[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                           VA ELECTRONIC HEALTH RECORD 
                           MODERNIZATION: GET WELL SOON?

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      THURSDAY, SEPTEMBER 14, 2023

                               __________

                           Serial No. 118-29

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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                    Available via http://govinfo.gov


                   U.S. GOVERNMENT PUBLISHING OFFICE                    
53-766                     WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                      
 
                     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

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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                      THURSDAY, SEPTEMBER 14, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mike Bost, Chairman................................     1
The Honorable Mark Takano, Ranking Member........................     2

                               WITNESSES
                                Panel 1

Mr. Neil Evans, M.D., Acting Program Executive Director, 
  Electronic Health Record Modernization Integration Office, U.S. 
  Department of Veterans Affairs.................................     4

Mr. Robert Fischer, M.D., Director, Mann-Grandstaff (Spokane, 
  Washington) VA Medical Center, U.S. Department of Veterans 
  Affairs........................................................     6

Mr. Scott Kelter, Director, Jonathan M. Wright (Walla Walla, 
  Washington) VA Medical Center, U.S. Department of Veterans 
  Affairs........................................................     6

Ms. Meredith Allison Arensman, M.D., Chief of Staff, Chalmers P. 
  Wylie (Columbus, Ohio) VA Ambulatory Care Center, U.S. 
  Department of Veterans Affairs.................................     7

Ms. Thandiwe Nelson-Brooks, Associate Director, Roseburg, Oregon 
  VA Medical Center, U.S. Department of Veterans Affairs.........     8

                                APPENDIX
                     Prepared Statement Of Witness

Mr. Neil Evans, M.D., Prepared Statement.........................    45

                        Statement For The Record

Ms. Teresa D. Boyd, D.O..........................................    51

 
       VA ELECTRONIC HEALTH RECORD MODERNIZATION: GET WELL SOON?

                              ----------                              


                      THURSDAY, SEPTEMBER 14, 2023

                    Committee on Veterans' Affairs,
                             U.S. House of Representatives,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:31 a.m., in 
room 360, Cannon House Office Building, Hon. Mike Bost 
(chairman of the committee) presiding.
    Present: Representatives Bost, Radewagen, Bergman, Mace, 
Rosendale, Miller-Meeks, Murphy, Franklin, Van Orden, Luttrell, 
Ciscomani, Crane, Kiggans, Takano, Brownley, Pappas, Mrvan, 
Cherfilus-McCormick, Deluzio, McGarvey, Ramirez, Landsman, and 
Budzinski.
    Also present: Representative McMorris-Rodgers.

            OPENING STATEMENT OF MIKE BOST, CHAIRMAN

    The Chairman. Good morning, everyone. The committee will 
come to order, and I want to welcome our witnesses. I also want 
to ask unanimous consent that Representative McMorris-Rodgers, 
and Newhouse, and Schrier be able to participate in today's 
questioning. Hearing no objections, we will proceed.
    The Cerner Electronic Health Record (EHR) went live in 
Spokane, Washington nearly 3 years ago. It then went live in 
Walla Walla, Columbus, and Roseburg about 2-1/2 years ago. 
Things still are not right with these medical centers and their 
clinics. When I went to Walla Walla and Columbus last year, 
there were still struggles to get back to normal. The number of 
appointments was still cut back, the employees were furious, 
and the veterans were confused.
    I understand these facilities have managed to get close to 
normal patient volumes by adding a whole lot more staff. That 
is more people to do the same amount of work. We still can not 
trust Oracle Cerner EHR to be safe and accurate. VA employees 
are being forced to doublecheck everything. Those extra 
employees cost us a lot of money.
    The staff costs, reduced collections, and higher community 
care costs have put some of the medical centers in permanent 
budget deficits. This is outrageous and a terrible situation. I 
do not know how anyone with a share of judgment could call EHR 
a success. A parade of VA and Cerner executives repeatedly 
tried to tell us how great it was over and over and over again, 
and it just was not. We kept seeing it.
    I want to tell you that the problems that came to us did 
not just come to one side of the aisle. Both Republicans and 
Democrats have agreed we see this problem, and we have tried 
desperately to get it fixed. The problem became overwhelming 
when Secretary McDonough finally did the right thing in April 
and declared an indefinite pause. This is a pause I had been 
calling for since 2021 because our staffs, as I said, on both 
sides of the aisle, had been watching and seeing things go 
south.
    Now, the VA is in a reset where Dr. Evans has to figure out 
how to fix up a broken system. Dr. Evans, I do not envy your 
task at all. Your punch list has got to be a mile long. Not 
only does the EHR have a lot of built-in problems, VA created 
new problems in trying to customize it as well. VA leaders are 
going to have to make hard decisions they have been avoiding, 
and veterans care depends on it.
    Unfortunately, the previous directors of the project wasted 
far too much money. They spent over 50 percent of the budget 
and only completed about 3 percent of the rollout. This is a 
deep hole to climb out of. If you are able to pull it off, we 
are going to see the improvement in these medical centers. I am 
not going to accept anything less.
    Under no circumstances should VA deploy the Oracle Cerner's 
EHR elsewhere until these facilities have made and are made 
whole. Now that is the test. Congress has been letting VA grade 
its own test for too long. We were far too hands off at the 
beginning of this project. When setting our goals and when they 
really mattered, we kept our hands off, but we are not keeping 
our hands off anymore. We need to establish a clear in what our 
expectations are so that everyone knows and understands where 
we want to go. I want to thank the Ranking Member Takano for 
working with me over the last few months to refine the EHR 
reset legislation. I also want to thank Senator Tester and 
Senator Moran for collaborating with us. Now, our staffs are 
going to be working together to hammer out an agreement. It is 
simple. The project has to deliver results or end.
    We cannot allow it to stumble along and spend more money 
and more time and not get the results we need. We are going to 
find a solution that gives veterans the level of service that 
they have earned and does right by the VA staff. Now, that is 
my commitment. Ranking Member Takano, I now recognize you for 
your opening statement.

        OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

    Mr. Takano. Well, thank you, Mr. Chairman. Thank you to the 
witnesses for being here today to discuss this critical project 
at the Department of Veterans Affairs. I want to start off by 
welcoming Dr. Evans. This is the first time that we have had 
you before our committee and before the full committee since 
you assumed leadership of the Electronic Health Record 
Modernization (EHRM) program. Welcome, Dr. Evans. The program 
needs strong and stable leadership, and I am optimistic that 
you are the person for the job. I am optimistic, as well, that 
we are going to be working together with you to ensure that the 
EHRM gets back on track.
    Like most committee members, I was supportive of VA's 
announcement of a reset of the EHRM program and the decision to 
delay any further go-lives while VA and Oracle fix the issues 
at the five sites currently live on the Cerner system. I am 
concerned, though, to hear that VA is moving forward with the 
program at the Lovell Federal Healthcare Center. While I 
understand that Department of Defense (DoD) needs to go live at 
the Lovell facility to complete its program, I think it is 
risky to deploy a system that has been so problematic at a 
facility that is very different from any other facility in VA 
or DoD. We cannot allow DoD to pressure VA into going live 
prematurely just so that DoD can reach its goals. This program 
cannot afford another failed go live.
    I am glad to see witnesses from most of the live sites 
today. I am hoping to hear about their perceptions about 
progress with the system. The frontline staff at these 
facilities have borne the brunt of the struggles with this 
program. We owe it to them to ensure that their feedback is 
being taken into consideration at this reset, as this reset 
moves forward.
    VA has a major task ahead of it to change the hearts and 
minds of staff about the benefits and potential success of the 
program. I hope that the program office is taking its 
obligations to the frontline staff seriously. I am also very 
concerned that it appears that VA is too busy treating the 
symptoms of this program to think strategically about 
preventing these issues from resurfacing at the next facilities 
to go live. I share Ranking Member Cherfilus-McCormick's belief 
that VA must focus on developing a baseline EHR that minimizes 
deviations as the program moves forward.
    I also believe that VA needs a robust governance structure 
to ensure that any changes made to the baseline are absolutely 
necessary and are in the best interest of veterans. Constant 
change requests have and will continue to have major impacts on 
the cost and timeline of the project and will force staff at 
the active sites to continually adjust their workflows. Because 
of this and my concerns about the future of the program, I am 
pleased that Chairman Bost and I have been working together to 
draft the House's version of the EHR Reset Act, building on the 
great work from Chairman Tester in the Senate.
    We have spent a considerable amount of time discussing the 
struggles with the program, and now we need legislative action 
to force some of the structural and accountability measures 
that are necessary to get this program on track. It cannot be 
understated how big this problem is, both in terms of cost and 
scale, but a modern EHR is necessary if we want VA to be able 
to provide world class healthcare and for its providers and 
veterans to be able to access new healthcare technology.
    It is clear that we need to give VA and Congress more tools 
to manage and oversee this program. I look forward to 
continuing to work with my House and Senate colleagues to 
ensure that we get this bill finalized and enacted into law as 
soon as possible. I thank you, Mr. Chairman, and I yield back.
    The Chairman. Thank you, Ranking Member Takano. I now will 
introduce the witnesses. First, we have Dr. Neil Evans, the 
Acting Executive Director of EHRM Integration Office. We also 
have Dr. Robert Fischer, who is the Director of the Spokane 
Medical Center, Mr. Scott Kelter, Director of Walla Walla 
Medical Center, Dr. Allison Arensman, Chief of Staff for the 
Columbus Ambulatory Care Center, and Ms. Thandiwe Nelson-
Brooks, Associate Director of the Roseburg Medical Center. If 
each of you can rise and raise your right hand, please.
    [Witnesses sworn]
    The witnesses have all responded in the affirmative, and 
let the record reflect as such. Dr. Evans, you are now 
recognized for 5 minutes for your opening statement.

                    STATEMENT OF NEIL EVANS

    Dr. Evans. Thank you very much. Good morning, Chairman 
Bost, Ranking Member Takano, and all distinguished members of 
this committee. Thank you for this opportunity to testify. As 
you have just heard, accompanying me today are the leaders of 
our facilities, Mr. Scott Kelter, Medical Center Director of 
the Jonathan M. Wainwright Memorial VA Medical Center in Walla 
Walla, Dr. Rob Fischer, Medical Center Director of the Mann-
Grandstaff VA Medical Center in Spokane, Washington, Ms. 
Thandiwe Nelson-Brooks, Associate Director of the Roseburg VA 
Health Care System, and Dr. Allison Arensman, Chief of Staff of 
the VA Central Ohio Health Care System in Columbus.
    I am very grateful that they have been able to travel to 
join us today. Local medical center and Veterans Integrated 
Services Network (VISN) leadership, and for that matter, VA 
frontline staff and clinicians, are the most important members 
of our community when it comes to successfully implementing a 
new electronic health record in VA, and their perspectives are 
critical.
    First, I would like to take a step back. As you are aware 
and just heard, VA needs to modernize its electronic health 
record system, and the Department remains steadfast in its 
commitment to doing so. The replacement of VA's EHR is one of 
the most complex health IT projects ever undertaken. The 
project will impact more than 300,000 VA employees and more 
than 100,000 trainees who will 1 day use the new system every 
year, and more than 7 million veterans whose care will be 
orchestrated and documented within the system every year.
    I should emphasize that this is more, much more than just a 
technology project. The EHR change, by its very nature, 
requires VA to revisit, reconsider, and where possible, 
standardize clinical processes and workflows. Electronic health 
records profoundly impact operations, including how care is 
delivered in the modern healthcare system, how providers access 
the information that they need, how instructions for care, also 
known as orders, are transmitted and received within the 
hospital, how highly complex care is organized in our intensive 
care units (ICUs), how surgeries are successfully planned and 
completed, how prescriptions are ordered and delivered. Getting 
this right requires a massive team effort across the VA 
enterprise, attention to detail, effective communication, and 
consistent execution.
    In fact, as has already been mentioned, the suite of 
technologies that make up a modern electronic health record are 
just part of a larger ecosystem of technologies needed by VA to 
enhance the quality and safety of healthcare delivery. It is 
this entire suite of technologies, both the Federal EHR and 
other critical health information technologies that need to be 
modernized and integrated effectively to simplify the 
healthcare experience for veterans and VA staff and to enhance 
standardization across VA's enterprise.
    As you are aware, VA is implementing the very same 
electronic health record solution as the Department of Defense, 
U.S. Coast Guard, and National Oceanic and Atmospheric 
Administration (NOAA). This system is often referred to as the 
Federal EHR.
    DoD completed their deployment in the Continental United 
States, and they are still going to go live at the Captain 
James A. Lovell Federal Health Care Center in North Chicago, 
Illinois, as well as their outside of the Continental United 
States sites. Together, we are planning an implementation of 
the record in North Chicago with a go-live currently planned in 
spring of 2024. In VA, the Federal EHR is in use at five VA 
medical centers, 22 community-based outpatient centers, and 52 
remote sites such as call centers and telehealth hubs that 
support the facilities led by the individuals to my left.
    We have been listening to veterans, clinicians, and 
frontline leaders such as my colleagues here at this table. In 
doing so, it became clear that the Federal EHR was not and is 
not meeting expectations. Therefore, in April 2023, VA 
announced a program reset, halting work on future deployments 
except for the Lovell Federal Health Care Center. As a result, 
we are now focusing on delivering the improvements needed for 
our current system users, while also preparing the enterprise 
for future deployment successes. Staff productivity levels, 
revenue collections, technical system performance, user 
adoption and satisfaction, and more require dedicated attention 
and positive improvements before deployments resume at full 
pace.
    VA has organized its work during this program reset into 3-
month increments, and just completed its first increment on 
August 31. Initial efforts focused on planning and making 
necessary system configuration changes, improving the technical 
stability of the system, enhancing user support and ticket 
management, addressing communications within VA, and developing 
a larger cohort of VA experts who can support the new system in 
the years to come.
    I suspect you will hear from my colleagues that some of the 
necessary improvements they have been asking for are starting 
to be seen, but that there is still much to be done before we 
will be ready to publish a new schedule and proceed with 
deployments across the rest of the VA healthcare system. I am 
appreciative of the frontline leaders you see represented here. 
As I mentioned earlier, switching to a new EHR requires 
resiliency and demands a lot from staff. Frontline leaders such 
as my colleagues here are the cornerstone of any successful 
transition and are best equipped to support and lead staff 
through the process. Their remarks will follow, and I look 
forward to hearing those.

    [The Prepared Statement Of Neil Evans Appears In The 
Appendix]

    The Chairman. Thank you, Dr. Evans. The written statement 
of Dr. Evans will be entered into the hearing record. Dr. 
Fischer, you are now recognized for 2 minutes for your opening 
remarks.

                  STATEMENT OF ROBERT FISCHER

    Dr. Fischer. Good morning, Chairman Bost, Ranking Member 
Takano, and distinguished members of the committee. We are 
approaching the 3-year implementation anniversary of the Oracle 
Cerner electronic health record at Mann-Grandstaff VA Medical 
Center in Spokane, Washington and our clinics in Wenatchee, 
Washington, Coeur d'Alene and Sandpoint, Idaho, and Libby, 
Montana.
    I would like to take this opportunity to recognize the 
extraordinary efforts and dedication of our employees. In 
January 2020, during intense preparations to go live with the 
Cerner EHR, COVID-19 hit the West Coast of the United States. 
In April, our staff evacuated 41 patients testing positive for 
COVID-19 from our local Washington State Veterans Home to Mann-
Grandstaff for enhanced acute care that unquestionably saved 
many lives. Mann-Grandstaff went live with Cerner in October of 
that year, 2 months before the country experienced its historic 
peak in COVID-19 hospitalizations.
    Since implementation, our employees have recorded, 
investigated, and mitigated over 1,600 Oracle Cerner related 
patient safety events. They reviewed for potential intervention 
and mitigation more than 28,000 medical orders that populated 
the electronic health record queues when they did not execute 
successfully as anticipated. Our staff has entered 15,000 
break-fix incident tickets and 3,000 change requests since 
initial implementation. They have been engaged in continuous 
EHR process improvement through collaboration with peers, 
facility teams, risk management, patient safety, VISN 20, other 
live sites, VA Central Office, and Oracle Cerner.
    The diligence and resilience and often bravery of our staff 
in transitioning to a challenging new electronic health record 
during a deadly worldwide pandemic is absolutely nothing short 
of extraordinary. Their continued engagement in identifying 
gaps in training and functionality over the last 3 years is a 
testament to the high quality of our staff and their dedication 
to veterans' health. On behalf of the men and women of Mann-
Grandstaff VA Medical Center, please accept our gratitude for 
your continued support of veterans and our employees who serve 
them and have gone way above and beyond. Thank you very much.
    The Chairman. Thank you, Doctor. Mr. Kelter, you are now 
recognized for 2 minutes for your opening remarks.

