell us
which ones you can do the fastest.
Mr. Rosendale. Okay. We are still having these issues. Dr.
Ellzy, do you believe the Cerner pharmacy software is
satisfactory right now?
Dr. Ellzy. Is it satisfactory to meet all the goals of how
the VA practices pharmacy right now? No, it is not.
Mr. Rosendale. Mr. Sicilia, you testified to the Senate
Veterans' Affairs Committee hearing in March that, quote, ``we
can achieve quite a bit of this by reconfiguring the system
without touching the code, and it can be done relatively
quickly. I am talking weeks, not months,'' end quote.
Does Oracle stand by the decisions you have made about when
to rewrite the software code and when to just reconfigure the
system?
Mr. Sicilia. Yes. Yes, we do. The pharmacy examples, of
which we are not finished, and I think that is the driver for a
lot of the dissatisfaction, because of the seven major things
that need to be fixed for pharmacy; three have now been
delivered. As I said in my opening statement, they are focused
on the provider side of a prescription, not the pharmacist
side. The next four are focused on pharmacists.
In terms of reconfiguring, my testimony during that hearing
was specific to the feedback that I heard in Columbus when I
was with Dr. Evans and the rest of--and some of the rest of the
team. I heard direct feedback around the workflows in the
system, not having anything to do with pharmacy but just
general workflows in the system, which the team described to me
as being too restrictive, too locked down, and not giving
enough, if you will, autonomy at the edge to configure those
systems.
I stand by my statement that should the VA choose to make
those statements, they are configuration changes that we can
make in weeks; not months, not years. The pharmacy piece--the
pharmacy piece is a recoding of the--recoding of functioning.
Mr. Rosendale. Okay. I am out of time here. I am going to
have to move on. Thank you for your comments.
Representative Cherfilus-McCormick.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
My question is for Dr. Evans.
As I said in my opening, I am concerned about the number of
change requests that are still showing up more than 2 years
after the first go live. I suspect that the VA's history of
allowing the medical facilities to operate independently of
each other has made this program complicated.
What is the status of establishing a baseline EHR that all
facilities would expect to adopt?
Dr. Evans. There are many layers to that question. I think
first one of the places where we do have opportunity is in the
devices and capabilities that connect to the electronic health
record. Again, in order to deliver a comprehensive solution
that allows us to have the technology necessary to deliver the
safe, high quality health care that we expect to deliver in the
VA, we need more than just an electronic health record.
We need bedside monitors in the Intensive Care Unit (ICU).
We need an intravenous pumps. We need laboratory equipment,
radiologic systems, what we call Picture Archiving and
Communication (PAC) systems, for reading imaging; and many of
those buying decisions have been made at the local level
traditionally because the interface of that system only had to
be plugged into the local instance of our electronic health
record, Computerized Patient Record System (CPRS) or VistA.
As we move forward with an enterprise health care system,
every one of those additional systems bears a cost for us, as
we have to interface it with the Federal electronic health
record. That is not technology that Oracle brings to the table.
These are technologies that we are buying to be able to run our
gastroenterology suites, et cetera.
We are working to establish a baseline, and we are close,
of what we believe would be the capabilities that--for which we
have existing interfaces so that plugging them into the
electronic health record is easier and faster as we move
forward with deployments.
The second part of the question is about a baseline around
workflows. How do you run a primary care clinic? How do you do
preoperative care? How do you take care of somebody after an
operation? What are the--what should the screens show? What are
the questions we are going to ask nurses or clinicians to
answer?
That is work that our councils assist us with and that,
frankly, the voice of the field is incredibly--of our end users
is incredibly important because we do need to increasingly
standardize what that looks like, but it needs to be a standard
that is workable from an efficiency standpoint in the delivery
of health care. Both of those areas are significant areas of
focus as we engage in the reset.
Ms. Cherfilus-McCormick. Presently, how have you evaluated
workflow and practices across the enterprise to ensure that the
baseline meets everyone's needs?
Dr. Evans. One of the ways we do that is through the
clinical councils. We have just recently made changes to how we
organize the clinical councils. The clinical councils are now a
part of the Veterans Health Administration. We actually have a
co-chair here. All of the councils are now co-chaired,
including field representation, and they all include existing
users of the new modernized EHR.
In part, what we need to do is make sure we have the voices
of--representing end users across the system in making those
standardized decisions. We are still learning, but this is an
area where I think we are seeing--we are seeing positive
movement in the right direction.
Ms. Cherfilus-McCormick. Ms. Harris, do you have anything
to add to this when it comes to the baseline EHR?
Ms. Harris. I think that that is--establishing a baseline
is critical if you are intending to standardize across an
enterprise, especially one as complicated as VA.
I think what I would like to note is that it is very
important that--increased rate at which Cerner addresses these
issues. I know, Mr. Chairman, you had mentioned the 79 business
change requests. I mean, to date--I mean, that was 2 1/2 years
ago. The list is growing. Only six have been completed. That is
a major issue.
The rate at which these issues are addressed need to--I
mean, Cerner needs to step up, as well as VA in terms of their
program management and contractor oversight as well.
