[Senate Hearing 118-150]
[From the U.S. Government Publishing Office]








                                                        S. Hrg. 118-150

                       EXAMINING THE FUTURE PATH
                    OF VA'S ELECTRONIC HEALTH RECORD
                         MODERNIZATION PROGRAM

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 15, 2023

                               __________

       Printed for the use of the Committee on Veterans' Affairs







     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]













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

53-821 PDF                WASHINGTON : 2023         
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
                 Jon Towers, Republican Staff Director  
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

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                             March 15, 2023

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Murray, Hon. Patty, U.S. Senator from Washington.................    13
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    15
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    16
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    19
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    21
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    23
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    27

                               WITNESSES

Neil C. Evans, MD, Acting Program Executive Director, Electronic 
  Health Record Modernization Integration Program, Department of 
  Veterans Affairs; accompanied by the Honorable Shereef M. 
  Elnahal, MD, Under Secretary for Health; the Honorable Kurt 
  DelBene, Assistant Secretary for Information and Technology and 
  Chief Information Officer; and Michael D. Parrish, Chief 
  Acquisition Officer and Principal Executive Director, Office of 
  Acquisition, Logistics, and Construction.......................     3

Mike Sicilia, Executive Vice President, Oracle Global Industries.     5

Carol Harris, Director, Information Technology and Cybersecurity, 
  Government Accountability Office...............................     7

                                APPENDIX
                          Prepared Statements

Neil C. Evans, MD, Acting Program Executive Director, Electronic 
  Health Record Modernization Integration Program, Department of 
  Veterans Affairs...............................................    39

Mike Sicilia, Executive Vice President, Oracle Global Industries.    46

  Attachment--Oracle Cerner 2022 Year-End Congressional Report...    58

Carol Harris, Director, Information Technology and Cybersecurity, 
  Government Accountability Office...............................    93

  Attachment--March 2023 GAO Highlights..........................   124

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Kyrsten Sinema............................................   127
  Hon. Dan Sullivan..............................................   132
  Hon. Thom Tillis...............................................   133
  Hon. Angus S. King, Jr.........................................   141
  Hon. Jerry Moran...............................................   143

                   Questions for the Record (cont'd)

Oracle response to questions submitted by:

  Hon. Angus S. King, Jr.........................................   153
  Hon. Thom Tillis...............................................   155

 
                       EXAMINING THE FUTURE PATH 
                    OF VA'S ELECTRONIC HEALTH RECORD  
                         MODERNIZATION PROGRAM 