                   STATEMENT OF SCOTT KELTER

    Mr. Kelter. Thank you and good morning, Chairman, Bost, 
Ranking Member Takano, and distinguished members of the 
committee. Thank you for your engagement in the EHR 
modernization process and your commitment to veterans. Having 
now used the Cerner Millennium EHR for 18 months, the VA 
Medical Center in Walla Walla, Washington is recovering toward 
our pre-Cerner productivity, but is still not as efficient as 
we were prior to Cerner go-live in 2022. Clinical staff are 
working long days but are making improvements in efficiency and 
productivity.
    From 2022 to 2023, primary care providers' time per patient 
in the medical record decreased by 10 percent, and they are 
seeing 24 percent more patients. Patient satisfaction with 
their appointment date and time also improved 7 percent 
throughout 2023. At VA Walla Walla, we added a modest number of 
permanent staff, 4 percent of our total staffing, to meet the 
demands of utilizing the Cerner Millennium Platform, including 
nurses, pharmacy staff, charge analysts, health informaticists, 
and an additional patient safety manager. Along with additional 
support from our network and the National EHRM Supplemental 
Staffing Unit, this has been sufficient to continue operations, 
but VA delivered care remains at 80 percent of our pre-Cerner 
levels. The number of Cerner related patient safety reports 
submitted by staff has declined by 73 percent from the initial 
spike after go-live, but remains 38 percent above pre-Cerner 
levels while staff still utilize workarounds outside of the 
software's designed workflow to complete tasks.
    We are pleased with the intent of this reset, enabling VA 
and Oracle Cerner to fix issues in the EHR, redirecting 
resources from deployment to work on optimizing the EHR at 
medical centers where it is currently in use. Veterans deserve 
the very best healthcare, and we are committed to delivering 
that for them. I am optimistic about the eventual success of a 
modernized EHR within the Veterans Health Administration. I 
look forward to any questions you have.
    The Chairman. Thank you, Mr. Kelter. Dr. Arensman, you are 
now recognized for 2 minutes.

                 STATEMENT OF ALLISON ARENSMAN

    Dr. Arensman. Chairman Bost, Ranking Member, Takano, 
distinguished congresspeople, thank you for the opportunity to 
address the current State of the VA healthcare system in 
Central Ohio. I am a physician and the chief of staff, and I am 
here to represent our hardworking, resilient, and incredibly 
dedicated team and the amazing veterans, many such as yourself, 
that we serve.
    The past 2 years have been incredibly challenging. We are 
proud that we developed an extensive preparatory plan. We 
increased our staffing. We set aggressive goals to try to reach 
our pre-deployment productivity and access. We have 
unfortunately found that the new electronic health records has 
largely provided no meaningful improvements in safety, 
efficiency, or communication.
    Our clinicians are exhausted, sometimes tearful, and 
frankly, distressed that they are not able to provide the level 
of care that they could in 2019. Imagine being a doctor in 
Columbus and receiving a critical message about a patient you 
have never seen, who is admitted to a Department of Defense 
site thousands of miles away because his provider has a similar 
name. Imagine being an optometrist and finding an eyeglass 
prescription that has your signature that you know you never 
signed. Imagine being a social worker and being unable to print 
a transfer summary for a patient that is decompensating and 
needs a higher level of care. These are not possibilities. It 
has been the reality for our team in Columbus.
    While our productivity is nearing what it was pre-
deployment, it remains 84 percent of what it was pre-pandemic. 
Our collections are down 48 percent. Joint patient safety 
reporting is nearly threefold what it was before we went live, 
with over 70 percent of events attributed to the electronic 
health record. Our staff have spent over 8,000 hours on 
clinical lookbacks since go-live.
    Despite these challenges, our staff continues to persevere, 
working longer hours and manually completing workarounds to 
protect veterans every day. We are proud of our innovative 
culture in Columbus. We are concerned that the current 
strategies and product are not yet adequate nor scalable. We 
understand we can not flip the switch and go back to the Legacy 
system, although there are days that would be our preference. 
We hope for a dynamic, intuitive, and adaptable system that 
meets the unique needs of veterans. This will take time, 
resources, and a commitment for all our stakeholders. Thank 
you.
    The Chairman. Thank you, Doctor. Ms. Nelson-Brooks, you are 
recognized for 2 minutes of your opening statement.