Collectively, yes, the baseline is incredibly important.
Getting those user satisfaction scores to increase as well is
really critical to recovering from where we are today.
Ms. Cherfilus-McCormick. Mr. Chairman, I yield back.
Mr. Rosendale. Thank you.
Representative Self.
Mr. Self. Thank you, Mr. Chairman.
Mr. Sicilia, before I go on, I think I have heard you say
twice that it is not the pharmacists; it is the supply system.
Is that layman's terms?
Mr. Sicilia. The initial focus of the enhancement has been
on the provider side. In other words, the person ordering the
pharmacy not--we have not yet delivered enhancements that
pharmacists of the VA will consume. That is the next block of
delivery.
Mr. Self. Got it. Now I understand what you were saying.
There is a quote from one of your pharmacists: The
increased risks due to delays, inefficiencies, vulnerabilities,
manual workarounds, and the lack of responsiveness from Cerner
to identify patient risks, pharmacy staff must remain in a
constant state of hypervigilance to recognize and intervene on
those risks.
Hypervigilance by the pharmacists, can you comment on that,
because while this pharmacist used the word ``Cerner,'' there
are many factors. Address those concerns for me.
Mr. Sicilia. I would appreciate Dr. Ellzy's comments since
he deals with the clinicians.
Dr. Ellzy. Hypervigilance in pharmacy. Pharmacists are--I
am trying to find the PC way of saying it. They are very much
attention to detail-oriented when it comes to pharmacy, filling
medications. They want to make sure every I is dotted twice and
every T is crossed twice.
When you talk about hypervigilance and a pharmacist, that
is somewhat the norm. They are----
Mr. Self. Well, Doctor, that is not what this pharmacist is
saying. We are talking about staff burnout here under the new
system.
Dr. Ellzy. Sorry, sir. I do not understand your question to
me, though.
Mr. Self. The question is: Why do they think they have to
be hypervigilant under the Cerner system, as opposed to the
VistA system? Back to Dr. Ellzy's point, I, too, am a veteran,
and what I am hearing from the veterans is they are not getting
good pharmacy support under Cerner or VistA.
That is my question to you. Why do they have to be
hypervigilant under Cerner even more than VistA if what I am
hearing is VistA does not work that well either?
Dr. Ellzy. Sir, from my standpoint of where I sit, whenever
you change systems, you are going to not be as comfortable as
the system you have been working in for decades. It is going to
take time to learn the new system.
Mr. Self. Okay.
Dr. Ellzy. 2 years is not enough time to get comfortable in
the pharmacy sphere with a new system.
Mr. Self. Okay. Do you all have numbers as to the VistA
errors versus the Cerner errors on system-wide pharmacy errors?
Dr. Emmendorfer. Congressman Self, I do not have those
errors in front of me, but if I may just follow up a little bit
on the question that was just asked----
Mr. Self. Certainly. Go ahead.
Dr. Emmendorfer [continuing]. from a VA pharmacy
perspective?
Mr. Self. Please.
Dr. Emmendorfer. VA--pharmacists, in general, should not be
operating in a state of hypervigilance. We should be operating
within our well-established processes and procedures to safely
deliver prescription fulfillment services.
I've been a VA pharmacist for over 26 years, and I have
used our electronic health record over a portion of that
career, and I was--felt very safe and comfortable and not in a
state of hypervigilance.
VA takes a lot of pride in pharmacy, in what we do. We have
a very dedicated staff to the mission of our agency, which is
to care and serve our Nation's veterans, and that I just want
to say that I am very grateful for.
In regards to your question about the rates between VistA
and Cerner and the error rates, that is something I would have
to take back for the record, unless somebody else have those
rates in front of them.
Mr. Self. I would like to hear that.
Ms. Harris, do you have anything to add?
Ms. Harris. Well, the main thing that I want to add is
going back to your original question, which I think is so
important, which is: How do you recover?
In this particular situation, with where we are today with
the Cerner system or the new EHR system, implementing our 10
recommendations that we have open relative to increasing user
satisfaction, I mean, it is incredibly important that VA
establish goals to assess user satisfaction, number one. That
is the most important thing that they need to do and
demonstrate radical improvement before they move forward with
future deployments.
The second thing is to have VA really take ownership of the
change management strategy because all these things that we are
dealing with today, yes, there are system performance issues,
but, for the most part, it is so largely driven by that human
component where users have to understand exactly what it is
that they need to do in this new, changed environment. That is
really difficult to do.
VA needs to take that leadership role in getting their
users to be comfortable in this new environment.
Mr. Self. If the chairman will indulge me for one quick
question?
Do you have a recommendation? Can they do this?
Ms. Harris. I think that they can do this with very close
scrutiny and oversight from this committee. I think--as well as
through just really increased performance by both Oracle
Cerner, as well as through--as well as with VA as well.
Honestly, I was very disappointed to hear that while VA has
concurred with our recommendations, they expect to complete the
implementation of our recommendations by October 2023. That is
5 months away. To me, that suggests that they are unserious
about our recommendations and what it is going to take to
implement it.