                              ----------                              


                       WEDNESDAY, MARCH 15, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:30 p.m., in 
Room SD-106, Dirksen Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Murray, Brown, Blumenthal, 
Sinema, Hassan, King, Moran, Boozman, Cassidy, Tillis, 
Sullivan, Blackburn, and Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call the meeting to order. I apologize. 
We got tied up, and that is about enough, so that is it. But 
thank you all for being here.
    I want to recognize our panel, start by recognizing the 
folks from the VA that are trying to make this electronic 
health record work, to deliver for our veterans under what I 
see is pretty difficult circumstances. We spent about 10 
million bucks on this project so far. The new EHR has been 
deployed to give hospitals, 22 community-based outpatient 
clinics. It is being used by about 10,000 employees, which 
sounds big but in a system as big as the VA it is not where we 
need to be.
    By the VA's own admissions, OIG and GAO reports and 
independent industry analysts, it is clear that the tools in 
the Oracle system are not working, at least not working as they 
are intended to. There has been a number of screwups, lack of 
coordination between DoD and the VA. Within the VA we have seen 
a lack of clear goals and strategy and unstable, inconsistent 
leadership. And while the contractors have been what I believe 
abusing the taxpayers, we know the previous administration did 
not do veterans any favors by issuing a $10 billion no-bid, 
sole source contract that needs to be renegotiated, which I 
will talk about in a second.
    Today we need to hear from GAO that almost every part of 
this contract certainly has not lived up to my expectations and 
I doubt anybody else's either. For all the documented system 
crashes, incomplete technology, and poor training programs, 
Oracle Cerner has refunded the government about $325,100 of the 
$4.4 billion it has received through its contract. Make no 
mistake about it: we need to right this ship.
    And for me, all options but one are on the table to fix 
this new EHR. I am not going to ban the effort to modernize 
VA's health records. This is not in the cards, it is not 
sustainable to do, and quite frankly, our veterans need it, and 
that is why we need to work together on a bipartisan basis to 
get this program and contract working for our veterans, VA 
medical personnel, and the American taxpayer.
    And while the VA has shown some signs of making necessary 
steps getting this program back on track in recent months, with 
the help of some of the leaders here today, the following 
really needs to happen. The Secretary must bring together 
government and industry, best contract experts and renegotiate 
the Oracle Cerner contract that is due to expire on May 16th. 
And we need tougher teams, discounting prices, a narrow set of 
tasks for Oracle, and severe penalties for poor performance. 
And if Oracle will not agree to those terms then the VA should 
be prepared to roll up its sleeves and negotiate an entirely 
new contract or find a different team of partners.
    Just yesterday, VA informed Congress that at least six 
additional veterans that have been connected in some way to 
their care as delivered by Oracle Cerner system, four of them 
fatally harmed. This is as serious as our work on this 
Committee needs our full attention to get this back on track.
    It is going to be an interesting hearing today. We need to 
know exactly where the hell we are at and where we are going 
and what it is going to cost and when we can look for a timely 
delivery of a thing that we have been talking about here for 20 
years. We have all got to step up to the table.
    Over to you, Senator Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Mr. Chairman, we are here again to discuss 
the challenges of the VA electronic health records 
modernization program. I emphasize the word ``again.'' We have 
done this numerous times.
    The VA aims to create a unified health record for 
servicemembers and veterans, enabling more consistent health 
care. It is frustrating that the opposite has happened. The 
five medical centers that are using this system are struggling 
with delays, disruptions, and rising costs, and only yesterday 
we find out the system has been a factor in the loss of 
veterans' lives.
    We all have concerns about the VA's ability to manage this 
program, and that is not new. These delays and disruptions, the 
rising costs have had unintended but unacceptable impacts to 
the health of veterans and the programs that were created to 
serve them. The VA and Oracle Cerner are making improvements 
but they are gradual, and many of the most expensive, 
extensive, and most significant fixes are many months or even 
years away.
    Meanwhile, the VA tells us that they will begin rolling out 
EHR to new facilities in June, which is just around the corner. 
I have yet to see what has fundamentally changed in the system, 
training or program management that will make the 
implementation more successful. The changes in and lack of 
current programmatic leadership suggest to me that the whole 
effort may be sleepwalking toward an extremely destructive 
result. And due to changes in leadership at the VA it is still 
an open question, who will be leading this program three months 
from now.
    To justify additional spending on this program we need 
assurances that every penny is spent focused on creating and 
implementing a system that serves veterans and provides them 
with the high-quality care they deserve. I need to know if the 
VA still wants and believes in this program. I need to know 
what will be different this time under the next group of 
leaders.
    Mr. Chairman, thank you for your attention to this issue. I 
look forward to the discussion today.
    Chairman Tester. Thank you, Senator Moran. I want to 
associate myself with your remarks. I think they were very much 
spot on.
    Today we are going to hear from key VA leaders that are 
critical to this programs success, as well as representatives 
from the GAO and Oracle Cerner. From the VA we have Dr. Neil 
Evans, who is the Acting Program Executive Director of VHRM 
Integration Office. Dr. Evans, I believe you have been on the 
job for about three weeks, but like I said earlier, we have 
been at this for 20 years. And you have been at the VA--I am 
sorry--for 20 years, and you still provide the care to veterans 
at the local DCVA hospital. Thank you for that. Thank you for 
your willingness to serve. And you are accompanied by Dr. 
Shereef Elnahal, somebody who is very familiar to this 
Committee, Under Secretary for Health at the VA. Big job. Kurt 
DelBene, Assistant Secretary for Information Technology and 
Chief Information Officer. And Michael Parrish, who is the 
Chief Acquisition Officer and Principal Executive Director, 
Office of Acquisition, Logistics, and Construction.
    I believe, Dr. Evans, you are going to do the speaking for 
the trio and yourself, and you have the floor.