              STATEMENT OF THANDIWE NELSON-BROOKS

    Ms. Nelson-Brooks. Thank you. Chairman Bost, Ranking Member 
Takano, and distinguished members of the committee, thank you 
for the opportunity to speak today. The Roseburg VA is a rural 
facility comprised of five sites of care serving more than 
36,000 veterans in Southern Oregon and Northern California. On 
June 11, 2022, the Roseburg VA made the switch from the Legacy 
system to the new EHR. Under ideal conditions, implementing a 
new medical record system is challenging. For a facility 
challenged with delivering care in a rural setting, the 
transition to the new EHR was difficult.
    Post go-live, we saw increases in wait times, turnover of 
staff, and a decrease in patient satisfaction scores. In a 
survey of Roseburg VA staff conducted last April, 86 percent 
strongly disagreed with future deployments of the EHR in its 
current state, as it does not increase efficiency, improve 
patient safety, or meet expectations. I am happy to provide the 
committee with specific examples. However, these issues were 
elevated to leadership within the Department who heard the 
concerns of staff, deferred to their expertise, and implemented 
the reset. We applaud their commitment to getting it right, but 
it is not right yet, and our facility has adapted to ensure we 
continue to deliver safe, quality care.
    Since go-live, our facility has increased staffing, 
supported frontline staff, and expanded care models. Fifteen 
months in, we have seen improvements in staff level of comfort 
in the new EHR. Prescription fill times have decreased and 
productivity has increased but has not returned to baseline. We 
are moving in the right direction. However, the system in its 
current state is not ready for additional deployments.
    We are optimistic and committed to enhancing the system. In 
sum, our employees are the backbone of the organization. Their 
reluctance to simplify illustrates their commitment to our high 
reliability principles and the delivery of safe, effective 
quality care. Thank you to the committee for your advocacy on 
behalf of our veterans.
    The Chairman. Thank you, Ms. Nelson-Brooks. Before we go 
further on to questions, at the VA's request, I would like to 
enter into the record for the hearing statement of Dr. Teresa 
Boyd, the Director of VISN 20.
    Without objection, so entered.
    Now, we are going to go to questions. Before I go to 
questions, I want to make one statement to each one of you. 
Please deliver the message back to your employees that we know 
they are doing the best they possibly can in a very, very hard 
time in their careers, and we want to get this right.
    I will go to questions first. Dr. Arensman, what impact has 
Cerner's EHR had on the delivery of care to veterans, 
especially how many veterans you can treat in a day, and how 
has your team dealt with that?
    Dr. Arensman. Thank you for the question. Initially, it had 
quite an impact on the number of patients we could treat a day. 
The answer is somewhat diverse depending on what service we are 
considering. We were able to regain our productivity in our 
surgical clinics by August. We went live in April of last year.
    In other places, we still have not quite reached what our 
productivity was before, particularly in primary care. The 
gains have been much more incremental and the slope much more 
shallow. We are approaching about 80 percent to 85 percent in 
some of those services.
    The Chairman. Can you also let me know about the system 
downtime? Oracle and Dr. Evans' teams are reporting dramatic 
improvements. Are your staff seeing dramatic improvements?
    Dr. Arensman. Is that question for me as well?
    The Chairman. Yes, please.
    Dr. Arensman. Thank you. We have seen over the past 6 
months, there have been fewer total downtimes, so total 
outages. Our staff still is seeing at least once a month 
incidents that leads to having to go to downtime procedures. 
Functionally for those trying to take care of patients when 
they need to put pen to paper, that has still happened. It 
actually happened two times in the past 2 weeks.
    The Chairman. Okay. I am going to stay with you for all my 
questions and then I think others will be going to the others.
    Dr. Arensman. Yes, sir.
    The Chairman. Is your facility running better than it was 
before the Cerner EHR was implemented?
    Dr. Arensman. Operationally, I think our facility is 
running quite well. I would say that operating with the Cerner 
record has posed new and interesting challenges and we have had 
to dedicate resources that otherwise would have been dedicated 
to strategies to improve care.
    The Chairman. Well, it sounds like you have done what you 
could do to make what you have been handed work to the best of 
your ability. Some of the big improvements will be beyond your 
control because it is going to be Cerner that has got to come 
in and right the wrong. In the current situation, is it a band-
aid or is it sustainable? If it is not sustainable, how long is 
it sustainable?
    Dr. Arensman. I am sorry, can you clarify the question?
    The Chairman. Basically where you are fixing now, are you 
going to be able to keep it together or is it going to have to 
be changed tremendously?
    Dr. Arensman. It is a great question. We are taking care of 
the veterans in Central Ohio and I think we are doing an 
amazing job. At what cost? It is cost a tremendous amount in 
terms of additional staff, in terms of additional overtime, and 
in terms of, I think a degree of moral distress among our 
providers.
    The Chairman. This is not on my questions, but it is on my 
mind, okay? Right now, we are turning up the The Sergeant First 
Class Heath Robinson Honoring our Promise to Address 
Comprehensive Toxics (PACT) Act. Your workload is going to get 
a lot bigger. Are you going to be able to handle the workload 
that we are sending to you through the PACT Act with the system 
and the situation that we are with right now?
    Dr. Arensman. I have a bit of good news in that Columbus is 
really leading our region and I think our Nation in how we have 
addressed patients with toxic exposure screenings. We have no 
patients that are waiting for their follow-up exams for toxic 
exposure screening. I agree, if it increases our enrollments, 
it will be a challenge in the future.
    The Chairman. Let me tell you that we want to thank you for 
being here today. I want to say thank you for you and your 
staff. Like I said, I know we are going to have a whole lot of 
other people that need to ask questions here, so I am going to 
yield to the ranking member so we can go on with the rest of 
questions.
    Mr. Takano. Thank you, Chairman Bost. Yesterday, we 
received the quarterly patient safety data that was mandated by 
Representative Frank Mrvan's EHR Transparency Act in the last 
Congress. I have to say I was alarmed to see that there are 
quite a few of the reports from our facilities on patients. 
What is alarming is that we are seeing a few reports of 
facilities receiving reports on patients at other facilities.
    I thought that VA told us over a year ago that this issue 
had been fixed. Now, Dr. Arensman, you mentioned this 
particular issue in your opening statement. Can you give us an 
indication of how often this situation is occurring where 
facilities are receiving reports on patients at other 
facilities?
    Dr. Arensman. Thank you. I believe I mentioned in my 
opening statement that there was an increase in patient safety 
reports. I have heard that occasionally they have been sent to 
erroneous sites. I do not have the documentation as I do not 
actually have access to that system. It is a highly protected 
system given the obvious privacy concerns for anyone involved.
    I can say that there have been an increase in patient 
safety reports. I want to be clear, this is something we often 
celebrate and I think of as a good thing, because these are 
things that are recognized as dangers to patients. It does not 
necessarily mean there has been a catastrophic event. It means 
that something has been recognized as a potential patient 
safety concern. For a high reliability organization, we want 
people to speak up, and we encourage them to speak up. While it 
is concerning and while it is frustrating to me that we are 
spending a lot of time addressing these, I am proud of our 
staff, and I think that it is potentially a benefit.
    Mr. Takano. Excuse me, Dr. Arensman. What I am talking 
about are patient messages.
    Dr. Arensman. Oh, sorry. Okay.
    Mr. Takano. Patient messages. What specifically we are 
concerned about is facilities receiving reports on patients at 
other facilities.
    Dr. Arensman. Thank you for that clarification.
    Mr. Takano. Okay, great.
    Dr. Arensman. So----
    Mr. Takano. I mean, can you comment on how frequently this 
is occurring?
    Dr. Arensman. I hear about it happening on a weekly basis.
    Mr. Takano. On a weekly basis? Okay. Dr. Evans, can you 
shed light on why this continues to be a problem?
    Dr. Evans. I think of course, we do not want to ever see 
that happen. We want care to be--we want orders and messages to 
be delivered to the right recipient at the right facility. As 
we are deploying an enterprise EHR, that is a single enterprise 
EHR with the Department of Defense, Coast Guard, NOAA, and VA, 
we are moving into a very different paradigm than VA has been 
used to, where care was constrained within the local Veterans 
Health Information Systems and Technology Architecture (VistA) 
instance.
    We spend a lot of time working on optimizing the 
configurations of the record to try to make it such that that 
does not happen, that messages are not going to the wrong 
facility or wrong individual. It is a focus area of some of the 
configuration changes that we are doing in the reset. This is 
in some forms, there are real significant advantages to having 
an enterprise electronic health record, a single electronic 
health record that works for the entire VA healthcare system.
    We will be able to better share resources between our 
facilities. We will be able to deliver telehealth care, provide 
support from tele-ICU physicians to facilities all across the 
country with less burden. There is an advantage. That advantage 
comes with a corresponding risk. That risk is that we now have 
to function as a healthcare system with over 300,000 employees 
at the end of this in the same system.
    We are working on how do we mitigate that risk, how do we 
prevent that? I think there is been improvement, but we are not 
where we need to be, obviously, based on what you just heard 
from Dr. Arensman.
    Mr. Takano. Well, Dr. Evans, can you assure me that VA and 
Oracle Cerner, they are looking at a way to fix this problem?
    Dr. Evans. Yes, to address this problem, absolutely.
    Mr. Takano. Well, great. Well, you know, I just want to 
again, really thank Mr. Mrvan for the EHR Transparency Act. It 
is giving us already it is paying dividends in terms of giving 
us important reporting and enabling us to do better 
congressional oversight. I certainly hope we do get this issue 
fixed. I yield back, Mr. Chairman.
    The Chairman. The gentleman, yields back. Thank you, 
ranking member. Representative Radewagen, you are now 
recognized.
    Ms. Radewagen. Talofa lava. I want to thank Chairman Bost 
and Ranking Member Takano for holding this hearing today, and I 
thank the witnesses for being here. Mr. Kelter, how long did it 
take after Cerner was implemented at your facility for patient 
volumes to go back to 80 percent of normal? Please answer that 
in terms of primary care and specialties. I understand some of 
your departments are very large, while some are very small.
    Mr. Kelter. Similar to what Dr. Arensman described, our 
specialty care was fairly quick to recover and the record did 
not affect their throughput very much. Our pharmacy almost--I 
am sorry--our laboratory service almost immediately saw 
benefits to the system. In fact, our laboratory service is more 
productive and the system has made them more efficient.
    Primary care, as one of our largest departments, has had a 
very, also similar to Columbus, has had a slow slope. It took 
several months to--we started very slow with just a couple of 
patients a day as physicians and other members of the team 
learned the record. Incrementally grew from two to four to six 
to eight to 10 patients a day. It really has been--it probably 
took about a year before they were at the level, about the 
level that they are at now.
    Ms. Radewagen. Okay. Mr. Kelter, how have your wait times 
been impacted and how much more care are you sending out to the 
community compared to before Cerner?
    Mr. Kelter. The wait times initially increased 
significantly. Our patient care going out to the community was 
nearly double for some period of time. Our community care 
office is pretty much caught back up to the consult volume that 
we were at prior to when those consults built up in the Cerner 
go-live timeframe. Part of that has been due to the system 
itself and the efficiencies of the system, and part of that has 
been due to staffing variabilities that are unrelated to 
Cerner.
    Again, it has taken through a variety of factors, again a 
little bit over a year to catch up and get back to that as well 
as those departments, both the primary care department and our 
community care coordination department, quite a bit of work, 
not only in staffing, but in developing their own processes and 
working through those things to improve. They have worked 
extremely hard to get to where we are and also to help break 
those barriers to make it easier and to share those lessons 
forward to other sites to make it easier for sites that will 
deploy after us.
    Ms. Radewagen. How many more staff have you needed to hire 
since you got Cerner and what areas have you hired them in?
    Mr. Kelter. We have increased staff in our community care 
department specifically to help with the coordination of 
consults. We have added a patient safety manager. We have gone 
from one to two patient safety managers. We have increased some 
of our essentially the equivalent of one primary care team. 
Some of those increases are coupled with the normal recruitment 
challenges that we have as well. Increasing the authorization 
does not necessarily mean a rapid----
    Ms. Radewagen. Yes.
    Mr. Kelter [continuing]. increase in staff.
    Ms. Radewagen. How about your medical collections, the 
copays and insurance payments? How has Cerner affected them?
    Mr. Kelter. We have had a very limited ability to do third-
party collections, and our collections have been significantly 
decreased. We have very little revenue to show, and that is 
done through a third-party billing office. That is not done at 
the Medical Center. That is done at the network level.
    Ms. Radewagen. You are here to speak for your staff. How do 
they feel about the Cerner system? What are they saying in 
surveys and to you directly?
    Mr. Kelter. The majority of staff are still frustrated at 
the amount of time. For many it is essentially the process time 
and the number of clicks to get through a process where 
something might have taken six to 10 clicks before and now 
takes 30 to 50. The process time for many things is still 
double or triple what it was.
    Ms. Radewagen. I see. Thank you, Mr. Chairman. I yield 
back.
    The Chairman. The gentlewoman yields back. Representative 
Mrvan, you are recognized.
    Mr. Mrvan. My question is that commonality is the 
challenges that you are facing and we can not go back in time. 
If you could each just give me a little bit of perspective, if 
you think it is the capacity of the new system, if it was 
training, just very simply, what do you think led us to get to 
this point that you are before Congress because of the slow 
rollout and the risk that it provides?
    Dr. Evans. I suspect you are interested in the perspective 
from the medical center leadership?
    Mr. Mrvan. Correct.
    Ms. Nelson-Brooks. Thank you for the question. It is a 
rather complicated question. I think that there are a number of 
facets that are involved in what is led us to this point. The 
training that our staff initially received from Cerner was not 
what we expected and did not adequately prepare staff to be 
able to function effectively and efficiently in the medical 
record system.
    In addition to that, there were specific things that were 
not included in the medical record to take into account some of 
the complexities of care that the VA delivers. Cerner is a 
commercial off the shelf product not designed for the VA and 
does not take into account specific programs such as our 
Caregiver Support, our Homeless Program, and other programs 
along those lines. Similarly with DoD, we are very different.
    Then last, what I would say is that each medical center is 
different and is unique, and their capacity to handle change of 
this scale is very individualized.
    Mr. Mrvan. Can I hone-in on that? Can you tell me what you 
mean by the capacity of each individual organization and just 
kind of explain just a moment of that?
    Ms. Nelson-Brooks. Absolutely. The Roseburg VA is very 
rural. As a rural site, we are challenged with recruitment and 
retention of staff. We currently have a 40 percent vacancy rate 
in our primary care providers. Our position is very different 
from Columbus, where Columbus may not have been struggling with 
high vacancy rates in primary care and mental health.
    In addition to that, as a facility, we have had turnover in 
our leadership team. I am new to the Roseburg VA, having been 
there less than 2 years, and the new medical center director 
who really wanted to be here but could not be here today, began 
in April. As a facility, we have experienced turnover in our 
leadership team.
    Mr. Mrvan. Thank you. Anyone else?
    Dr. Fischer. I would say one of the root causes is related 
to Oracle Cerner's lack of appreciation for the complexity of 
VA operations when we began this journey. I would also say that 
their training----
    Mr. Mrvan. Can I ask? So----
    Dr. Fischer. Sure.
    Mr. Mrvan [continuing]. just to interrupt, I am going to 
follow up on that. We have transitioned from Cerner to Oracle. 
Consistently as chairman of Technology Modernization last year, 
there has been an absence of you sitting at the table trying to 
give your opinion. Has Oracle changed that? Have you had an 
opportunity or has Oracle changed your input into these 
situations?
    Dr. Fischer. I think that is an excellent question, sir. Do 
not forget, we are in a reset period now, and so the conditions 
and the environment has changed. Now we are starting to rev up 
meetings with both Electronic Health Record Modernization 
Integration Office (EHRM-IO) and Oracle Cerner, which is a 
consequence of this reset. It will be hard to say today what a 
month from now will look like when we are more into normal 
operations. Improvements are being made, and I suspect we will 
get more and more engagement from Oracle Cerner.
    Mr. Mrvan. Thank you. Dr. Evans, you talked about the 
ecosystem of technology that goes into the support, or I 
interpret it as support into the electronic medical records. 
Can you define what you mean by that?
    Dr. Evans. Sure. I think sometimes we think together that 
changing the EHR from VistA Computerized Patient Record System 
(CPRS), which we have been using in VA and are still 
successfully using in much of VA, to the Federal EHR, the 
Oracle record, is the sum total of what we need to modernize 
health information technologies to support a modern VA.
    The EHR in many ways serves as the equivalent of the 
operating system of a health information technology ecosystem. 
There are other critical applications, telehealth applications, 
connected to, you know, the bedside monitors that are in an 
intensive care unit, you know, measuring real time 
Electrocardiograms (EKGs) or telemetry, new clinical decision 
support applications.
    Mr. Mrvan. Does the new system not include those systems? 
Are they not working in conjunction with each other?
    Dr. Evans. I think in my opening statement when I mentioned 
that, I think in part, part of the promise of a modern 
commercial electronic health record is that we will more easily 
be able to integrate and deliver connected technologies that 
will enhance the function of the electronic health record. We 
currently have many interfaced technologies supporting the 
medical centers that you see represented at my left. I do not 
think that that is a problem. I was characterizing that as an 
important part of the overall modernization journey that we are 
on. We are modernizing the EHR as well as the rest of our 
health information technologies that support and work in an 
integrated fashion with that electronic health record.
    Mr. Mrvan. Thank you. With that, I yield back.
    The Chairman. General Bergman, you are recognized.
    Mr. Bergman. Thank you, Mr. Chairman. Listening to the 
testimony and the questions reminds me of an old saying about 
trying to fit a square peg into a round hole. I would suggest 
to you, the round hole is how the VA medical system has been 
delivering services to the veterans. The square peg is the new 
EHR. Okay? Now, you got two choices. You got a square peg, a 
new system, and you got the existing ways you are doing 
business, the round hole.
    The question is, how do you make the two fit, because they 
have to fit. Anytime, to use the square peg as the example, if 
you start shaving it to fit the round hole, you are going to 
cutoff some of your capabilities and make the whole system not 
work. That is just how that evolution works.
    Dr. Evans, just a thought here, because I heard you say in 
your opening testimony, where possible, standardize, and then 
you went on from there. Standardization is the key to 
controlling costs, standardizing care for everyone, ultimately 
standardizing the ability of your physicians and providers to 
actually do their job, and ultimately the long-term success of 
the new, you know, if you will, enterprise system. When it 
comes to the standardization, I ask anybody here to provide 
comment, how are you working to standardize roles and clinical 
processes at the sites rather than try to make the EHR system 
work for your existing processes? Anybody want to offer 
comment?
    Dr. Evans. Yes, I will start and then I would love to hear 
some thoughts from those to my left. First of all, I completely 
agree and I would argue that we have a square peg and many 
round holes, not just a square peg and a single round hole. 
And----
    Mr. Bergman. VA is the round hole.
    Dr. Evans. Correct. If we are trying to put a square peg, a 
single enterprise electronic health record, we are having to 
fit it to workflows, which may not be the same at 165 different 
medical centers.
    Mr. Bergman. I am going to just interject for a second here 
because in a former life, I was a commercial airline pilot, and 
we had 4,000 pilots on our seniority list. We all did things 
the same way, regardless of what aircraft we were flying. There 
was a little nuance in checklists and operation. Tell me again 
why it is going to be so different across the VA in other 
words.
    Dr. Evans. I am not. I am saying that we need to 
standardize. I fully agree with you that in order for us to 
successfully deliver an enterprise electronic health record, 
one of the significant tasks in front of us as part of this 
reset is standardizing how we deliver care, whether that be 
primary care----
    Mr. Bergman. What is----
    Dr. Evans [continuing]. whether that----
    Mr. Bergman [continuing]. the standardization, I would 
guess, is in the ball is in your court on that, because you are 
the providers. All this is, is a tool, if you will.
    Dr. Evans. Correct.
    Mr. Bergman. Right? We can eat up all the time here. 
Anybody else want to make any comments on the standardization 
as you try to move forward, in number one, upping in the 
quality of the healthcare, and the timeliness, and all of that 
across the entire system, but the challenges you have in 
standardizing? Anybody?
    Mr. Kelter. Sir, as we learn new things about the medical 
record, the Cerner Millennium product, and we continue to learn 
more things about it every month, across the live sites, we 
have a network.
    Mr. Bergman. When you learn new things, what then is the 
way of sharing the new things so that a, you know, a brush fire 
does not become a forest fire in this case? What is the 
mechanism that the VA is using to communicate across and to 
work with Oracle to iron out the inevitable kinks in installing 
a new system?
    Mr. Kelter. We have frequent recurring meetings across the 
five live sites, primarily within VISN 20 and including VISN 
10, as well as frequent recurring meetings with Cerner 
executives. Each time we discover something, our immediate 
question is, what are the other sites doing? How do we share 
what we have learned? How do we determine what is the best way 
to approach that and then engage EHRM-IO and Oracle Cerner with 
that solution?
    Mr. Bergman. Okay. Thank you. Mr. Chairman, I see my time 
is up. I yield back.
    The Chairman. Thank you. Representative Brownley.
    Ms. Brownley. Thank you, Mr. Chairman. Just to piggyback on 
this conversation, it seems as though getting standardization 
across the VA is a task, an objective that I am not sure is 
possible to achieve, honestly. I mean, since, you know, we have 
said--I have been on this committee for 10 years, and we have 
always said, if you have seen one VA, you have seen one VA. 
Each medical center has a lot of autonomy. I just do not know. 
To me, that is like the biggest cultural shift that could 
possibly occur within the VA is to gain standardization. It 
makes me worried that that is an essential key to making this 
all work. I am not going to ask a question around that. I am 
going to move on.
    The EHR has been deployed in the Coast Guard and NOAA, it 
sounds like successfully, understanding that there probably is 
standardization, you know, across those entities. The DoD has 
done half of their facilities have deployed the EHR. I guess it 
sounds to me that in all of those locations, you are having 
success. Is it just the standardization? Is that the key 
essential difference between VA not having success and they 
having success?