If they do effectively implement them, I think they are
going to be in a much better footing for success.
Mr. Self. Thank you.
Mr. Chairman, I yield back.
Mr. Rosendale. Thank you, Representative.
Ms. Harris, while you have the microphone hot there, do you
think that it is too much to expect someone that has a new
system that is supposed to improve their output to be able to
learn it, understand it, and be able to deliver it in 2 1/2
years?
Ms. Harris. Sir, based on the current management of the
system, I think that 2 1/2 years is not enough time. I think
that it is going to take a much longer runway for VA to change
their culture.
I mean, we have 130 different versions of VistA. The users
at these different medical facilities are used to doing
business in a certain way that is tailored to their facilities,
and standardizing across the enterprise is going to be a very
challenging thing.
Again, it takes VA senior leadership to really ensure that
the change management is done and done properly where users
feel--where users are in a better position to understand what
they need to do in this new system.
Mr. Rosendale. Dr. Silverman, turning to the April release,
it is my understanding that it is supposed to synchronize
PowerChart and the Medication Manager Retail, MMR, by
automatically deleting prescription records in one system and
creating them in another, eliminating the time-consuming double
entry process.
Can you explain how this works and what it entails?
Dr. Silverman. Yes. Thank you, Congressman.
The intended synchronization from enhancement 3B is for
when the pharmacy at a VA Medical Center dispenses a
prescription, it is within common pharmacy practice that there
may be some subtle changes of the prescription to dispense and
honor the original intent.
Simply put, if you have a prescription for 40 milligrams of
a particular drug and the stock available is 20-milligram
tablets, we update the directions accordingly, update the
quantity accordingly, and dispense.
The intent of that enhancement is to make sure that that
information goes from MMR back to PowerChart automatically
rather than asking the pharmacist to both make the dispensing
process and go to PowerChart to document that update.
Mr. Rosendale. Very good.
Is it true that you discovered a serious flaw in this
enhancement involving prescription instructions, and you are
rolling back the software update?
Dr. Silverman. That is correct.
Mr. Rosendale. Dr. Silverman, this was supposed to be the
biggest, most important pharmacy improvement. According to the
questionnaires, many of the pharmacists were already concerned
that it would make what they see in the system even more
cluttered and confusing, but it sounds like it blew up right on
a launchpad.
Why did this happen? What does it say about EHR's prospects
to improve?
Dr. Silverman. Thank you for that.
In terms of why it happened, I would like to assure that
the council was in close cooperation with Oracle Cerner on the
initial testing, the evaluation in our nonproduction domains,
and made our contribution to the overall decision; yes, let us
deploy this with the cube release.
What I believe happened, Congressman, is that what we have
not been doing as a VA and what we need to introduce is a
longer testing process that would include what I will call end-
to-end testing from the prescriber to the pharmacist reviewing
that prescription to simulated dispensing of that prescription
to our automated equipment.
Because we have not been testing to that thoroughness in an
environment that can adequately simulate our production, we did
not recognize what would happen with those patient
instructions. As soon as that issue was reported, and it was
reported through joint patient safety reporting system, as Dr.
Evans described, the council moved immediately toward request
and recommendation to disable the enhancement to give us the
time to analyze it.
Mr. Rosendale. Thank you. We appreciate that so that we did
not risk anymore safety to our veterans.
Mr. Sicilia, no offense, but do you think that it is fair
to use the VA and our Nation's heroes as a testing ground for
your products?
Mr. Sicilia. Well, I do not believe that we are.
Mr. Rosendale. Well, these are not coming off the shelf,
Okay. These are custom products. Do you think it is fair to use
the VA and our Nation's heroes as a testing ground for your
products?
Mr. Sicilia. We are not universally creating custom
products at our discretion. We are instructed and contracted to
do so by the VA. As Dr. Silverman just pointed out, there is a
testing process that happens so we are not rolling out
something that has not been tested and authorized by the
Veterans Health Administration (VHA).
In the event that issues are discovered after the rollout,
I do think Dr. Silverman's comments are correct. There has to
be more end-to-end testing. As something is discovered, we
quickly roll it back, as we do.
Mr. Rosendale. Thank you.
Representative Cherfilus-McCormick.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
Back to Ms. Harris.
My question, GAO has an extensive body of work on VA
struggles to implement large-scale Information Technology (IT)
projects. Specifically, on VA's struggle with program
management, can you elaborate on what GAO has observed and what
recommendations you have for the VA to be successful?
Ms. Harris. Sure.
What we have observed is--I think it stems back to poor
project--poor IT project management in general and not having
defined user requirements adequately upfront, and, also, not
really understanding the--or not having reliable cost and
schedule estimates for the--their IT initiatives. Those, in
general, have been many of the issues that we have identified
with IT programs, such as EHRM.
Now, in this particular case, we have made 15 total
recommendations related to the EHRM program. Ten of them are
priority and that comes from our most recent work. Again, it
goes back to increasing that user dissatisfaction and ensuring
that the satisfaction scores go up, that is critical to the
success of EHR, as well as improving their change management,
ensuring that their users are adequately trained in how to use
the system but also understanding the business process related
to the changes and the transformation that is happening
enterprise-wide relative to EHR.