                   STATEMENT OF NEIL C. EVANS

            ACCOMPANIED BY HON. SHEREEF M. ELNAHAL;

           HON. KURT DELBENE; AND MICHAEL D. PARRISH

    Dr. Evans. Thank you. Chairman Tester, Ranking Member 
Moran, and distinguished members of the Committee, thank you 
for this opportunity to testify in support of VA's initiative 
to modernize its electronic health record system.
    Before I get started I do want to express my gratitude to 
Congress and to this Committee for your commitment to serving 
veterans with excellence, and specifically for your interest in 
and oversight of this project.
    As you mentioned, today I am accompanied by my VA 
colleagues, Dr. Shereef Elnahal, Under Secretary for Health; 
Mr. Kurt DelBene, Assistant Secretary for Information and 
Technology and Chief Information Officer; and Mr. Michael 
Parrish, Principal Executive Director for the Office of 
Acquisition, Logistics, and Construction. The representation on 
this panel is indicative of VA's department-wide approach to 
its EHR modernization program and our shared desire to get this 
right.
    As the newest member of this team, having stepped into my 
current role, as you mentioned, less than three weeks ago, I 
greatly appreciate the opportunity that I will have to 
collaborate with these experts, with the teams that they lead, 
with our contracted partners in this effort, and most 
importantly, with the frontline VA staff who will depend on a 
modernized electronic health record to provide high-quality, 
responsive health care to the veterans that they serve.
    Though I may be new to my current role I am not new to this 
effort, having been a participant in this project from various 
vantage points across its life span to date. And I would add 
that I am also a future user of the system as a practicing VA 
primary care provider. This matters to me.
    As you are well aware, nearly five years ago VA began in 
earnest its journey to implement a new electronic health 
record, or EHR, replacing the EHR components of VA's VistA 
system that has served us well for upwards of 40 years. Our 
electronic health record modernization effort involves 
deploying across VA the very same commercial electronic record 
system provided by Oracle Cerner that is being implemented by 
the Department of Defense and the United States Coast Guard.
    As a brief aside, electronic health record systems, as you 
know, are far more complicated than the name might imply. They 
are much more than a record alone. They consist of many 
orchestrated IT capabilities that power clinical care delivery 
in the modern health care system, including care in outpatient 
clinics, hospital wards, emergency departments, operating 
rooms, clinical laboratories, intensive care units, pharmacies, 
radiologic suites, et cetera.
    These systems, in many ways, drive how health care is 
delivered, how work gets done, how patient care encounters are 
orchestrated, how communication and handoffs occur, and how 
both patients and health care providers access the data that 
they need for decision-making and more. These systems are 
extremely complex and they need to be highly reliable, 
available, and performant at all times.
    Transitioning from one set of EHR technologies to another 
is always a massive endeavor, one that is time consuming, 
disruptive, and challenging. Mature organizations also 
recognize that EHR transitions are more than just a technology 
changeout. They are opportunities to rethink the people and 
process side of health care delivery, opportunities to 
standardize and optimize how work is done across the 
enterprise.
    Where are we now in VA on our EHR modernization journey? We 
acknowledge that there have been challenges with our efforts to 
date. As we work through the challenges, our commitment remains 
unwavering, to provide world-class patient care and prioritize 
patient safety for the veterans we serve.
    We have learned a lot since our initial go-live at the 
Mann-Grandstaff VA Medical Center, and in 2022, we completed 
four further deployments in Walla Walla, Washington; Columbus, 
Ohio; Roseburg, Oregon; and White City, Oregon. And as you 
mentioned, the system is now in use at 5 VA medical centers, 22 
community clinics, 52 remote sites, by more than 10,000 VA 
medical personnel.
    VA is working aggressively to address issues with the 
configuration and performance of the new system, based on 
direct feedback from end users. We expect the same aggressive 
attention from Oracle Cerner.
    In October 2022, VA announced it would delay upcoming 
deployments to concentrate on assessing concerns that have been 
raised with the system and to develop solutions for the most 
impactful and critical issues, particularly those with a 
potential to affect patient safety.
    Though there is still a lot of work to do, important 
progress is being made. For example, last month's update to the 
system included three critical pharmacy enhancements with more 
on the way. We have addressed usability issues and enhanced 
training regarding order management in the system, and more.
    In terms of system stability, this has also improved. As of 
this month it has been more than 200 days, or six months, 
without a complete outage. System-incident free time, or the 
amount of time without users experiencing any disruption in 
their use of the system is not yet at its goal, though it is 
moving in the right direction.
    As improvements continue to be made over the next months, 
VA will continually evaluate the readiness of upcoming 
deployment sites as well as the EHR system itself to ensure 
success. It is important to take the time now to get things 
right, to provide a strong foundation for an accelerated 
deployment schedule later as the project proceeds.
    A modernized electronic health record, one that enhances 
the efficiency of care delivery, one that delivers 
interoperable health data, one that provides effective clinical 
decision support, one that serves as a springboard for future 
integrations and innovation, this is what is required to 
support the VA health care system of the future.
    Chairman Tester, Ranking Member Moran, and members of the 
Committee, thank you again for the opportunity to testify today 
and for all that you do to continue to support our Nation's 
veterans and their caregivers.