    Dr. Evans. That is a good question. The DoD is, I think, 
over 90 percent complete. The only sites that they have not 
deployed are outside of the Continental United States and the 
Captain James A. Lovell Federal Health Care Center in North 
Chicago.
    I think there are several factors. Again, we are different 
healthcare systems, but healthcare is healthcare. You know, one 
of the challenges that you face in deploying an electronic 
health record is the tension between needing to deploy the 
health record and needing to optimize it such that it is fit 
for purpose for how you deliver care in your healthcare system. 
I think DoD was probably further along in the standardization 
journey than we were when they started. They were moving from 
an electronic health record where I do not know that there was 
as much autonomy locally and nor was there as much sort of 
satisfaction with the EHR that they were moving from to the new 
EHR. I do think that a commitment to a baseline, here is how 
the record will be configured and how we need to move forward, 
was a part of the success story for those three health systems 
that you mentioned.
    I think, however, when you deploy an electronic health 
record you are never done. There is always a tension between 
pushing forward with the deployment but doing the optimization. 
It is really, as part of this reset, we are choosing rightfully 
so, absolutely have to, to get some of that optimization work 
done now to take the time to do that so that we can deploy a 
more standardized EHR that will meet the needs of our 
facilities moving forward.
    Ms. Brownley. Thank you for that. I assume that the 
deployment of those three organizations, they did that on 
budget, did not have any cost overruns in order to do it?
    Dr. Evans. Coast Guard and NOAA are very small 
organizations, and their deployments were supported by the DoD. 
The DoD took a very, very similar pause, reset. They did not 
call it a reset, but what we are in the middle of. 
Interestingly, when they came out of that, they were able, they 
addressed many of the same challenges, standardizing, deciding 
what the baseline is, fixing issues around training, revisiting 
their deployment methodology. As they came out of their pause, 
they were able to accelerate their deployments. They revisited 
the structure by which how they went live. I can not comment 
exactly on where they are with regard to their budget, but they 
did pick up speed by spending the time to do things during an 
equivalent of a reset. By doing those things right, it actually 
helped them on the back end.
    Ms. Brownley. I guess there is hope----
    Dr. Evans. I----
    Ms. Brownley [continuing]. that the same thing can happen 
within the VA. I appreciate your honesty in your written 
testimony that, you know, you do not have a firm timeline for 
the completion of the project. I appreciate that very, very 
much. There have been many who say it is going to take more 
than 10 years. I am wondering if you have any sense of where we 
might be without making a hard commitment.
    Dr. Evans. I think, as I just mentioned, I think this is 
actually an important part of the reset. Part of the reset as 
we move toward thinking about restart needs to be because we 
have promised that we will publish a schedule that we can stand 
behind at the end of reset. There is a lot of analysis that 
needs to go into understanding what that is and to, frankly, 
develop a schedule in partnership with our field leadership 
that makes sense.
    Should we be going live concurrently at medical centers 
that share resources and refer between each other? How do we 
want to revisit what that schedule looks like? That work is 
ongoing right now to analyze what the constraints are to 
develop a new schedule. We want to do this right. I feel an 
urgency. It is hard for me to commit to say where this is going 
to fit from a timeline. That is work that we need to do as part 
of the reset. I look forward to continuing conversations with 
this committee on that topic.
    Ms. Brownley. Thank you very much. I yield back, Mr. 
Chairman.
    The Chairman. Thank you. Mr. Rosendale.
    Mr. Rosendale. Thank you very much, Mr. Chair, and thank 
you to all the witnesses for coming here to D.C. to testify and 
answer questions. I have made it my mission to provide proper 
oversight of the Oracle Cerner electronic health record system, 
ensure that veterans are not being put in harm's way, and that 
taxpayers do not continue to waste billions of dollars, 
billions of dollars. Dr. Fischer, are you able to treat as many 
veterans today as you were before the Cerner system was 
introduced?
    Dr. Fischer. No, sir.
    Mr. Rosendale. Okay. If so, when do you anticipate that you 
would be able to return to that level? Any estimate?
    Dr. Fischer. I am optimistic that with Dr. Evans and the 
efforts of the Agency focused on improvement, once that gains 
appreciable traction, then I would expect we will therefore 
gain more productivity.
    Mr. Rosendale. We can not estimate.
    Dr. Fischer. It would be difficult for me to estimate.
    Mr. Rosendale. Okay. Dr. Fischer, I understand you have 
added about 20 percent more staff to treat the same number of 
patients, or as you say, a lower number of patients. Please 
help me to understand where the additional staff are working 
and why the Cerner EHR created the need for them?
    Dr. Fischer. Well, overall, we have added 20 percent more 
staff and 15 percent more clinical providers. I have not broken 
it down by specific departments. We have added to safety. We 
have added to quality. We have tripled our informatics staff. 
We have more administrative staff. Where we can----
    Mr. Rosendale. All of this improvement in addition to 
staffing, and yet your client treatment, the number of patients 
that you are treating is going down.
    Dr. Fischer. Well, it is not going down. It is simply not 
increasing at a great rate. We are about 70 percent of 
efficiency from prior to go-live. A year ago, we were at 50 
percent. We are seeing slow and incremental improvements, but 
we have told our staff to move at the speed of safety, and I 
believe that is what they are doing.
    Mr. Rosendale. What is the sum total of additional expenses 
due to staffing or investments that have been measured since 
the introduction of Cerner?
    Dr. Fischer. The annual rate for roughly 200 more staff is 
in the multimillion-dollar range, sir.
    Mr. Rosendale. Did Cerner cover any of that additional 
expense?
    Dr. Fischer. I do not know what the source is. I believe 
Veterans Affairs Central Office (VACO) covered those expenses, 
sir, central office.
    Mr. Rosendale. That is coming out of Veterans Affairs 
budget.
    Dr. Fischer. That is my understanding.
    Mr. Rosendale. Okay. Earlier this year, you were projecting 
about a $35 million deficit. There was a public controversy 
about whether the VISN was going to withdraw the funding that 
allows you to balance your budget, forcing you to lay staff 
off. Secretary McDonough even had to intervene and pledge 
support. Was your budget problem resolved? If so, how?
    Dr. Fischer. It was resolved. The VISN and VACO covered a 
$27 million deficit. We had some supplementary funding because 
of difficulty with third-party payers. We have got some 
activation funds for leases we are about to execute. Yes, the 
deficit was covered in total, and it always is every year.
    Mr. Rosendale. Let me make sure I understand. Oracle Cerner 
is continuing to receive their full payments, billions of 
dollars' worth of payments, and we are running budget problems 
at the facility. Even though Oracle-Cerner is not providing the 
work that they contracted for and is continuing to be paid, and 
it is costing additional expense at the medical facility, they 
are staying whole and the taxpayers are paying additional money 
for the additional staff. Is that fairly accurate?
    Dr. Fischer. I think that is fair.
    Mr. Rosendale. Mr. Chair, I yield back.
    The Chairman. Thank you. The gentleman yields back, Mrs. 
Ramirez.
    Ms. Ramirez. Thank you, Chairman Bost and Ranking Member 
Takano. I want to also thank every witness that is here today. 
I am one of the newer members in the committee. I have 
appreciated really learning from my colleagues here, and 
certainly, I know that this has been a hearing we have had 
before.
    The contract with Oracle Cerner and its implementation, the 
challenges really get us to the system of our root problem. I 
think it is deeper. I think we know that there have been 
failures at every level, unfortunately, in the VA, regarding 
veterans and healthcare and medical records.
    I recently, during August district work period convened a 
series of roundtables that brought together veterans from all 
over my district, from DuPage to Chicago. I asked the veterans, 
tell me what you are experiencing, what are the problems you 
are seeing, and what are the possible solutions that you think 
we should be implementing? Unsurprisingly, a disproportionate 
amount of their feedback was related to healthcare. The 
veterans I heard from shared their concerns, including that 
veterans were outright denied healthcare, expressing that the 
VA healthcare system needs to be better for veterans in 
general, and that the VA cannot successfully transfer medical 
records between the Department of Defense and the VA. I must 
have heard that at least 10 times.
    This signals to me that what we have in place for veterans 
is failing at multiple levels. It is not just the electronic 
health medical record modernization that is failing, but the 
entire healthcare system at the VA still needs some significant 
improvements. My hope is that as we continue to provide 
oversight of our electronic health record modernization 
efforts, that we come together to address the root causes in 
the VA healthcare system and what they are facing.
    Dr. Evans, I would like to get clarity on your efforts to 
improve the health records. I would ask you can you tell me a 
little bit of how you are soliciting feedback to improve the 
EHRM efforts? The second part to that question would be what 
groups are you engaging in and how are you deciding to engage 
these groups?
    Dr. Evans. An excellent question, and I appreciate your 
comments. I have been a primary care provider in VA for 22 
years and still see patients every week. I am incredibly proud 
of our healthcare system and agree with you that we need to be 
responsive to the veterans who are seeking care from us. I will 
also say that when I started 22 years ago at the VA oftentimes, 
I could not find records from the DoD. With the Joint 
Longitudinal Viewer, I cannot remember a time in the last, 
probably 5 to 10 years, that I could not find a piece of 
information from the Department of Defense that I needed to 
take care of a patient. We are sharing records between the DoD 
and all VA sites, and it is visible in the Joint Longitudinal 
Viewer.
    Now, we sometimes run into trouble where somebody does not 
actually know where to look for that. That is something we 
continue to work to improve to make sure that all of our staff 
are available, that are aware that that information is 
available. It is available. It will be even more available and 
even easier to access as we deploy the Federal EHR, a single 
record between DoD and VA.
    Ms. Ramirez. Dr. Evans----
    Dr. Evans. On the topic of your question----
    Ms. Ramirez [continuing]. my time is running out though, so 
I would love to hear. I think it is important for the veterans 
to hear how you are soliciting some of that feedback.
    Dr. Evans. Absolutely, absolutely. With regard to 
soliciting feedback, we do a regular survey of Federal EHR 
users, and by that, I mean staff. It is a standard set of 
survey questions that are provided and actually used across the 
healthcare industry by they are called the Kent Gale, Leonard 
Black, Adam Gale, and Scott Holbrook (KLAS), K-L-A-S, 
questions. That is one way we are seeking feedback.
    We are also regularly engaged with end users of the system 
as we are resolving problems and getting input from folks in 
the field. Specifically for veterans, we regularly survey 
veterans about their satisfaction through a survey called the 
SHEP Survey, Survey of Healthcare Experience of Patients, and 
through our Veterans Signals (V Signals) platform. After clinic 
visits, we send satisfaction surveys and we read and pay 
attention to that feedback, including when there are 
suggestions about how we should improve our electronic health 
systems.
    Ms. Ramirez. Thank you, Dr. Evans. I know I am running out 
of time. Just a quick yes or no question. This is about 
oversight of the system improvements. It is imperative that 
there is a third party that can objectively provide some of 
that feedback. Is there any third-party organization providing 
oversight or plans to contract with a third-party organization? 
That is a yes or no.
    Dr. Evans. There is work that is happening at the 
enterprise level around contract validation and verification 
from independent parties, yes.
    Ms. Ramirez. Thank you, Chairman. I yield back. Thank you, 
Dr. Evans.
    The Chairman. Dr. Miller-Meeks, you are recognized.
    Ms. Miller-Meeks. Thank you, Mr. Chair. I would like to 
thank the committee and of the witnesses for appearing before 
us today. Let me say that I have provided care as a physician 
and a nurse when I was both active duty and then as a volunteer 
in our VA hospitals and institutions. Our VA in Iowa City 
provides some of the best care around. I have also had the 
opportunity, I am so ancient, that have gone from paper records 
to electronic health records and certainly know of its main 
dysfunction, which is a reduction in productivity and a 
reduction in the interaction and face to face interaction of 
providers with their patients.
    Having said that, and having been through transitions from 
one type of EHR to another when it is necessary to be system 
wide, even though I am a specialist ophthalmologist which 
another EHR would be much more adapted to my use, I know how 
difficult it can be in order to institute EHR throughout a 
system, and especially one as vast as the VA system, the VA 
healthcare system. However, the rollout was in five VA medical 
centers and there had already been experience with an 
electronic health record system. This is for all of our medical 
leaders here. Has your facility's overall experience with the 
Oracle Cerner electronic health record changed over time? As 
you have realized improvements, how many of those were due to 
the system itself improving versus measures you and your staff 
did in order to adapt the system to you? Then second follow-up 
question is, having been both in the military and the VA, is it 
really that critical that we have the same system through both 
active duty military medical and VA?
    Mr. Kelter. Thank you for that. I would also to your 
comment about going from paper records to an electronic health 
system, I have had providers who did the same speculate that it 
is probably a more difficult conversion in a large scale from 
one electronic medical record to another than it was going from 
paper to electronic. I would say in the last year and a half, 
our satisfaction, and our ability to use the platform to do 
what we need to do has improved. It has been based on both of 
those factors, both the changes that have been made along the 
way. It is very heartening for staff to be able to see changes 
that occurred because of something that they recommended or 
asked for in terms of a configuration change. As well as the 
ongoing efforts to learn how to use it better to engage in how 
to optimize their own workflows and to see those changes in, 
you know, maybe going from 47 minutes to complete a task down 
to 42. Optimally, we would still like to see it at half of that 
time, but to see those changes and improvements over time.
    Ms. Miller-Meeks. That is the problem we have had all along 
with EHRs. That is you are adapting your workflow to an 
electronic health record and electronic system rather than the 
electronic system being designed around your work, which is why 
productivity is reduced. When productivity is reduced, guess 
what? We are delivering less care to fewer veterans. With that, 
I know I asked you all to comment, but my time is running out, 
so I am going to yield back.
    The Chairman. Representative Budzinski, you are recognized 
for 5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman, and thank you to 
the panelists for being here today. I had some questions 
specifically around some of the challenges and how this has 
impacted rural healthcare. I appreciated that Ms. Nelson-Brooks 
mentioned that obviously she services a medical center in a 
rural community and some of the unique challenges around 
interoperability with the new EHR system. I wanted to maybe 
start out by asking Dr. Evans a question related to this topic. 
Has anyone done an evaluation at any of those rural sites to 
determine if or how much the system is improving communication 
between the VA and community care?
    Dr. Evans. First of all, the importance of our delivering 
care in rural parts of our country is absolutely critical. I do 
not think--and I think I would be interested in Ms. Nelson-
Brooks' opinion on this--I do not think that the technology 
itself is appreciably different with regard to interfacing with 
community care, that is, the electronic connections to get a 
referral sent to a community care provider.
    There are differences around the sufficiency of the 
community care network in rural America and how we manage, you 
know, the capacity to deliver care to veterans in those 
communities. I do not think the technology should be a barrier. 
Do you have any further thoughts on that?
    Ms. Nelson-Brooks. Thank you. I agree with Dr. Evans. I do 
not think that there is anything within the medical record 
itself that has improved communication between our facility and 
our community care providers.
    Ms. Budzinski. Okay. Maybe I can now switch to a different 
topic around veteran mental health and suicide prevention, 
which are two topics that have become very extremely important 
to me. I have heard from some VA staff at the first go-live 
sites that there were a lot of issues with Cerner when it comes 
to the behavioral health and case management applications. 
Maybe this is a question for the medical center directors, and 
maybe I could start again with you, Ms. Nelson-Brooks. What 
progress has been made to improve these functions?
    Ms. Nelson-Brooks. Immediately post go-live, we had 
challenges with high-risk flags not being visible in the 
medical record. Those have since been fixed, as well as some 
additional changes that were made. I am not able to fully 
explain all of the changes that were made, but what I can tell 
you is that as a facility, we have seen marked improvement in 
our Charm One metric, which we had not seen the year prior. 
Charm One has to do with suicide prevention and our case 
management activities around suicide prevention. We have seen 
improvement there.
    Ms. Budzinski. Is there any area in particular that there 
has not been improvement that we should be working toward 
improvement on, if you could speak to that?
    Ms. Nelson-Brooks. Specifically in mental health?
    Ms. Budzinski. Mm-hmm, yes.
    Ms. Nelson-Brooks. None that I am aware of, but I will 
yield to my colleagues to see if they can add anything 
additional.
    Dr. Arensman. Thanks for the question. I was walking around 
the veteran memorials last night and thinking a lot about the 
mental health and all the things we try to do to help our 
veterans and sometimes going above and beyond what they can 
expect in the community in terms of their care. We have had 
some challenges, I think, particularly with relation to care 
plans. Sometimes it is as simple as having enough space to put 
in enough information for an accurate care plan. That is 
something that I am told is being worked on. We had some 
significant challenge with long acting injectables, which are 
the drugs that patients who have psychoses need to take because 
they are not good at necessarily taking their oral medications. 
This has been something that we have seen an improvement in 
since go-live.
    Ms. Budzinski. That is great. Would anyone like to add 
anything else? Okay, thank you very much. I yield back, Mr. 
Chairman.
    The Chairman. The gentlewoman yields back. Dr. Murphy, you 
are recognized.
    Mr. Murphy. Thank you, Mr. Chairman, and thank you all for 
coming today. I will try to make these very quick and brief. I 
actually still use a medical record system I have for, I guess, 
20 years now. Yes, I was a dinosaur and used paper system, and 
there were a lot of things that were actually good. Electronic 
medical record system came in, number one for billing. That was 
the primary source. number two was for order entry because they 
thought there were too many errors going on in prescription 
writing, et cetera. Come to find out, yes, errors are still 
occurring at the exact same rate. There are different errors 
when you click the wrong click to get in.
    Also, it was reportability of the electronic medical 
record, and that is an absolute, in my opinion, the best whole 
thing. The fact that I still see VA patients and I can not get 
records from a VA is inexcusable. I am almost ineffable about 
your comment, Mr. Kelter, that it is 30 to 50 clicks to 
complete a task. Thirty to 50 clicks to complete a task that is 
unconscionable. That is unconscionable. Mr. Evans--or, Dr. 
Evans, did you say it might be 10 years until this problem is 
fixed?
    Dr. Evans. No, I did not. That specific question was around 
how long it was going to take us to complete the deployment 
from when this project began 5-1/2 years ago, whether we would 
complete the deployment within the 10-year cycle that was 
originally proposed.
    Mr. Murphy. All right, well, let me ask you this, if you 
will, are you happy with the support that Oracle has provided 
you for Cerner? My understanding, a comment made in another 
committee the other day that Oracle did not think it was a big 
deal. Is that correct or not correct? Are you happy? You say, 
hey, I am having this problem, can you come fix it? Are they 
there that day, the next day? What has been their response 
rate?
    Dr. Evans. Yes. I mean, they are highly responsive and 
motivated to move this forward. You know, I think one of the 
things that we have identified as a critical part of our moving 
forward with the reset is, I mean, Oracle will do what we ask 
them. We need to be able to ask them to do things in a way that 
delivers the kind of experience that is not 30 clicks. Some of 
that requires internal expertise within VA with regard to 
informatics, partnering with their team to deliver a better 
experience.
    Mr. Murphy. All right, so that is where my problem, the key 
error is. They are asking you to create your own medical record 
system with their expertise. Instead of them bringing a product 
to you that you can then conform to the VA. You should be able 
to, within just a few clicks, if somebody shows up at a VA from 
literally across the country, access their medical record, be 
able to read everything that they have done, and move on. You 
should also have a medical record that if somebody goes out 
into the community that they should be able to access.
    I would consider this--I have not been in the military. It 
has just not been my bailiwick. I have been a surgeon for 30-
plus years. I would consider this an absolute failure. If you 
have an error rate that is higher now, an inefficiency rate 
higher now, 5 years, 5 years afterwards, it is an absolute 
failure. If this were out in the private community, that 
company, the cord would have been cut and moved on.
    Cerner now, and I am just going to be very plain with this, 
Cerner is losing market share in large systems. It may be 
gaining some in smaller systems. The last time I checked, the 
VA system is the largest in the country. My recommendation, I 
will be very plain and simple with it, I think Cerner has 
failed you. I think it will continue to fail you. I believe you 
ought to cut the cord and go to another, larger system.
    There are systems. I use a system now that I was not happy 
with at first, but it is seamless, and I can go to another 
institution, boom, I can find their record. I think this is an 
absolute failure. I think it is putting lipstick on a pig and 
pouring millions, if not billions of dollars into a system that 
is not providing the best care for veterans, period. I think 
you can keep working this system and milking it and milking it. 
This is not a good system for the VA Healthcare Center.
    I am incredulous that 5 years out, it seems like there is 
even more problems than there were to begin with. That 5 years 
out, you are still having to bring people and basically rebuild 
a system from the beginning. That is not what the electronic 
medical record is supposed to be.
    Yes, we know there will be inefficiencies compared to being 
able to write something on a piece of paper and send it out. 
That is well documented, and I think it is accepted at this 
point in time. The fact that you can not do that now, 5 years 
out and efficiency is down 40 percent still, is inexcusable, 
absolutely inexcusable. There should be, in my opinion, another 
system. There are other systems out there that are much better, 
in my opinion, that could well translate to the needs of the 
veteran and the VA. With that, Mr. Chairman, I will yield back.
    The Chairman. Thank you. The gentleman yields back. 
Representative Cherfilus-McCormick.
    Ms. Cherfilus-McCormick. Thank you so much, Mr. Chairman, 
for having this hearing, and also, Ranking Member Takano. I 
wanted to go back to the standardization issue, since it seems 
that standardization is intimately tied to the success of the 
EHR. Dr. Evans, in your testimony, you mentioned that one focus 
of the VA's EHR reset is to improve the Federal EHR baseline. 
What progress have you made on the baseline EHR?
    Dr. Evans. Again, this does get to the point of 
standardization. We are currently working through items that 
have been identified by end users at our live sites and making 
those configuration changes. I think what you heard is we are 
trying--not just trying--we are doing that in a way that is 