Ms. Cherfilus-McCormick. In your testimony, you stated that
contractor change management activities focus on activities
required to deploy the system but did not address user
challenges when transitioning to new workflow processes.
Is there any reason why VA should continue to focus on and
fund training for Oracle Cerner system until they have focused
and standardized workflow processes?
Ms. Harris. Yes, I think that the priority should--or a
significant amount of their effort needs to be paid toward
training the users on the new business processes, the new
workflows, understanding what they need to do in the new
system, as well as understanding, as a whole, what they are
expected to do.
I think that at these facilities, I think that they are
team players. They want to--I think they want to--and they are
on board with changing. It is just that the systems--the EHR
system has a significant amount of issues, and, again, Cerner
also needs to step up, in addition to VA, in terms of
addressing those performance issues.
Again, I will go back to the 79 business change requests.
Only six have been addressed in 2 1/2 years. That pace is
unacceptable.
Ms. Cherfilus-McCormick. The EHR Reset Act required that
change management activities be led by VA rather than the
contractors. Is this consistent with your recommendation? Would
this benefit VA long-term to take greater control over the
change management activities?
Ms. Harris. Absolutely. Having an independent validation
and verification of the system post deployment is critical. It
is something that we have made a recommendation on so that VA
can have a third-party go and take a look and systematically
catalog what those issues are and then systematically address
those issues.
That is something that is called for by best practice. It
is also something that DOD did when they rolled out Military
Health System (MHS) Genesis. After their first deployment, they
paused the program, did the Independent Verification and
Validation (IV&V), and they did not deploy to future sites
until they addressed everything related to those issues in that
report.
Ms. Cherfilus-McCormick. Your testimony addresses issues
with user satisfaction and VA's lack of established targets.
Can you expand on your testimony and let the committee know why
not establishing user satisfaction goals is detrimental to the
future use of the program?
Ms. Harris. Yes, absolutely.
It is hard to tell how much progress has been made if you
do not have a baseline established for where you are and where
you need to be relative to user satisfaction. You have to have
those metrics in place so that you are measuring and being very
objective about the progress made and being in a position to
show that you have demonstrated adequate improvements before
you move forward with future deployments.
Ms. Cherfilus-McCormick. Thank you so much. Mr. Chairman, I
yield back.
Mr. Rosendale. Thank you, Representative Cherfilus-
McCormick.
Okay. Dr. Evans, we have been hearing about many of the
unresolved issues described in the questionnaires for over a
year. I am not talking about technicalities. I am talking about
things with serious health and safety consequences, like
dispensing duplicate medication, refills have failed to be
created, and prescriptions that never reach the pharmacy
request file.
How are you going to implement these fixes without creating
more complications?
Dr. Evans. Well, first, I think, as you have heard Ms.
Harris testify, one of the--we need to balance an increased
velocity of delivering these fixes, as well as increased rigor
on the testing and understanding of--and prioritization of how
we deliver those fixes. That is something that is going to
require really tight collaboration between the council, our end
users who are using the system and know what it feels like and
is every day, Oracle, and the program as we execute this at the
larger level.
In part, it is about getting aligned and prioritizing what
the most important issues are and then executing those with
sufficient velocity. I agree that we are--I do not think we
have been executing with the velocity that we need to in order
to get where we need to get to have this system functioning in
a way that meets VA's needs, where the pharmacy--the
pharmacists and the providers are functioning as a single team,
reading from the same sheet of music, caring for the same
veterans.
Mr. Rosendale. Thank you.
Mr. Sicilia, making these enhancements to Oracle's pharmacy
software and the EHR in general, I apologize, but it seems
similar to constantly patching a leaking roof to me, okay, to
the general public. Is the only true solution to scrap the
pharmacy modules and buy or build new software?
Mr. Sicilia. I am sorry. I missed the end of that. Buy and
build new software?
Mr. Rosendale. Is the only true solution to scrap the
pharmacy modules and buy or build new software?
Mr. Sicilia. I do not believe so. I mean, I believe, as I
said in the beginning, you know, the VA process for pharmacy,
as we know, is different than the rest of the world, and we
have been working together to build the enhancements. As I
said, there are seven main things. Three of them are done. The
next for to go. I think it is early in the pharmacy process to
judge as to whether or not the end product is not so good.
I am not surprised to hear that right now people do not
like it, because it is not complete. It is not finished.
Mr. Rosendale. The problem is, though, Mr. Sicilia, is that
the taxpayers continue to pay for this experiment, and the
veterans continue to pay for this experiment. At what point is
Oracle going to either take possession of this obligation, this
responsibility that they entered into, that they took on, and
to stop laying the responsibility off onto everyone else?
Mr. Sicilia. I do not believe we are laying the
responsibility on everybody else. Ten and a half months ago
when we took this responsibility, the time--the estimated
timeframe to complete the pharmacy enhancements was 3 years. We
delivered the first three in 4 months. We will deliver the rest
of them this year.
Mr. Rosendale. All right.
Dr. Evans, Mr. Sicilia, is this a situation where we can
have it good or fast but not both?
Dr. Evans. I think that is a general--I mean, that is a
maxim, in general, right, but I do--I guess I would say I think
we are--you know, we are working together to identify what good
is. We have had a discussion about that during this hearing.
One of the reasons that together--you know, that the VA
announced a reset is to say we need to be able to turn our
attention toward these improvements; that is, turn all of our
attention to the improvements that are necessary. We are not
balancing both the significant effort of preparing for
deployments at new facilities and actually executing those
deployments with the improvements of the system.
I do believe that there is an opportunity for us, by
focusing just on the system improvements, for us to get more
people, more talent directed at making the improvements that
are necessary faster while preserving quality. I do think there
is a path to both good and faster.
Mr. Rosendale. Thank you. I appreciate that, but from my
standpoint, what I see is some things getting fixed at the top
of the list. This creates more problems that then get added to
the bottom of the list, and the list continues to get larger.
With that, I will yield to Representative Cherfilus-
McCormick.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
Dr. Evans, earlier when we were talking about baseline EHR,
you seemed to indicate that VA was still developing it.
How do you expect to move forward with the program if the
baseline has not been establishing? It feels like we are
building a plane while flying the plane at the same time.
Dr. Evans. It is interesting you say that. That is actually
in the press release when we announced the reset is exactly
what I said, that we are building the plane while we are flying
it, and that is one of the reasons we have elected to say let
us focus on some of these significant program improvements that
are necessary to prepare us for the longer term success of the
program.
That is, let us stop flying the plane while also building
it. Let us build the plane as it needs to be, and a piece of
that is increased clarity around the system baseline to support
the delivery of an enterprise system, which is a big change for
VA, an important change and a big change.
That is partly what we are doing during the reset is doing
that important work.
Ms. Cherfilus-McCormick. Dr. Evans, in your testimony, you
mentioned that go live preparations are ongoing at the Lovell
Federal Health Care Center. My question is: Will the system
deployed at Lovell be more aligned with DoD's version of
Millennium or VA's?
Dr. Evans. Yes. The James A. Lovell Federal Health Care
Center, as you are aware, is a unique facility. It is a fully
integrated joint VA and DOD health care facility. The staff
there come from both the DOD and the VA, and they operate as a
single staff, caring for both veterans, servicemembers, and
beneficiaries of the DOD. Their needs are unique.
We--the deployment, the only path forward to a deployment
there is a synchronize deployment where we come together with
the DOD and the Federal Electronic Health Record Modernization
Office in support of the James A. Lovell Federal Health Care
System to deliver the capabilities that they need.
We will be looking at what the DOD's workflows are and what
the VA's workflows are and are reconciling that to allow us to
deliver a single experience to support care delivery at that
site.
I do not think I can predict exactly what percentage of
DOD-specific workflows will be chosen versus VA or what that
hybrid will look like, but what I can say is that we are fully
committed to that being an aligned path forward; again,
coordinated by the Federal Electronic Health Record
Modernization Office with DOD and VA driving the success there
at that facility.
Ms. Cherfilus-McCormick. If the system is not prepared to
be rolled out in any other VA facility, why are you planning to
deploy there?
Dr. Evans. By the time we get to the James A. Lovell
Federal Health Care Center, the system will have been deployed
across the entire Department of Defense health care system,
with the exception of the James A. Lovell Federal Health Care
System, again, a joint facility.
When we arrive there, the only DOD employees who will not
be using the system when we arrive there for the go live, the
only DOD employees will be those who are employees of the James
A. Lovell Federal Health Care System.
I think first we--it will be a system that is being used
across that entire enterprise.
Second, I anticipate we will benefit from this program
reset. The scheduled go live is not until 2024. We have
numerous months ahead of us that the improvements that we have
been talking about here as part of the reset will be able to be
delivered in anticipation of that go live. We will be adding
value to what has been a successful program in the DOD.
Ms. Cherfilus-McCormick. Ms. Harris, I have a quick
question. Do you have any recommendations for the VA before
undergoing this go live?
Ms. Harris. Yes, I think that taking very seriously the
recommendations that we have made is going to be critical.
Understanding the user's needs and what Dr. Evans has just laid
out I think is going to be very critical for VA. This
integration with DOD, ensuring that they are tightly committed,
which it sounds, according to Dr. Evans, is going well so far.
I think that that is going to be really important.
Again, ensuring that the users understand what it is that
they need to do in the new system and adequately training them
not just in the system itself but on the new workflows is
essential.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman. I yield
back.
Mr. Rosendale. Thank you, Representative Cherfilus-
McCormick.
I am glad to recognize Representative Carey. Thank you for
joining us.
Mr. Carey. Thank you. Thank you, Mr. Chairman.
I sent a letter last November after two veterans who were
patients at the Columbus VA died. One of the veterans never
was--was never--received his antibiotic, and the other was not
contacted to reschedule after he had missed an appointment.
Dr. Evans and Dr. Silverman, the VA responded to our letter
in February and provided some information. It turns out that
the antibiotic was never actually mailed. The tracking number
in the system was misleading. The family never knew that they
were supposed to pick up the medication.