standardized across the five sites. There are capabilities 
where we may need to revisit some of the original decisions 
around what the baseline of the EHR looks like and possibly 
simplify that in order to move closer to a model approach, a 
recommended ideal approach for the configuration, and that work 
is ongoing in the next several months.
    Ms. Cherfilus-McCormick. Specifically, what I was asking is 
how are you measuring progress and success of the work that you 
have been doing to move toward standardization and also the 
baseline? How are you measuring that? Have you seen any 
improvement with what you have been doing so far?
    Dr. Evans. Yes, I do not know that I have an answer to how 
we are measuring it, other than we are working to compare how 
the VA has configured its record or how this particular record 
is configured with what Oracle recommends as its ideal 
baseline. We are doing that work right now to compare the 
configurations to see whether there are lessons learned where 
we can move toward a more standardized and optimized 
configuration.
    Ms. Cherfilus-McCormick. I am assuming that the Federal 
baseline is different from the VA's baseline. Where are you at 
in the establishment of the VA's enterprise wide EHR workflow 
baseline?
    Dr. Evans. There are a couple things that matter from a 
baseline perspective. There is a baseline around what are the 
interfacing systems that we can support at baseline? When we 
deploy the electronic health record, what Intravenous Line (IV) 
pumps, what bedside monitors can we support, what other 
applications that connect to the EHR are part of the approved 
baseline? We have made considerable progress on essentially 
identifying what is that baseline of connected technologies. 
That will save us money over time by minimizing interface cost 
requirements. We are also working on the baseline of the 
configuration as part of our overall standardization effort as 
was just mentioned.
    Ms. Cherfilus-McCormick. I am very concerned that the VA 
appears to be focusing only on the first five sites, which I 
agree must be fixed, but it is not thinking strategically about 
the rest of the go-lives. I am afraid that we are going to 
continue to have problems in VA and VA does not focus on 
standardization needs in order to roll the system out in future 
sites. What steps are you taking to actually consider not just 
the five that you have rolled out, but the ones that you are 
going to be rolling out in the future?
    Dr. Evans. Sure. In our improvement efforts, we bring 
together not just representatives of the five sites, but the 
clinical councils, as well as the clinical program offices. The 
clinical councils are groups of individuals who understand the 
healthcare delivery in their lane, whatever that might be, 
ambulatory care, virtual care, surgery, who are spending time 
making recommendations and support for how the EHR should be 
configured. The program offices are responsible for the 
national delivery of that type of care. We bring program office 
representation and council representation to these decisions so 
that when we are making a decision about how to configure 
things for one of the five live sites, we are doing so in a way 
that will meet the needs of the entire enterprise.
    Ms. Cherfilus-McCormick. I still have concerns about the 
systems in place to measure success because you can create 
these different practices and plans, but how do we know that it 
is actually going to manifest itself into a successful system? 
Also, looking at feasibility, have you been looking at the 
feasibility of having that standardization in that baseline? Do 
you have these systems in place? I have not really heard of 
systems of measuring success and feasibility.
    Dr. Evans. We do have success criteria for the reset that 
we are developing and already measuring parts of these. I would 
start by saying that at the core, the system has to be rock 
solid from a technical perspective: up, available, with high 
performance for a user. There is nothing more frustrating than 
trying to log into a system and it is not working. It has to 
work from a technical perspective.
    There is the technical metrics. We are looking at user 
satisfaction and user adoption. The Oracle record has tools 
that we do not have available to us in CPRS VistA that can 
allow us to look at individual users' use of the system and 
identify folks who are struggling or places where workflows are 
inefficient. There are others that we are measuring. I know we 
are running out of time. Looking at individual users, 
understanding the technical behavior, looking at productivity, 
as you have heard, looking at revenue collections are areas 
where we are measuring metrics to demonstrate that we are 
improving.
    Ms. Cherfilus-McCormick. Thank you, Mr. Chairman. I yield 
back.
    The Chairman. Thank you. Mrs. Kiggans.
    Ms. Kiggans. Thank you, Mr. Chair. I just wanted to 
piggyback off of Dr. Murphy's comments, and he is no longer 
here. You can be very forthright. Just if you could each go 
down the row and just respond to what he said about, you know, 
is this system failing you and should we be pursuing another 
direction? Just curious.
    Dr. Evans. The one comment I would like to make is that--
and I will answer your question--the Joint Health Information 
Exchange has been one of the successful parts of this project 
that we have delivered. VA and DoD are now exchanging data on 
three health information exchanges. Data is exchanged with more 
than 90 percent of U.S. hospitals. I actually rarely walk to 
the fax machine anymore. I can find the record from community 
providers. I think I just wanted to make that point.
    Second, as I mentioned earlier on, we are committed to 
moving forward. We have invested a significant amount in the 
success of this project. I think we are beginning to see 
improvements as a result of the reset. It is slow and 
incremental, and we expect it, and frankly, it must accelerate. 
I still believe that we should proceed forward.
    Ms. Kiggans. Okay. Thank you.
    Mr. Kelter. The interoperability of healthcare systems 
between our medical center, other VA medical centers, other 
agencies, and private sector is extremely important. As we 
heard the ability to if one of my patients is being seen in 
Spokane and then needs to go to a private hospital in Spokane, 
and then is going to come back to my medical center, I want my 
providers to be able to access all that information 
immediately. That integration is extremely important. I think 
the systems are moving in the direction that that will be 
achieved. We are not there yet, but I think we have the 
capacity within the current system to get there.
    Ms. Kiggans. Good. Thank you.
    Dr. Fischer. Good morning.
    Ms. Kiggans. Good morning.
    Dr. Fischer. I believe the ability to successfully 
implement this record in a level one facility will be very 
informative and telling. I think until we have reached this 
point, we certainly support the Secretary and the 
Undersecretary of Health's vision for a new electronic health 
record.
    Ms. Kiggans. Thank you.
    Ms. Nelson-Brooks. Thank you. The system as it exists now 
is currently not meeting our needs. Having said that, there 
have been marked improvements in specific areas. One area for 
our facility is the ability for our pharmacy technicians to be 
able to refill prescriptions in Medication Manager Retail 
(MMR), which takes some of that responsibility off of our 
pharmacists. In addition to that, in lab, they have been able 
to identify a number of efficiencies as well. Manifests are 
better, as is the chain of custody. The lab add on process is 
much more efficient. It is easier to see who placed a point of 
care test and tests that are sent out are available a lot 
sooner.
    While we are not where we need to be, we believe that, you 
know, VA central office has made the right decision to commit 
to getting this right at the sites where the system currently 
exists.
    Ms. Kiggans. Thank you.
    Dr. Arensman. Thanks for that question. I think, to be fair 
to the majority of my staff, they would say that the current 
system is not yet meeting their needs. They would say there 
needs to be major changes, not just in terms of incremental 
gains, but really human-centered design to make this an 
efficient and usable system for the future of the VA.
    Ms. Kiggans. Do you think that that will be possible with 
this system, that we can get there?
    Dr. Arensman. I hope so. I think we need to see a change in 
the slope of improvements in order to think that that would be 
the case.
    Ms. Kiggans. Thank you very much for your responses. A 
couple of you did talk about compatibility just with outside 
providers. I represent Virginia's second District, so Hampton 
Roads, one of the largest veteran populations and active-duty 
military. I am also a primary care provider, nurse 
practitioner. For me, the frustration with dealing with the VA, 
there was no compatibility. We pretty much wrote you off if you 
were a VA patient and our primary care patient. We relied on 
your word of mouth. Tell us what happened at the VA. What meds 
are you on over there?
    That is wrong. I can only imagine the errors that stemmed 
from those conversations. Also, being a provider who has sat 
through two different electronic charting implementations at 
nursing home facilities, you know, I remember the company 
coming and just sitting with us and really, one on one, you 
know, what is right, what is wrong about this EHR.
    I think, Mr. Kelter, you talked about the process with the 
staff for configuration changes. What does that look like? Does 
Oracle sit with the staff? Is there a form they fill out? Do 
they have written documentation that they write on? What does 
that process look like?
    Mr. Kelter. Sure, both of those happen. We have Cerner 
staff at our medical center on a weekly basis. Our staff do 
have the opportunity to sit elbow to elbow with them and walk 
through some things, explore their understanding of how the 
system works, and could it be done differently. The formal 
request for a change, it is through an electronic ticketing 
system where they can request a configuration change.
    Ms. Kiggans. I have other questions, but I am out of time, 
so I will yield back. Thank you.
    The Chairman. Representative Franklin.
    Mr. Franklin. Thank you, Mr. Chairman, and thank you, 
panel, for being here today. I appreciate your time. This to me 
is the quality of panel and the makeup that we should have had 
yesterday in a similar hearing we had in Military Contruction-
Veterans Affairs (MilCon-VA). Dr. Evans, you were there, but 
the directors were not. I am really glad you all are here today 
to join us.
    Yesterday in that hearing, it was on the same topic, 
electronic health records, we were joined by Mr. Sicilia, who 
is the executive vice president of Oracle and I presume is 
responsible for the rollout of the system here. I want to quote 
a little bit and I want to get into a little bit on training. I 
should apologize up front, I have been bouncing between 
hearings, so if you have shared any of this, I apologize. Would 
love to kind of get it all encapsulated here.
    On the topic of training, he said, I still struggle with 
the idea that we have to put people through extensive classroom 
training to learn to use the system. You do not have to learn 
to use many IT systems these days. It should be fairly 
intuitive to be able to pick up a system and use it. That kind 
of stunned me that he would say that. In the corporate world, I 
rolled out a few IT systems over the years. While nothing on a 
scale of what you all are trying to do and I am not trying to 
underestimate going through it because it is a pretty colossal 
task. I would like to know, and I am curious to know, you know, 
is he out of touch with what you all are experiencing? We do 
know from initial reports of the Mann-Grandstaff rollout that 
the VA acknowledged the Cerner system created unacceptable 
levels of productivity losses, patient safety risks, and staff 
burnout. Some of you had alluded to that earlier. I would love 
to hear from the staff directors your feedback, what you have 
received from your staffs on the ease of the system to use and 
the training they have received in order to complete their 
tasks. We do not have a whole lot of time, but if you would 
kind of be mindful. Yes, Mr. Kelter, if you could start but be 
mindful of your other three cohorts there, I would love to hear 
from them too.
    Mr. Kelter. Thank you. I would agree that a well-designed 
intuitive system should not require a lot of training. This 
system does require quite a bit for the nuances and the 
differences and some of the things that might not be so 
intuitive for staff to learn.
    Mr. Franklin. Well, I guess, so a question, a real quick 
follow up there then. Is it designed properly if we have some 
of these steps? I understand there are going to be some 
specialized things in there, but if some of these steps take as 
many as 30 to 60 clicks to complete, is that properly designed, 
in your opinion? Should anything require that that is supposed 
to be--automation is theoretically supposed to make our lives 
easier and more accurate, but as we are seeing bear out, that 
does not seem to be the case. Is it a design flaw then, or is 
it a training issue?
    Mr. Kelter. I think some of it is design. I think some of 
it is configuration. For example, if we could set up the system 
instead of presenting all of the possible options, some fields 
are more customizable than others. If we could limit the 
options that are immediately presented to the ones most likely 
to be used, that would make it less likely for somebody to make 
an error. Maybe my top five comes up instead of the 2,000 
possible choices.
    Mr. Franklin. Okay. Dr. Fischer.
    Dr. Fischer. Mr. Franklin, as you were mentioning Mr. 
Sicilia, I was thinking to myself, was that an aspirational 
comment about use of the electronic health record? I do not 
believe the Cerner record as it exists today is intuitive. I 
think the training, according to feedback from my staff as 
recently as last week, is that training is generally considered 
to be poor.
    Mr. Franklin. Thank you.
    Ms. Nelson-Brooks. I would agree with Dr. Fischer. Staff do 
not believe that the system is intuitive, nor is it easy to 
use. In addition to that, training was subpar. I think, as Dr. 
Arensman mentioned, it lacks that human-centered design 
component.
    Dr. Arensman. I agree with my VA colleagues. I do not think 
the system in its current state is one that is intuitive. I 
would love to get to a point where it may not be as easy as my 
4-year-old trying to work my iPhone, which she does quite well, 
but to see a system where we can have a trainee, we have a lot 
of medical trainees rotate through VA medical centers, and we 
can not spend a week of their training teaching them how to use 
the electronic medical record. They need to be in the operating 
room. They need to be seeing patients and able to intuitively 
do their work.
    Mr. Franklin. During this reset period, is your feedback 
and input being solicited to help improve the training in the 
rollout? Or is it just being sort of an edict handed down from 
on high?
    Dr. Arensman. Our training--sorry--our input is being 
solicited. I think the reset is really just starting. The 
feedback for the training in particular, I would have to defer 
to Dr. Evans for the plans for that.
    Mr. Franklin. Well, I see my time is up, Mr. Chairman.
    The Chairman. Representative Van Orden.
    Mr. Van Orden. Thank you, Mr. Chairman. I just want to go 
back to something earlier. It was a question that was asked to 
you, Dr. Fischer, by my colleague, Mr. Rosendale. He asked you 
if the VA--or excuse me--that Oracle, and everybody is still 
getting paid even though they are not doing anything. You said, 
I think that is fair.
    I looked up fair, and it says, open to legitimate pursuit, 
attack, or ridicule. That is what is going down now. That is a 
yes or no question, sir. Is Oracle still getting paid? We are 
pushing $49.8 billion over the lifecycle of this. Is Oracle 
getting paid? Yes or no? I do not want any other words. One or 
the other, sir.
    Dr. Fischer. I apologize. It is not a yes or no question, 
in my opinion.
    Mr. Van Orden. Okay, then it is----
    Dr. Fischer. I do not know what----
    Mr. Van Orden. No, we are not doing that.
    Dr. Fischer. Fine.
    Mr. Van Orden. I am not doing that.
    Dr. Fischer. Understood.
    Mr. Van Orden. That is a yes or no question, and you know 
it. This is absurd. I live in a really small town, and we have 
an independent, nonprofit hospital that is doing everything 
that apparently you can not to the tune of $49.8 billion over 
the lifecycle. Unacceptable. Just not.
    I want it to be clear that you are not doing anything new 
or novel. How many hospitals, Dr. Evans, are in the United 
States of America? How about a guess?
    Dr. Evans. I do not know the answer to that.
    Mr. Van Orden. Okay. Yes.
    Dr. Evans. Several thousand.
    Mr. Van Orden. Check me out, the next biggest town up the 
river from me, you can call 911 from a farm in the middle of 
rural Wisconsin, and before you are at the emergency room, they 
have the appropriate bed for you waiting for you in rural 
Wisconsin. I just I am beside myself. Dr. Evans, where do you 
get your healthcare?
    Dr. Evans. That is a good question. My wife reminds me 
regularly that I need to get a primary care provider.
    Mr. Van Orden. Okay, great. Where do you get your 
healthcare, man? This is not a funny ha-ha thing. Where? I 
mean, is it the VA?
    Dr. Evans. I do not get my healthcare at the VA.
    Mr. Van Orden. Mr. Kelter, where do you get your health 
care? Is it the VA?
    Mr. Kelter. It is.
    Mr. Van Orden. Okay. Where?
    Mr. Kelter. Walla Walla, Washington.
    Mr. Van Orden. Okay, right on. How about you, Mr. Fischer?
    DR. Fischer. In the community.
    Mr. Van Orden. Okay. Ms. Nelson.
    Ms. Nelson-Brooks. In the community.
    Mr. Van Orden. Doctor.
    Dr. Arensman. I am not a veteran, so not eligible for VA 
care.
    Mr. Van Orden. Okay, so, we got one person. Where did you 
serve?
    Mr. Kelter. I was active-duty Air Force for 10 years and 
reserve for 20 years.
    Mr. Van Orden. Right on, excellent. Okay. Is your 
healthcare good at the VA?
    Mr. Kelter. It is.
    Mr. Van Orden. Okay. So is mine. I want to make sure you 
understand this across the board. I get all my healthcare at 
the VA, and I am very proud of my staff. I go to Tomah Health 
System, La Crosse, to do that. I have to do some community care 
if it is unavailable. This is not on them. It is on you. Dr.--
Mr. Evans--Dr. Evans, that is Dr., D-R-M-D, correct? Not PhD?
    Dr. Evans. Correct.
    Mr. Van Orden. Okay. You have been onboard for quite a 
while, right?
    Dr. Evans. Six months.
    Mr. Van Orden. That is your bio. Do not tell me 6 months, 
man. In 2018, the VA awarded a sole source contract for this 
stuff. Did you have any participation in those negotiations at 
all?
    Dr. Evans. No.
    Mr. Van Orden. Okay. Then you guys scrubbed the program. 
You picked up the mantle here as interim director in 2019. Then 
in 2023, I think it was March, you guys renegotiate, did your 
reset, right? This is as successful as the Russian reset, by 
the way. This was all thrown out and something else was picked 
up. You were the interim director. Did you have any 
participation in those negotiations when you renegotiated this 
stuff with Oracle? Did you? I will remind you that that man 
swore you in, and you are under the potential threat of--you 
are under the oath, and if this is not accurate, you will be 
held liable for perjury. Did you help negotiate these 
contracts, the new ones?
    Dr. Evans. I need to clarify that question. First of all, 
in 2019, I was the Interim Director of the Federal Electronic 
Health Record Modernization Office.
    Mr. Van Orden. Senior Advisor at the Federal Electronic 
Health Record Modernization Program Office, leading efforts to 
implement single common Federal electronic health record at 
Department of Defense.
    Dr. Evans. Which is a joint office between the VA and the 
DoD.
    Mr. Van Orden. All right, dude. Hey, you know what, 
director is a director. Did you have any participation in the 
renegotiation of these billion-dollar contracts that are 
failing, yes or no?
    Dr. Evans. Are you talking about in May when we negotiated 
with Oracle?
    Mr. Van Orden. You negotiated with Oracle. Have you been--
have you participated between these private for-profit 
entities? Have you participated in negotiating these contracts?
    Dr. Evans. We awarded--so, the contract was awarded in 
2018, as you mentioned.
    Mr. Van Orden. I know.
    Dr. Evans. It was a 5-year contract----
    Mr. Van Orden. Yes.
    Dr. Evans [continuing]. with a 5-year option period.
    Mr. Van Orden. May 16, 2023. Did you participate in these 
negotiations?
    Dr. Evans. I was not actively participating in 
negotiations, but as the senior leader, I was involved with the 
decisions on where that ended.
    Mr. Van Orden. All right. I want to talk to you later.
    Dr. Evans. Okay.
    Mr. Van Orden. I want dates and times because we are 
talking $49.8 billion and it is working worse than before. That 
is unacceptable. I suggest, Mr. Evans--Dr. Evans, you listen to 
your wife, get a primary care physician, see if we can get a 
waiver, so you are seen at the VA. You do not have a dog in 
this fight. That is wrong.
    With that, sir, I am sorry for going over time.
    The Chairman. Representative Mace.
    Ms. Mace. Thank you, Mr. Chairman. I want to thank our 
witnesses for being here with us this afternoon and answering 
our questions. I am going to dive right in. Dr. Evans, I will 
start with you. The VA serves our veterans, veterans who 
understand and have lived their lives within the context of a 
chain of command following orders. Why does the VA not think 
they need to follow suit in terms of implementing a 
standardization?
    The second or upcoming phase of the reset seems to be the 
place where the current live sites will see the most benefit. 
Can you give us an update on the work expected in this next 
phase and how you are working with both site and VISN 
leadership to deliver improvements to the system?
    Dr. Evans. On your first question, I think there is 
recognition within the healthcare system about the importance 
of standardization in order to successfully implement the EHR. 
I think that recognition is at the leadership level. I was 
heartened. I was at a field informatics conference a few months 
ago where the informatics leaders, frankly, from the five 
sites, stood up and talked about how much they understood the 
importance of standardization. I think there is an 
understanding that we need to do that. Doing it is the 
challenge that we are in now.
    Ms. Mace. When will the VA start making standardization 
decisions?
    Dr. Evans. We are currently making those.
    Ms. Mace. Mm-hmm. How is the VA going to shift this culture 
of standardization, you know, across the board? I mean, the DoD 
has done it, but the DoD has a very cohesive there is a chain 
of command. You know, it is unilateral across the board. The VA 
seems to, you know, there is a lot of it seems like infighting 
or people that want to do their own thing and not go along with 
a national standard. How long do you think will take the VA to 
accept this shift and a change in the way you look at it?
    Dr. Evans. Yes, you know, I bring it up a notch. I think 
what people want is the electronic health record to work for 
them. People do not resist standardization, if the way we are 
standardizing makes sense, is intuitive, and works as part of 
clinical care delivery. And so, in part, we----
    Ms. Mace. Does the VA, I mean, have culpability I mean, is 
the VA responsible for where we are today, yes, or no?
    Dr. Evans. I mean, I think, look, we have----
    Ms. Mace. Does the VA accept any responsibility with where 
we are today with the implementation of this?
    Dr. Evans. Of course we are a part of this, right? We are 
implementing the record. The decisions that we have made to 
date are done as part of a partnership in moving forward, 
right? This is where I mentioned earlier, one of the things 
that we need to do and we know we need to do, is build the 
expertise of the VA workforce. Change does not happen to an 
organization, an organization leads through change.
    Ms. Mace. In moving from 130 systems and processes to one, 
governance will play a central part, and that is not an easy 
feat. The VA must take a more aggressive role in change 
management for the good of the 171 Veterans Administration 
Medical Centers (VAMCs) within it and the 9 million veterans 
enrolled in the system. What kind of governance mechanisms will 
you rely on to get to a standard product and processes and then 
be able to maintain it?
    Dr. Evans. Yes. In part and related to your earlier 
question about what are we doing at this phase of the reset, 
this is actually part of the work that we are doing. We have 
identified an initial set of items that we need to fix, and we 
are working through that list. In part, that is not just about 
fixing the items, but it is about solidifying the governance 
structure, about how we will efficiently make those decisions 
about the changes we need to make and the standardization. We 
call it the rapid EHRM baseline improvement. We use that word 
rapid because we are looking to not just establish strong 
governance around decision-making, but also efficient 
governance.
    Ms. Mace. I would love to see efficiency at the VA. I hope 
you make good on that promise. Understanding within the 
enterprise system, all of that, and the challenges ahead in 
terms of a national standard and adhering to a standard for the 
betterment of the VA, will each of you commit to a national 
standard so we can move this thing forward and get it done 
with? Yes or no? Dr. Evans?
    Dr. Evans. Yes.
    Ms. Mace. Mr. Kelter.
    Mr. Kelter. Yes.
    Ms. Mace. Dr. Fischer.
    Dr. Fischer. Yes.
    Ms. Mace. Ms. Nelson-Brooks.
    Ms. Nelson-Brooks. Yes.
    Dr. Arensman. I would like to qualify that it needs to be a 
standard we can validate that we can meet the needs of our 
veterans.
    Ms. Mace. It is yes or no question. This is not an 
argument.
    Dr. Arensman. Well----
    Ms. Mace. We have 9 million veterans enrolled in this 
system, and I am trying to have a constructive conversation 
about how we move forward and not be an asshole when I am in 
this room, because it is just too important to members of my 
family and to millions of vets across the country who are 
enrolled. Either you can be a team player or not. If you are 
not going to be, I would find a new job. Thank you, Mr. 
Chairman, and I yield back.
    The Chairman. Mr. Luttrell.
    Mr. Luttrell. Dr. Evans, in the past 5 years, what is the 
roundabout dollar amount that we have spent on this program to 
date?
    Dr. Evans. At this point, we spend money in support of----
    Mr. Luttrell. Just give me a good round number. I do not 
have that much time.
    Dr. Evans. A good round number would be on the EHR itself 
we have expended $3.5 billion, on infrastructure, $2.1 billion.
    Mr. Luttrell. Okay. Roughly around $5 billion for five 
hospitals. Do the five hospitals communicate well, or are they 
siloed?
    Dr. Arensman. We are able to see the record for the entire 
five hospitals that are live.
    Mr. Luttrell. If you needed to talk to Ms. Nelson, you 
could do that----
    Dr. Arensman. I could.
    Mr. Luttrell [continuing]. effectively.
    Dr. Arensman. I could.
    Mr. Luttrell. There are 171 hospitals across the 
Continental United States, and so far, it has cost us $5 
billion for four hospitals, five of which the one in Chicago, 
that is not stood up yet. Is that correct?
    Dr. Evans. That is correct, North Chicago.
    Mr. Luttrell. $5 billion, and we have got another 166 to 
go. Give me a good round number on how much that is going to 
cost us.
    Dr. Evans. I do not have the----
    Mr. Luttrell. Remember, I have to answer to my----
    Dr. Evans. I understand.
    Mr. Luttrell [continuing]. my base back home. If I am going 
to tell them I have to spend a billion dollars on every single 
hospital.
    Dr. Evans. Yes. I think the first thing is to understand 
that of that $5 billion, much of--a good portion of that 
investment has also been made in the infrastructure 
improvements in many sites that we are preparing to go live, 
and we will not lose that investment.
    Mr. Luttrell. Which we have absolutely failed on if we are 
in a hard reset. The young ladies at the end of the table just 
said that it is not working well enough for their employees to 
maneuver through it.
    Dr. Evans. Right, but these are infrastructure----
    Mr. Luttrell. If we are in a hard reset, which in your 
statement, you said, we do not have a firm timeline for 
completion of this project. As a military man myself, I do 
appreciate if we are going to run an operation, the one thing 
that we do know is when it is going to happen. I find it 
challenging to understand how you are going to complete this 
journey that you are on without any given timeframe whatsoever, 
because next time you sit in front of us and ask for a couple 
of billion dollars, we are more apt to say no.
    Dr. Evans. Yes, so I think two things. We are making an 
investment. It is the investment in infrastructure is providing 
value now. That is improved Wi-Fi networks. The network 
upgrades that were necessary to support the system benefit the 
delivery of care with the current record, telehealth care, 
telehealth delivery at those sites.
    One of the things we have promised is that as we come out 
of reset, we will do two things. We will publish a schedule and 
a lifecycle cost estimate. That is part of the analysis we are 
doing right now. We feel an urgency to get restarted. We do 
feel an urgency to get restarted. We can not restart until we 
see sufficient improvement at the live sites, until we have 
learned from----
    Mr. Luttrell. Is it too deep of a hole for me to ask what 
that looks like to you?
    Dr. Evans. What improvement looks like?
    Mr. Luttrell. Yes.
    Dr. Evans. Rock solid technical performance of the system. 
Improved user satisfaction as measured by the voices of our 
clinicians.
    Mr. Luttrell. What does that number look like, Ms. Nelson? 
Is that a 95 percent? Is that 100 percent? I am curious how he 
is going to know how to activate, what number is going to come 
from the hospitals that you operate, any one of you, in order 
for our leadership to move forward.
    Ms. Nelson-Brooks. Specifically looking at user 
satisfaction?
    Mr. Luttrell. Yes, ma'am, we can start with that.
    Ms. Nelson-Brooks. I would say that, you know, if we take 
into account the survey that we did in April, where 86 percent 
of our staff did not agree with deployment in----
    Mr. Luttrell. Eighty-six percent did not?
    Ms. Nelson-Brooks. Eighty-six percent of staff did not 
agree with future deployment of the record in its current 
state. I would say that at a minimum, we would have to get to 
more than 50 percent of our staff would recommend use of the 
system.
    Mr. Luttrell. Seems like a pretty deep hole, Mr. Evans.
    Dr. Evans. That is why we are in a reset.
    Mr. Luttrell. With no timeline.
    Dr. Evans. I would not say that we have no timeline. I 
think we have had, you know, in this program, and again, I am 
not----
    Mr. Luttrell. I understand this is probably frustrating to 
you, but you got positioned----
    Mr. Evans. I----
    Mr. Luttrell [continuing]. in this little spot, so I am 
going to have to hold you accountable because you are the boss.
    Dr. Evans. I understand. You know, it--when I transitioned 
to this program 6 months ago, it was very--as the leader, it 
was very clear to me that we had to take the time to get things 
right. It has been mentioned, you know, we took earlier in the 
program a strategic pause, and we spent a lot of time thinking 
about the strategy. One of the challenges there was we had--we 
put a hard stop on that. We said we are going to start 
deployment activity again, right, and so, we did not take the 
time that we needed to get it right.
    Frankly, what I have heard from this committee and the 
Technology Modernization Subcommittee very consistently has 
been VA, take the time to get this right. Not VA, take the time 
to get this right and take your time. No. Feel an urgency to 
get it right. I feel an urgency because of the folks to my left 
and the frontline providers that they represent and the 
veterans that they serve. We feel that urgency, but we are 
taking the time.
    We are very specifically saying there is not a hard end 
date to the reset because we need to get this right. I think we 
can not be in reset forever, right? This is an investment we 
are making. We are again measuring our improvement. We are 
going to be looking at how things are improving over the coming 
months. We are going to learn from a go-live at the North 
Chicago facility at the Lovell Federal Health Care Center in 
the spring of 2024. That will be the first level-one facility 
where we go live. We will benefit from partnership from the DoD 
in that.
    Then as we move toward the, you know, early summer next 
year, I think we should be having some very significant 
discussions about restart. Now, restart does not mean a go-live 
right away. It means that we are starting to do the deployment 
preparations for other sites while continuing to improve. We 
are on a journey where we will need to be continuing to improve 
this record in perpetuity. No record is static.
    Mr. Luttrell. Thank you.
    Dr. Evans. Thank you.
    Mr. Luttrell. I yield back, sir.
    The Chairman. Mr. Ciscomani, you are recognized.
    Mr. Ciscomani. Thank you, Mr. Chair. I would like to allow 
my colleague, Ms. McMorris-Rodgers, to go before me, sir, if 
that is okay?
    The Chairman. That is perfect because she is the one that 
probably has been affected the most by this.
    Mr. Ciscomani. Absolutely, please.
    The Chairman. Ms. McMorris-Rodgers, you are recognized.
    Ms. McMorris-Rodgers. Thank you. I thank the gentleman for 
yielding. Thank you, Mr. Chairman and ranking member, for 
bringing us all together here today, holding this hearing, and 
giving me an opportunity to address the committee.
    The Oracle Cerner electronic health record system has been 
a complete failure. It has created more problems than it has 
solved. From the beginning, veterans in Eastern Washington have 
been sounding the alarm about the issues with the EHR. We have 
had prescription errors, dropped appointments, lost referrals, 
costly mistakes that have directly harmed nearly 150 veterans, 
150 men and women who risked their lives for our country, 
harmed by the very agency who promised to care for them upon 
their return.
    Irresponsible does not even begin to describe it. To make 
matters worse, this broken system has completely demoralized 
employees who were not adequately trained on the new system. 
Providers and support staff have struggled to overcome the 
software glitches and the constant outages.
    They have been hung out to dry trying to help frustrated 
veterans navigate a system that they themselves are burdened 
by. For too many, it has become too much. The devastating 
amount of employees that are quitting because they are 
exhausted and just can not take it anymore. This is making bad 
staff shortages worse, creating longer wait times, and making 
it even more difficult for veterans to get the care that they 
need. This system has become such a problem that it is 
consuming the budgets of our local VA facilities, causing them 
to operate at a loss.
    For months, we have heard rumors of reducing staff and 
services to make the numbers work, which is not the solution 
that should even be on the table. While Secretary McDonough 
committed to me that this will not happen, I need to reiterate 
that any cuts would be unacceptable. We have already invested 
billions of dollars into what was once a great idea that has 
unfortunately failed to achieve its sole purpose to improve 
healthcare for veterans in the United States.
    We have given the VA and the Oracle Cerner every possible 
opportunity for improvement, but the problems with the system 
are endless. Veterans in Eastern Washington have had enough, 
and they are tired of being the guinea pigs in this failed 
experiment. They have pleaded for it to stop, but their 
concerns and mine have been dismissed at every turn. The VA's 
lack of transparency has led to a devastating breakdown in 
trust among veterans, and it must change.
    We all agree that we have to get this right for our 
Nation's heroes. I believe it is time to pull the plug on this 
deeply broken system and let us go back to one that is going to 
work. Until then, I am committed to helping get this working as 
much as we can for our veterans who have no other choice. I 
wanted to ask just a couple of questions. Dr. Fischer and Dr. 
Arensman, I understand Mann-Grandstaff in Columbus are the only 
VA medical centers using the Oracle Cerner's oncology modular 
right now, and it has created serious problems. Can you explain 
some of the multi drug chemotherapy orders work and where the 
problem is, starting with you, Dr. Fischer?
    Dr. Fischer. Well, we have a very experienced medical 
oncologist in Spokane, and he is very reluctant to utilize 
multi-agent chemotherapy currently. He would like to test those 
power plans in production to make absolutely sure that there 
are no medication errors because they can be lethal with the 
use of these very, very significant medications.
    Ms. McMorris-Rodgers. Thank you.
    Dr. Fischer. Sure.
    Dr. Arensman. Thank you for that question. The power plans 
have been a significant challenge in Columbus as well. We have 
actually dedicated a half-time oncologist and a half-time 
pharmacist. They are full-time employees, but half of their 
time is spent essentially editing, correcting, and validating 
power plans.
    The caveat that I mentioned with Ms. Mace's question 
earlier was actually standardization is wonderful and it is 
important, and I fully believe in it, but we do not want to 
standardize to the point where the only anti-nausea med on a 
power plan is one you do not have in stock in your city. We do 
not want to standardize to the point when there is supply chain 
shortages, we can not meet the care of the veteran because we 
do not have that particular bag of saline or the diluent that 
is necessary. That is why it takes a long time to try to get 
this right, and we want to make sure----
    Ms. McMorris-Rodgers. Thank you.
    Dr. Arensman [continuing]. we are doing that.
    Ms. McMorris-Rodgers. Thank you. Dr. Evans, I would like to 
ask how long you have known about the oncology prescription 
problem with the Cerner software and what you are doing about 
it.
    Dr. Evans. I visited the Columbus facility probably within 
2 weeks of my starting in this position approximately 6 months 
ago, and this was a point of significance--We spent an entire 
hour on the oncology discussion.
    We are spending a lot of time working on the Power Plans as 
has been mentioned and also essentially empowering us as an 
organization to edit our Power Plans and determine what those 
look like. That is part of this workforce development I was 
talking about earlier about bringing the expertise into VA so 
that we can configure the ordering and make sure we deliver 
that to Oracle to put into the system in a way that best meets 
the needs of veterans.
    Ms. McMorris-Rodgers. Thank you. This is just one example, 
but it underscores how grave the situation is. To all who work 
at the VA at the medical centers I represent in Spokane and 
Walla Walla, I just want to say thank you for trying to make 
the best of what has been an extremely difficult situation for 
our veterans. I yield back.
    The Chairman. Mr. Ciscomani.
    Mr. Ciscomani. Thank you, Chairman Bost. Thank you to the 
witnesses for being here today for providing your testimonies 
as we conduct oversight over the effort to replace the VA's 
electronic health record.
    Now, for years, Cerner has been working to develop this 
software for our veterans and the VA facilities, but this 
system has been plagued with issues. I think we have been 
discussing a lot of them here today. Issues with the electronic 
health record crashing and freezing and requiring excessive 
steps to complete routine functions resulting in software not 
being user friendly, difficulty in veterans ordering 
prescription refills, and other problems that five VA medical 
facilities with the system are now facing.
    Now, I represent Arizona's 6th congressional District, and 
veterans in my district go to the Tucson VA Medical Center, 
which luckily is not one of these five facilities mentioned. 
Mr. Evans, Dr. Evans, the VA gave the committee a timeline 
showing what steps you intend to take during the reset period 
that you have talked about to improve the Oracle Cerner 
electronic health record system. One of the steps is to, and I 
quote, ``initiate team efforts at one of the five live sites to 
address and identify issues.'' In other words, put boots on the 
ground at one of the medical centers to figure out what they 
really need. Which facility has been picked for that and why? 
How is it going to represent the other four facilities?
    Dr. Evans. We hosted several weeks ago, a planning event in 
Kansas City to plan the work. The specifics on that is some of 
the configuration changes that we need to make do not require 
us to be onsite and sort of in the operations. We do not want 
to interfere with the delivery of patient care in fixing the 
EHR, but there are times where being onsite, observing exactly 
how the system is working is going to help us make the right 
decisions.
    All five sites are involved with all of the discussion, and 
as I mentioned before, the national programs, since we need to 
not just configure the record for the benefit of----
    Mr. Ciscomani. I am sorry, I have limited time here. What 
you are saying is you have not picked one yet.
    Dr. Evans. We are going to work with all five sites.
    Mr. Ciscomani. You changed course?
    Dr. Evans. It is not just one.
    Mr. Ciscomani. The plan to pick one and tackle that, you 
know, after what you just mentioned, you decided to go after 
all five at the same time?
    Dr. Evans. We are going to go to where we need to go in 
order to fix the problem, yes.
    Mr. Ciscomani. Okay, so you changed plans and so you are 
not choosing one anymore on that. Then the question for, I 
guess, the center leaders here, you know, now that your 
facility is not going to be chosen individually, because that 
was going to be one of my questions, once that facility is 
chosen, what happens there? Since now the plan changed, 
apparently, and you are tackling where it needs it and quite 
frankly seems to be that all five it, the question is for all 
of you, when your facility is chosen, which has been declared 
now that everyone is chosen, how are you going to make sure 
that these needs are addressed? How do you go into there and 
actually look at the needs and then make sure that they are 
addressed? I do not have a lot of time, so I would appreciate a 
direct concise answer.
    Mr. Kelter. I think there would be different capabilities 
that would be appropriate to test at each facility. Certain 
capabilities exist at different facilities that do not exist at 
all of them. That approach makes sense from that perspective.
    Then how do we make sure they work? What can be tested 
without actually making the configuration changes may be 
limited. I am not sure what can be done in a test environment 
versus in the production environment at this point.
    Mr. Ciscomani. Dr. Fischer.
    Dr. Fischer. Ask the end user. I have 1,400 experts that 
function every day to deliver healthcare or support healthcare. 
We will know we are making traction by simply asking the end 
user, is the product better? Do you like it? Is it helpful? 
These are simple assessments and we will need to do those type 
of surveys repeatedly.
    Mr. Ciscomani. Is that being done now?
    Dr. Fischer. It is, but it is----
    Mr. Ciscomani. Are you seeing results now?
    Dr. Fischer. Not yet. These type of surveys----
    Mr. Ciscomani. Something is not working here. We are 
missing something here. It is just, you know, that sounds to 
me, Dr. Evans, like a meeting to plan for the meeting that we 
are going to plan to do something. I am not understanding maybe 
this correctly. It just seems that we are not addressing the 
issue. You are not addressing the issue directly here. You have 
a plan that seemed like a plan that might work of choosing a 
facility, digging deep into that. Now you are going across all 
five. As we are going across here, whatever plans that are 
being shared with us here, they sound good, but they may not or 
may be working. We do not know that. The timeline here is what 
worries me. You are way behind.
    Dr. Evans. Yes, if I may. The timeline that we shared with 
the committee, we initially thought we would have our initial 
kick off meeting at one of the sites. We chose to have that in 
Kansas City so we did not disrupt operations. Then we have 
identified where do we need to go. You heard that two of our 
facilities have oncology services, two do not. Where we need to 
go to make changes if we need boots on the ground, will be 
determined on the impact on that site, whether they can host us 
and what services are delivered there. We are all in this 
together. We are building a single and we are improving a 
single electronic health record.
    Mr. Ciscomani. I have got more to say, but I am out of 
time. Thank you. I yield back.
    The Chairman. Mr. Crane, you are recognized.
    Mr. Crane. Thank you, Mr. Chairman. Thank you all for 
coming today. I understand centralization and standardization 
of a system this large nationwide is a monumental task. I also 
understand the benefit this effort could create for staff and 
patients alike. However, it obviously sounds as if right now it 
has been an absolute failure.
    I want to start with you, Doc, on the end. Knowing that you 
and the rest of Americans continue to pay for this debacle, 
Doc, what level of confidence do you have in partnerships, the 
current partnerships, and leadership engaged in this effort? I 
am really asking clearly about your level of confidence moving 
forward.
    Dr. Arensman. Thanks for the question. Obviously, it is a 
hugely challenging process and a daunting task. I think I have 
been very pleased to see Dr. Evans' leadership and 
understanding of the issues and commitment to stop and take the 
time we need to get this right and not push forward when things 
are not safe or when things could be improved.
    Mr. Crane. What is your level of confidence? That was a 
question I asked you.
    Dr. Arensman. In what? In an individual, in a process?
    Mr. Crane. Yes. In the partnerships that we have, the 
company that you are, the corporation company that you are 
working with, and in the leadership that you have.
    Dr. Arensman. I think I have a moderate level of 
confidence.
    Mr. Crane. Okay, moderate. Ms. Nelson-Brooks, what about 
you, ma'am?
    Ms. Nelson-Brooks. In terms of my level of confidence in or 
leadership's ability or their commitment to getting this right, 
I would say I have a high level of confidence. I believe that 
Dr. Evans, Dr. Elnahal, Secretary McDonough are committed to 
fixing the system as it exists currently. In terms of Cerner's 
ability to meet our needs, I would say my level of confidence 
is a lot lower. On a scale of one to 10, I would give it a 
five.
    Mr. Crane. Ms. Nelson-Brooks, do you think that we should 
scrap what we are doing and go back to the old system, based on 
what you are observing and the percentage of your staff that 
seems to be very disappointed with where things are?
    Ms. Nelson-Brooks. I agree that our staff are very 
disappointed with the way things have gone. I do not believe 
that we are at the point currently where we need to pull the 
plug entirely.
    Mr. Crane. What is the biggest effect that you have seen on 
patients with the rollout of this new system?
    Ms. Nelson-Brooks. The biggest effect for our facility has 
been our increase in wait times. Pre-Cerner, we were able to 
see new patients in for primary care appointments in less than 
30 days. Currently, our new patient wait times in Eugene, one 
of our largest facilities, is approaching 80 days. For 
Roseburg, our other location, it is over 80 days. It is closer 
to 85 days for in person care. The caveat that I will mention 
there, however, is that if patients are willing and able to be 
seen by telehealth, we do have the ability to get them in 
within seven days.
    Mr. Crane. Doc Fischer, what is your level of confidence?
    Dr. Fischer. I would agree with Dr. Arensman. I would say 
it is moderate.
    Mr. Crane. Moderate. What would you like to see going 
forward, Doc?
    Dr. Fischer. Improvements in the functionality of the 
system, less degradations, more user satisfaction, things you 
would anticipate you would see with a successful electronic 
health record.
    Mr. Crane. Are you saying that most of your disappointment 
is in the partner that we have chosen here?
    Dr. Fischer. Hard for me to say, sir. I am not an expert in 
IT. All I know is that our employees are fatigued, tired, 
stressed. They feel like they are the individuals that stand 
between the health record and making our patients safe. They 
have been largely successful, but at a cost.
    Mr. Crane. Mr. Kelter, same question for you.
    Mr. Kelter. I would say between the commitment of our 
leadership from the Secretary on down to the recently 
renegotiated contract and the fact that we have a 1-year 
contract options instead of a 5-year contract option, and the 
current reset period, I think our chances are better now than 
they have been in the past.
    Mr. Crane. Doc Evans, did I hear you say you have been 
doing this role now for 6 months?
    Dr. Evans. That is correct.
    Mr. Crane. Are you ahead or behind of where you thought you 
would be coming into this at the 6-month mark?
    Dr. Evans. I would like to have been further. I do not 
think we are--you know, I think the changes have been slow and 
incremental. They need to accelerate. Anytime you are starting 
the reset and sort of retooling for moving forward, it is going 
to take a little time to get the engine running and to build 
the momentum that we need to build.
    Am I proud of the organization for listening to this 
committee, for making the right decision on behalf of veterans 
and the staff that you know or you have heard are represented 
by the folks to my left? Absolutely. We made the right choice 
to reset. We still have a lot of work to do, and we are 
committed to doing it.
    Mr. Crane. Thank you, Mr. Chairman. I yield back my time.
    The Chairman. Thank you. At this time, I would like to 
recognize Mrs. Cherfilus-McCormick for the closing remarks of 
the ranking member.
    Ms. Cherfilus-McCormick. Thank you, Mr. Chairman. I thought 
we had a productive discussion today. Dr. Evans and his team 
have their work cut out for them. I look forward to working 
with you all to make sure that veterans and VA staff get the 
technology they need to support the world class care our 
veterans deserve. I would like to thank the chairman again for 
his and his staff's collaboration and effort on the House's 
version of the EHR reset.
    It is even more evident to me now how necessary this 
legislation is. We need to put the VA on a course where they 
can be successful. Veterans and staff have endured enough. 
Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you. I want to thank everybody for 
being here today. I want to thank the witnesses for joining us, 
especially the medical center directors who traveled here.
    The VA EHR is a bipartisan mess, and it calls for 
bipartisan solutions. We can not stand by anymore and hope VA 
and Oracle-Cerner figure it out. That approach already produced 
two pauses and failed to solve the problem. We have to insist 
on results and accountability. I appreciate the Ranking Member 
Takano and Chairman Rosendale, and Ranking Member Cherfilus-
McCormick for standing shoulder to shoulder with me to do that.
    Now, I ask unanimous consent that all members shall have 5 
legislative days in which to revise and extend their remarks 
and include any extraneous material. Hearing no objection, so 
ordered. This hearing is now adjourned.
    [Whereupon, at 12:49 p.m., the committee was adjourned.]
    