Can you explain how this happened and how is that being
corrected?
Dr. Evans. Dr. Silverman.
Mr. Carey. Either one of you.
Dr. Silverman. Thank you.
I am aware of the incident that you described. While I
cannot discuss the specifics of the patient case, the root of
the information was that a report in the system that identified
that tracking number was providing erroneous information. This
case identified that, and the report that provided that
misinformation has since been corrected.
Mr. Carey. It is not going to happen again?
Dr. Silverman. That will not happen again.
Mr. Carey. Let me ask you, in the other veteran case, one
of the VA staff was supposed to call and reschedule his
appointment. The system was supposed to remind them to do that.
Why was there no automated reminder? Absent of that, how do the
veterans fall through the cracks in situations like that?
Either one of you.
Dr. Silverman. Dr. Evans, if you do have information. I am
not familiar with that particular case.
Dr. Evans. I am not either. I can say that appointment
reminders are an important capability of the electronic health
record. They are really an ancillary capability. They are done
differently. Sort of the technical solution for appointment
reminders with the Oracle record has been different than how we
do appointment reminders in VistA; although, we are working to
align that back to a single, common approach to appointment
reminders.
I would have to take for the record to look into more of
the details of the specific case.
Mr. Carey. I missed a doctor's appointment, not one I
really wanted to do anyway, but I missed a doctor's
appointment, and I got like five reminders that I missed it,
not to mention the five reminders from my wife to tell me that
I missed an appointment. I mean, it was very simple. I got
emails. I got texts.
It just seemed very odd that there was no follow up on
that.
I appreciate it. Thank you, Mr. Chairman.
Mr. Rosendale. Thank you, Representative.
I am going to yield to Representative Cherfilus-McCormick
for some closing statements now.
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman.
Thank you, everyone, for your testimony today. I thought we
had a productive discussion this afternoon. We spent a lot of
time talking about pharmacy issues today, but it is clear to me
that these issues are a symptom of something much bigger.
VA has a long history of failure when it comes to IT
modernization efforts, and most of those failures are because
VA lacks strong program management. VA--with VA's delay of
future go lives and EHR Reset Act, I am confident that we can
move the needle forward.
Thank you so much, Mr. Chairman. I yield back.
Mr. Rosendale. Thank you very much, Representative
Cherfilus-McCormick.
I want to thank all our witnesses for appearing today to
discuss pharmacy and the future of the electronic health record
modernization effort.
You are responsible for the well-being of millions of
veterans. As I said in the last hearing, this cannot be a
conversation just about IT systems. It has to be a conversation
about whether the VA health care is meeting our veterans' needs
and what policies and systems support them.
The only honest conclusion is the Oracle Cerner pharmacy
software is failing to do that, and that failure stretches far
beyond the pharmacy. The worst thing the VA could do is
continue down this dead-end road perpetuating the same failed
strategy and paying out billions of dollars. That would be
incredibly irresponsible.
The contract renegotiation deadline is coming up next week,
and I expect to see VA disentangle itself from this monopoly.
If there is a continued role for Oracle, it is in using its own
resources to improve its products to make the existing Oracle
Cerner sites whole.
Today's hearing gives us every indication that many of
those products simply are not capable of improving in the
timeframe that we need. The VA should cut their losses and move
on; otherwise, you are doing nothing more than continuing to
march down the same dead-end road and betraying the veterans
and the taxpayers that you are supposed to serve.
I want you to think about that very carefully.
Thank you all, again, for your participation in today's
hearing.
I ask unanimous consent that all members have 5 legislative
days to revise and extend their remarks and include extraneous
material.
Without objection, so ordered.
This hearing is adjourned.
[Whereupon, at 4:48 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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Prepared Statement of Witnesses
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Prepared Statement of Neil Evans
Good afternoon, Chairman Rosendale, Ranking Member Cherfilus-
McCormick and distinguished Members of the Committee. Thank you for the
opportunity to testify today in support of VA's initiative to modernize
its electronic health record (EHR) system. I am accompanied by VA's
senior leaders critical to this initiative, Dr. Mark Upton, Deputy to
the Deputy Under Secretary for Health; Dr. Thomas Emmendorfer,
Executive Director of the Pharmacy Benefits Management Services; and
Dr. Robert Silverman, Veterans Health Administration (VHA) Pharmacy
Council Co-Chairman for the Electronic Health Record Modernization
(EHRM) Program.
I want to begin by thanking Congress and this Committee for your
continued support and your shared commitment to Veterans. Successful
deployment of a modern electronic health record (EHR) is essential to
the delivery of lifetime world-class health care and benefits for
Veterans. In the end, our goal is a unified, seamless, trusted
information flow between VA, the Department of Defense (DoD), the U.S.
Coast Guard and community providers that will empower Veterans and
their families, caregivers and survivors to achieve and sustain health
and wellness. Because Veterans are at the center of everything we do,
their health and well-being and ensuring they receive the care they
have earned is our highest priority.
We readily acknowledge there have been challenges with our efforts
to modernize VA's EHR system. On April 21, 2023, VA announced that, as
part of a larger program reset, future deployments of the new EHR will
be halted while we prioritize improvements at the five sites that
currently use the new EHR. The only exception to the full-stop on
deployment activities is the Captain James A. Lovell Federal Health
Care Center in Chicago, which is the only fully integrated VA and
Department of Defense health care system. During this reset, VA will
fix the issues with the EHR that were identified during the recent
``assess and address'' period, continue to listen to Veterans and
clinicians about their experience with the EHR, and redirect resources
to focus on optimizing the EHR at and on behalf of the sites where it
is currently in use: Mann-Grandstaff VA Medical Center (VAMC), Jonathan
M. Wainwright Memorial VAMC, Roseburg VA Health Care System, VA
Southern Oregon Healthcare System, and VA Central Ohio Health Care
System.
VA has an obligation to Veterans and taxpayers to get this right
and will take the time needed to do so. We understand the concerns of
this Committee regarding the EHR system and its impact on Veterans and
the care our health care personnel provide. We are committed to full
transparency, and we appreciate your oversight. We look forward to
further engagement with you and your staffs to ensure that this
modernization is successful. We commit to you that we are working
diligently to address identified issues and to implement enhancements
and improvements. In delivering world-class health care to Veterans, VA
strives to be a High Reliability Organization, and remains committed to
a goal of zero patient harm.
EHR Readiness
Based on our recent assessments, including the ongoing ``assess and
address'' period and the Readiness Assessment, VA determined that the
new EHR is not yet ready for future deployments. Additional deployments
will not be scheduled until VA is confident that the new EHR is highly
functioning at current sites and ready to deliver for Veterans and VA
clinicians at future sites. This readiness will be demonstrated by
measurable improvements in the clinician and Veteran experience;
sustained high-performance and high reliability of the system; improved
productivity at the sites where the EHR is in use; and more. When these
criteria have been met and the reset period concludes, VA will update
and release a new deployment schedule and resume deployment activities.
As mentioned earlier, the only exception to the full-stop on
deployment activities is at the Captain James A. Lovell Federal Health
Care Center in North Chicago, where the new EHR is scheduled to go-live
in March 2024. This is a jointly run VA and DoD facility; the EHRM
program reset will allow VA to dedicate additional resources to this
joint deployment effort, to ensure that after the go-live, all patients
who visit this facility will be covered by one common Federal EHR.
VA has always said the EHR will not go live at any site with
unresolved or insufficiently mitigated safety-critical findings. We
also remain firm in our resolve to continue deployments of the
modernized EHR when it is ready. It is important to take the time now
to get things right--to provide a strong foundation for an executable
deployment schedule as the project proceeds. The continuous focus will
be on assessing and remediating any identified issues at live sites and
designing for safety and efficiency at future deployment sites.
System Stability and Reliability
Corrective actions within the system data base configuration and
the architecture and management of overall set of technologies within
the Federal EHR have led to an overall improvement when it comes to
complete outages. Entering the month of April 2023, there had not been
an outage for 8 months. Unfortunately, there were two outages totaling
294 minutes in April 2023, resulting in EHR system downtime.
Improving system reliability and availability remains a critical VA
focus. Cerner is contractually obligated to meet 99.9 percent uptime
commitment per measurement period (monthly) for the EHR production
system, meaning that the system is functional and available for use. In
addition, our immediate target is to achieve at least 95 percent system
incident free time, which we define as the percentage of time in which
all solutions are functioning as intended for all users. As of April
2023, Cerner has achieved 95 percent or higher system incident free
time on 2 months out of the previous 12 months.
Because not all system interruptions are the result of Cerner
activity--issues with other systems that connect to the EHR can impact
it--VA continues to work with our partners at DoD and the Federal
Electronic Health Record Modernization office to reduce downtime with
the EHR enclave and connected systems.
VA established a Performance Excellence workgroup in March 2022 to
review technical performance issues with Cerner and resolve problems
with system stability, reliability and performance. The goal of this
workgroup is to remediate identified reliability and performance issues
before deployment of the EHR system to additional sites and minimize
any disruption to access of care.
Pharmacy and Medication Management
On February 17, 2023, three priority pharmacy enhancements were
installed as part of the Block 8 upgrade to the EHR system. These
enhancements provide incremental improvements to system usability,
improving providers' visibility of available prescriptions, optimizing
system options for maintenance medications and expanding details on
prescription expiration dates--all of which are necessary to support
our health care personnel in delivering Veteran care. Demonstrating the
lessons we have learned from the past, these enhancements underwent
rigorous testing prior to installation.
The Pharmacy Benefits Management (PBM) program office, in
cooperation with the EHRM National Pharmacy Council, continues to work
toward additional system upgrades to further improve provider
visibility into prescription details. For example, the April 2023
``cube release'' included additional pharmacy capabilities and
features, reducing the number of clicks and complexity to users sending
prescriptions electronically to an outside (non-VA) pharmacy and
allowing clinicians to see the actual prescription status of the mail-
order pharmacy in the EHR system. This is expected to be followed by
the August 2023 Block 9 update, with three more improvements for
pharmacy workflow and prescription refill processing. The Pharmacy
Council supports our sites already using the new EHR via regular office
hours calls and on-station visits and provides recommendations within
VHA through the Assistant Under Secretary for Health for Patient Care
Services (AUSH-PCS).