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                         A  P  P  E  N  D  I  X

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                     Prepared Statement of Witness

                              ----------                              


                    Prepared Statement of Neil Evans

    Good morning, Chairman Bost, Ranking Member Takano and 
distinguished Members of the Committee. Thank you for the opportunity 
to testify today about VA's initiative to modernize its electronic 
health record (EHR) system. I am accompanied by Mr. Scott Kelter, 
Director, Jonathan M. Wainwright (Walla Walla, Washington) VA Medical 
Center, Robert Fischer, M.D. Director, Mann-Grandstaff (Spokane, 
Washington) VA Medical Center, Thandiwe Nelson-Brooks, Associate 
Director, Roseburg, Oregon VA Medical Center and Allison Arensman, M.D. 
Chief of Staff, Chalmers P. Wylie (Columbus, Ohio) VA Medical Center.
    I want to begin by thanking Congress and this Committee for your 
continued support and your shared commitment to Veterans, and more 
specifically, for your support of VA's electronic health record 
modernization efforts. For VA, successful deployment of the Federal EHR 
system will facilitate seamless health care transitions for Service 
members and Veterans among Federal care settings. The Federal EHR will 
provide an accurate, lifetime health record for Veterans among partners 
using the Federal EHR. For the newest members of the military, this EHR 
will serve them from the day they begin their military service through 
the rest of their lives.
    The suite of technologies that make up a modern EHR are part of a 
larger ecosystem of orchestrated technologies needed by VA to enhance 
the quality and safety of health care delivery; empower clinical teams 
with effective decision support; and advance Veteran engagement. In 
furtherance of these goals, the new Federal EHR system integrates with 
other health information technologies and will ultimately simplify the 
experience for Veterans and for VA staff; enhance standardization 
across the VA enterprise; and improve VA and Department of Defense's 
(DoD) interoperability with the rest of the U.S. health care system.
    Moreover, the adoption of a product used by both VA and DoD will 
help to simplify health care delivery by providers in both Departments, 
benefiting patients who receive care in both systems or who are 
transitioning from DoD to VA for care. One of the program's other goals 
are to deliver and optimize unified, seamless, trusted information flow 
between VA, DoD, the U.S. Coast Guard (USCG) and community providers.
    DoD has completed its deployment of the Federal EHR, which in DoD 
is known as Military Health System (MHS) GENESIS, at all its clinical 
sites in the continental United States, with the exception of the 
Captain James A. Lovell Federal Health Care Center (Lovell FHCC) in 
North Chicago, Illinois, a joint VA/DoD facility. DoD will complete its 
deployments outside of the continental United States this fall, and the 
final implementation at Lovell FHCC in Spring 2024. In addition to VA 
and DoD, the USCG and National Oceanic and Atmospheric Administration 
have also adopted the Federal EHR. Their deployments, while smaller 
than VA's and DoD's, are both complete.
    In VA, the Federal EHR is currently in use at five VA medical 
centers (VAMC), 22 community-based outpatient clinics and 52 remote 
sites (such as VA call centers, consolidated patient accounting 
centers, clinical resource hubs and the like, which support the 
aforementioned medical centers and clinics). The five VAMCs where the 
Federal EHR is currently in use are the Mann-Grandstaff VAMC in 
Spokane, Washington; the Jonathan M. Wainwright Memorial VAMC in Walla 
Walla, Washington; the Roseburg VA Health Care System in Roseburg, 
Oregon; the VA Southern Oregon Healthcare System in White City, Oregon; 
and the VA Central Ohio Health Care System in Columbus, Ohio.
    Since the initial go-live dates of the Federal EHR in VA, we have 
been listening to Veterans and clinicians, and it's clear that the 
system is not yet fully meeting their expectations. As part of an 
Electronic Health Record Modernization (EHRM) Program Reset (Reset) 
announced in April 2023, VA halted work on future deployments of the 
Federal EHR, with the exception of our planned deployment at Lovell 
FHCC, while the Department prioritizes improvements at the five sites 
that currently use the Federal EHR. The purpose of the Reset is to 
optimize the current state of the Federal EHR; closely examine and 
address the issues that clinicians and other end users are 
experiencing; and position VA for future deployment success.
    During this Reset, VA is fixing issues with the Federal EHR, 
redirecting resources from deployment activities to work on optimizing 
the Federal EHR at the sites where it is currently in use. Staff 
productivity levels, revenue cycle management, technical systems 
performance and other areas require dedicated attention and resolution 
before deployments resume at full pace.
    VA has an obligation to Veterans and taxpayers to get this right. 
We understand the concerns of this Committee regarding the Federal EHR 
system and its impact on Veterans and VA staff who rely on it. 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 effort, and related health information 
technology modernization efforts, are successful.