Despite this progress, ongoing support and planned future updates,
feedback from our pharmacy community on the recently deployed
enhancements to the pharmacy solution is that the improvements have
been small and incremental. Although these updates are gradually
improving the clinician experience, pharmacy staff need an accelerated
delivery of upgrades to the new EHR system to eliminate the burden of
the labor-intensive human mitigation strategies currently in place. As
the current pace of new requests for upgrades and enhancements exceeds
the planned delivery schedule of changes that address those requests,
the EHRM reset period will allow VA to focus on execution of system
updates and systematically resolve key issues before resuming future
deployments.
Additional Program Improvements
VA has also made progress in completing implementation of many of
the VA Office of Inspector General's (OIG) recommendations for the EHRM
program. As of the date of this testimony, 45 of OIG's 68
recommendations are closed, including the final recommendation from the
Unknown Queue report that was closed in January 2023. Thirteen (13)
additional recommendations are targeted for closure by the end of May
2023. Twenty-three (23) recommendations remain open, including two from
the oldest report focused on access to care at Mann-Grandstaff VAMC.
These two recommendations relate to evaluating the EHR system's impact
on productivity and the impact of mitigation strategies on the user and
patient experience and are targeted for closure by June 2023. VA
continues to drive each to closure. We have established VHA EHRM
governance bodies and processes to ensure enterprise standardization
and health system decisionmaking. As part of this work, EHRM-IO
transitioned the EHRM National Councils to VHA to be incorporated into
VHA's governance process.
Continued Engagement at Live Sites
VA continues active engagement with sites already using the new EHR
system, and supporting those sites will be our primary focus as we
reset the EHRM program. We are grateful for their hard work and
dedication to patient care. In fact, these sites have provided vital
feedback on challenges with the new EHR that have resulted in necessary
improvements.
For staff at the five sites where the EHR is currently in use, this
reset means that we are devoting our resources to improving the EHR
experience from the ground up. When EHR systems are at their best, they
are intuitive, responsive and reliable. Clinicians should not be
waiting for an EHR; it should always be ready for them. All too often,
the new EHR has not provided that type of seamless experience for VA
staff. We will ensure that the new EHR is delivering for VA clinicians
and empowering them to deliver world-class care to Veterans. VA
continues to actively work on issues impacting system reliability and
usability to include addressing system performance, testing, training
and functional optimization.
As we continue to support existing sites, VA has developed and
sustained a training regimen to ensure new hires are properly trained
and existing users are getting opportunities to optimize their
performance in the EHR system. We routinely communicate system changes,
planned maintenance events, upgrades and outages. We also leverage our
weekly User Impact Series, which is attended by over 200 super users,
site and VA leaders, and subject matter experts. The lessons learned
from these sites have enabled VA to improve the level of support
provided before, during and after go-live.
Contract Update
VA's initial sole source contract award was awarded to Cerner on
May 17, 2018. The EHRM Indefinite Delivery/Indefinite Quantity (IDIQ)
contract was structured with an initial period of performance of 5
years, after which another 5-year option period is available to
exercise at the Government's discretion. The current period of
performance for VA's contract ends May 16, 2023. Our Office of
Acquisition, Logistics, and Construction, together with other
stakeholders in VA, has conducted acquisition planning and preparation
to support option period negotiations with Cerner. Those negotiations
began on March 13, 2023, and are ongoing. VA and Cerner are currently
working toward an amended contract that will increase Cerner's
accountability to deliver a high-functioning, high-reliability, world-
class EHR system.
Budget Overview and Cost Estimate
The VA EHRM program will not be seeking the 25 percent funding
withhold (totaling $439,750,000) of the VA EHRM budget line for FY
2023. As part of the reset, VA remains committed to working with
Congress on resource requirements for the agency's EHR Modernization
efforts. When the reset period concludes, VA will update its EHR
deployment schedule and program life cycle cost estimate and will
provide an updated version to Congress once completed.
Conclusion
Our focus is keeping Veterans at the center of everything we do,
and our top priority remains and continues to be advancing a culture of
safety and high reliability, with the goal of zero incidents of patient
harm. Veterans deserve high-quality health care that is timely, safe,
Veteran-centric, equitable, evidence-based and efficient.
As improvements continue to be made throughout the duration of this
reset, VA will continually evaluate readiness and the EHR system to
ensure success. This includes close collaboration with EHRM-IO, VHA,
site and VISN leadership and other key stakeholders.
I again extend my gratitude to Congress for your commitment to
serving Veterans with excellence. With your continued oversight and
support, VA will realize the full promise of a modern, integrated
health record to cultivate the health and well-being of Veterans. We
are happy to respond to any questions that you may have.
______
Prepared Statement of Mike Sicilia
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Prepared Statement of Carol Harris
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