Program Reset

    To successfully support the deployed sites and continue to position 
the new system to meet the pace and rigor of future deployments, VA has 
three primary goals for the Reset: address the concerns of the live 
sites and ensure the new system is working as promised; invest in the 
necessary enterprise work to ensure we are positioned for success when 
deployments resume; and prepare for the Lovell FHCC deployment in March 
2024. During its first three-month increment of effort, which began 
June 1, 2023, VA is managing the Reset work through six workstreams. 
All six workstreams are focused on continuous value delivery; many of 
these workstream efforts will continue into the second increment of 
work, which begins this month. Several additional focus areas will 
likely also be added.
    The current Reset focus areas/workstreams include the following: 
(a) an effort to more rapidly improve the Federal EHR baseline through 
configuration changes and optimization of the change process and user 
adoption support; (b) workforce development to increase VA's ability to 
independently manage the Federal EHR, initially focused on informatics 
staff both at the enterprise and field levels; (c) work to improve end 
user support with a focus on Help Desk functions and incident 
management; (d) a technical ``Get Well'' plan to improve system 
reliability and performance; (e) work to enhance transparent 
communications for all stakeholders in the project; and (f) preparation 
for the Lovell FHCC deployment. As mentioned, VA is prioritizing the 
work that can be achieved using its current resources; VA will likely 
be adding further workstreams in the second increment of effort 
beginning in September 2023. Examples include: (a) standardizing key 
clinical workflows; and (b) evaluating VA's deployment methodology and 
initiating planning for a deployment schedule for the remainder of the 
project.
    As part of regular and ongoing operations, VA is implementing a 
range of enhancements and improvements to the Federal EHR system and 
associated processes in the areas of system stability and reliability, 
usability, training, change management and end-user engagement. 
Further, VA is continuing to refine functional and technical standards, 
defining success metrics regarding access to care, clinical operational 
efficiency, financial performance and more.

Readiness to Resume Deployments and Lovell FHCC

    VA has decided that the Federal EHR will not go live at any new 
site until that site and the system are ready. We also remain firm in 
our resolve to continue deployments of a modern Federal EHR. We do not 
have a firm timeline for completion of this project. Rather, we are 
committed to getting this right for Veterans and VA clinicians alike 
and to taking the time necessary. VA will not schedule additional 
deployments of the Federal EHR until we are confident that it is highly 
functioning at current sites and is ready to deliver for Veterans and 
VA clinicians at future sites. That assessment will be based on 
measurable improvements in the clinician and Veteran experience; 
sustained high performance and high reliability of the system; improved 
productivity at the sites where the Federal EHR is in use; and more. 
When our goals have been met, and the Reset concludes, VA will release 
a new deployment schedule and resume deployment activities with greater 
confidence in the readiness of both the Federal EHR system and the VA 
health care system to successfully navigate the change.
    The only exception regarding future deployment activities is the 
planned deployment at the Lovell FHCC in March 2024. Lovell FHCC is the 
only fully integrated, jointly run VA and DoD health care system and 
will be the final deployment of the Federal EHR at a DoD-affiliated 
site, thus ensuring that the Lovell FHCC is using the same EHR as all 
other continental United States DoD sites. The joint VA/DoD deployment 
will go ahead as planned to ensure that all patients who visit this 
facility are covered by one EHR system. Given the unique mission at 
Lovell FHCC and singular focus on this joint medical center, this 
deployment will benefit from the added support VA will be able to 
provide during this Reset period and will also help inform decisions 
about restarting deployments at other VA facilities. Support efforts 
include resources across VA, DoD, the Federal Electronic Health Record 
Modernization (FEHRM) office, the Leidos Partnership for Defense Health 
and Cerner Government Services, Inc.

Contract Update

    Since the announcement of the Reset, VA negotiated a new option 
period structure for its current EHR contract with Cerner, modifying 
from a single 5-year option period award to five 1-year option periods. 
This will allow regular re-evaluation of the program and contract 
performance each year, with the potential to re-open contract 
negotiations, if needed. New accountability metrics around system 
performance and user support were also added to the contract. In 
addition, after the first 1-year option period was exercised and in 
place, VA reviewed active contract actions and issued stop work orders 
to Cerner with respect to activities that were not slated to continue 
during the Reset period. These stop-work orders allow for a more 
coordinated focus on improving the Federal EHR system. Deployment 
efforts can be reinitiated when needed.

System Stability, Reliability and Usability

    VA is working to resolve issues with the Federal EHR system's 
performance and usability. VA has significantly reduced unplanned 
outages through corrective actions taken within the Cerner data base 
configuration. Until an unplanned outage on April 17, 2023, it had been 
nearly nine months since the last complete outage. Performance 
degradations of the system have also decreased. Improving system 
reliability and availability remains a critical focus. Cerner is 
contractually obligated to meet 99.95 percent uptime commitment per 
measurement period (i.e., monthly) for the Federal EHR system, meaning 
that the system is functional and available for use. For the last seven 
months ending July 31, 2023, Cerner met that requirement for six 
months. Beginning September 1, 2023, Cerner will also be contractually 
obligated to achieve at least 95 percent system incident-free time, 
which is defined as the percentage of time the hosted environment was 
free of unplanned events impacting user functionality and/or system 
performance. Incident free time is trending upward since April 2023. 
Although not yet contractually obligated, Cerner exceeded incident-free 
time requirements in May, June and July 2023. Because issues with other 
systems that connect to the Federal EHR can impact the system, VA 
continues to work with its partners at DoD and the FEHRM to reduce 
downtime within the Federal EHR enclave and the systems connected to 
it.
    VA has also completed several tasks to address usability issues 
identified by its health care providers who are currently using the 
system and continues to make further improvements. VA is standardizing 
activities across the VA health system to optimize business processes, 
reduce user adoption issues and improve training and testing.

Training, Change Management and End-User Engagement

    Supporting VA's end users and helping them fully adopt the new EHR 
is a key to program success and integration of the Federal EHR into VA 
operations. VA continues active engagement with the sites that are 
using the Federal EHR. These sites have provided vital feedback on 
challenges with the Federal EHR and with training and adoption 
initiatives to date. As part of continued support at existing sites, VA 
has developed a training regimen to ensure new hires are properly 
trained, and existing users have opportunities to optimize their 
performance using the Federal EHR system. VA routinely communicates 
system changes, planned maintenance events and system upgrades to 
facility leadership, informatics leadership and end users. VA also 
communicates through a weekly User Impact Series, attended by over 200 
super users; site and VA leaders; and subject matter experts. The 
lessons learned to date will enable VA to improve the level of support 
provided before, during and after future go-lives.
    To ensure users have completed assigned systems training on the 
Federal EHR system, the Electronic Health Record Management Integration 
Office (EHRM-IO) has developed a robust data management system to 
extract and share data from VA's Talent Management System, showing 
training completions. EHRM-IO provides Power Business Intelligence (or 
BI) dashboards to help key stakeholders monitor day-to-day training of 
thousands of users across various sites and populations. In addition to 
the dashboards, EHRM-IO supports local facilities to ensure the sites 
complete training by delivering daily supplemental reports; monitoring 
open bridge lines to facilitate real-time response to concerns; and 
deploying EHRM-IO staff onsite to support active training.
    VA has also taken a number of steps to address training concerns. 
First, VA addressed user concerns with contracted trainers and the 
sandbox simulated training environment. Second, we established core 
competencies and optimized the involvement of super users, who are 
critical in providing specific, on-the-job guidance to our health care 
providers. Last, we made training more modular and based on specific 
system functionality. This allows us to further target training 
requirements to end users' specific system roles, aligning content with 
the work users perform and reducing the overall amount of training 
required for many users. Beyond these specific changes, we are doing a 
better job managing expectations around training, so that our staff 
understand it is only one part of the overarching adoption pathway for 
the new system.
    To that end, in Fiscal Year (FY) 2023, EHRM-IO and VHA assigned 
training to National Councils and the Office of Health Informatics 
(OHI) to provide foundational knowledge of the system for users to 
perform their job duties and collaborated to define user readiness and 
adoption and improve end user engagement. EHRM-IO also converted 200-
level curricula to computer-based trainings (CBT) to reduce scheduling 
complexity and increase flexibility of training and updated more than 
200 training artifacts, while also piloting the transition of 400-level 
curricula to VA ownership. These activities demonstrate continued 
progress in the areas of change management and training and provide 
increased collaboration with VHA, in line with the 10 recommendations 
from the General Accountability Office's (GAO) March 2023 report.

Program Accountability and Governance

    EHRM-IO, VHA and the Office of Information Technology are working 
in a collaborative fashion to address program accountability, 
integrated readiness criteria, enterprise standards, change management 
and training. VHA has already made internal changes to further drive 
accountability across the enterprise. Specifically, EHRM-IO and VHA are 
developing more robust system-lifecycle governance that clarifies the 
business need and/or issue; prioritizes solutions for development; 
secures customer agreement on user acceptance criteria; and ensures 
customer (e.g., clinicians, nursing staff, administrative staff) 
signoff on user acceptance criteria. VHA EHRM National Councils will 
represent the customer for this purpose. Additionally, VHA is planning 
to develop oversight programs for compliance with user acceptance and 
realization of business goals which will be reported to committees of 
the VHA Governing Board.
    To further drive program accountability, VA appreciates the 
continued oversight of the VA Office of Inspector General (OIG) and 
GAO. As of August 2, 2023, 47 of 68 OIG recommendations are closed; 21 
remain open. There are only two OIG recommendations that are older than 
3 years; these and several others may be put on pause for the duration 
of the Reset. EHRM-IO continues to work closely with its partner 
offices to expeditiously adjudicate the outstanding recommendations. As 
of July 18, 2023, three of the five GAO recommendations have been sent 
to GAO for closure. The remaining two will remain open for program 
monitoring.

Budget Overview and Cost Estimate

    In April 2023, VA reviewed impacted financial resources in the 
context of the Reset and determined that FY 2023 costs could be reduced 
by approximately $400 million. As a result, VA did not seek the 25 
percent funding withhold (totaling $439,750,000) of the VA EHRM budget 
line for FY 2023. VA also proposed reducing the FY 2024 budget request 
by $529 million and the FY 2025 initial budget calculation by $481 
million. VA requests FY 2023 funding that is unobligated as a result of 
the Reset remain available in FY 2024. EHRM-IO will continue to require 
FY 2024 funding to support Federal EHR operations, sustainment, 
infrastructure and integration, as well as continued improvements to 
the Federal EHR at current productionsites. FY 2024 funding will not 
support any new site deployments, but it may support current site 
reviews.
    VA is committed to fiscal responsibility and transparency with this 
Committee as we implement an enterprise EHR system that meets the 
combined needs of the Veterans and the medical professionals serving 
them. VA continually drives toward meaningful standardization and 
prioritizes system changes that have the most beneficial enterprise 
impact (i.e., not customizing based on the needs of every site). This 
includes cost considerations, with the end goal of delivering a system 
that can support improved access, outcomes and experiences for Veterans 
through a single health record from entry into military service to VA 
care.

Federal EHR System Imperative

    VA must continue to move forward with a modern, commercial EHR 
solution in close coordination with our Federal partners, including DoD 
and FEHRM. This new Federal EHR will allow VA to standardize workflows, 
training and systems across VA, to better coordinate with the DoD, 
other Federal partners and private sector health providers, and to 
spread innovation system-wide more quickly through new integrated 
health information technologies and capabilities.

Conclusion

    Veterans remain the center of everything we do. They deserve high-
quality health care that is safe, timely, Veteran-centric, equitable, 
evidence-based, and efficient. As improvements continue to be made 
through the duration of this Reset, VA will continually evaluate 
readiness of sites and the Federal EHR system to ensure success and 
patient safety. With the activities and improvements that are now 
underway, VA leaders are optimistic about the eventual success of the 
current Reset and subsequent full implementation of the Federal EHR 
throughout VA.
    I again extend my gratitude to Congress for your commitment to 
serving Veterans with excellence. We look forward to responding to any 
questions that you may have.

                        Statement for the Record

                              ----------                              


                   Prepared Statement of Teresa Boyd

    Good morning, Chairman Bost, Ranking Member Takano and 
distinguished Members of the Committee. I very much appreciate the 
opportunity to provide testimony in support of VA's journey to 
modernize its electronic health record (EHR). During the past 5 years, 
I have been involved in the EHR modernization from many vantage points 
- as former Assistant Deputy Under Secretary for Health for Clinical 
Operations (ADUSH/CO), and since Fall of 2020, as the Network Director 
for VISN 20 - a Network that encompasses most notably four (4) of the 
facilities that are now live with the new EHR system. Dr. Evans has 
introduced the three leaders that were able to travel to be here today. 
These leaders - Mr. Kelter, Ms. Nelson-Brooks, and Dr. Fischer - led 
their respective staff through the early days of training, excitement, 
and uncertainty as a new electronic heath record was deployed at their 
sites - one that was new to VA. Dr. Cellura, Medical Center Director, 
and former Chief of Staff at Southern Oregon Rehabilitation Center and 
Clinics was unable to join today, but my comments incorporate her 
input. It is not lost on anyone that healthcare delivery is complex, 
and the transition to any new system or tool or process brings with it, 
challenges. Over 4500 VISN 20 staff use the new EHR each day - whether 
at the local facility, the clinical resource hub, or the clinical 
contact center (call center). The facility leaders, including their 
respective leadership teams, continue to champion quality and timely 
healthcare delivery as they support their frontline staff through the 
sometimes frustrating, and seemingly never-ending, growing pains of the 
new EHR. The staff at the collective five (5) live sites are to be 
commended for not only their resiliency and perseverance but for their 
unmatched contribution to the important work of ``getting it right'' 
with regards to the new electronic health record.
    VISN 20 EHRM Deployment Team has been an integral part of our day-
to-day operations with regards to the activities involved with pre-
deployment and now through sustainment and improvements. In addition to 
daily touchpoints with facilities, the team rapidly socializes any new 
or urgent issues so that all live sites are aware - including our VISN 
10 counterparts - a model for a learning organization in action. This 
deployment team reinforces clear and transparent communication among 
all live sites as well as the conduit to national councils, program 
offices, VHA EHR leadership and EHRM IO.
    I look forward to being a part of change that VISN 20 is leading. 
If the 4500 plus VISN 20 users were to speak, they would ask for 
improved education on proper workflows that would inspire confidence 
and no doubt increase positivity among the staff; increased bi-
directional transparent communication regarding issues at hand 
(tickets); and streamlining of workflows to decrease the number of 
clicks. No doubt the dedicated staff from the field and VACO will 
formulate a successful way forward as we keep lessons learned front and 
center as we focus on our humble missions.
    Chairman Bost, Ranking Member Takano and Member of the Committee, 
thank you for this opportunity and for your unwavering support of our 
nation's Veterans and those who have dedicated their life work to 
delivering on our promises.

                                 [all]