    [The prepared statement of Dr. Evans appears on page 39 of 
the Appendix.]

    Chairman Tester. Thank you for your statement, Dr. Evans. I 
appreciate it very, very much, and I appreciate your commitment 
to our veterans throughout your professional life.
    Next we have Executive Vice President of Oracle, Mike 
Sicilia. Mike is also familiar to this Committee. I like to say 
Mike is where the buck stops. I think that is correct when it 
comes to Oracle and this system. I hope we get a head nod for 
that.
    And you have the floor, Mike.

                   STATEMENT OF MIKE SICILIA

    Mr. Sicilia. Chairman Tester, Ranking Member Moran, and 
members of the Committee, thank you for inviting me here today.
    When I last testified before you Oracle was just over a 
month into its acquisition of Cerner. I made several 
commitments about adding resources, bringing new engineering 
and technical expertise, and making VA's EHRM program Oracle's 
most important priority. Since then, we have done that and 
delivered significant improvements in a short amount of time.
    The technical fixes we have made to the system have 
resulted in meeting the 99.9 percent availability requirement 
in five of the last six months. Average downtime minutes 
dropped from 345 minutes per month prior to the acquisition to 
21 minutes per month in January and February. The goal of every 
system should, of course, be as close to zero as is possible, 
and we are marching toward that.
    End users should also be feeling a notable difference 
across key workflows, with 28 improvements delivered in the 
most recent Block 8 update in February. We also delivered the 
top three pharmacy enhancements in four months instead of the 
originally estimated three years, as I promised we would do 
last July. In August, we provided updates for the unknown 
queue, and now, on average, only one order per site per day 
enters the queue, which represents a dramatic improvement from 
where we are.
    At the same time, we are very aware that there is more to 
do, and nobody--VA, the medical centers, veterans, all of you, 
or Oracle--is satisfied yet.
    Last week I was in Columbus, Ohio, with Dr. Evans, getting 
on-the-ground feedback. We met with the medical center's 
director and leadership team. The bottom line from their 
feedback is while the system functions, it can be made better. 
I wish to thank the leadership team in Columbus for their 
candid, constructive, and well-formed feedback.
    Providers felt the performance improvements but they also 
want the new system to be easier to use, with defaults that are 
more relevant to their daily work. We can achieve quite a bit 
of this by reconfiguring the system without touching the code, 
and it can be done relatively quickly. I am talking weeks, not 
months, noting, of course, that direction and permission to do 
so resides with our partners at the VA VHA.
    This post-rollout feedback is not uncommon. In fact, we 
have experienced this before in our commercial business and 
have always quickly tailored the system to make it easier for 
providers to use. Nobody in Columbus told me that they want to 
go backwards.
    The system is functioning at five VA sites and across 75 
percent of DoD, and all of the Coast Guard. The Cerner EHR is 
the most utilized system of its kind on the planet. It supports 
national and defense health systems in allied countries as 
well. The core system was built for major missions, and Oracle 
has invested in making it more secure, scalable, and reliable.
    It is logical to ask, though, why the VA rollout has been 
subject to more issues than all of us wish to see. While 
modernization, especially at this scale, is never easy, the 
initial DoD rollout was similarly challenged in the first two 
years, only completing four deployments and then taking a two-
year pause to improve governance and fine-tune a standard 
enterprise baseline system. Those efforts enabled DoD, in a 
little over three years' time, to accelerate deployments from 
four sites to being 75 percent complete today, with 140,000 
total users live on the system. The domestic deployments at DoD 
will be completed this year, on time and on budget.
    As I look back on what has been accomplished in the last 
nine months, I am more optimistic than ever that we are now on 
the right trajectory and we can get this program on track, on 
schedule, and on budget. Our working relationships across VA 
leadership is very strong. Dr. Evans and I have only known each 
other for a short amount of time, but I think it is fair to say 
that we are already working from the same page.
    The VA's recently issued Sprint Report outlines a path 
toward better governance and expedited decision-making that 
will enable, for example, faster decisions from National 
Councils on plans to simplify workflows.
    Oracle's significantly expanded team is steadily working 
every day to continuously improve the system and address issues 
like we heard about in Columbus, and that we know also exists 
in Washington State and Oregon. We believe, though, from a 
performance and scalability standpoint, the system is ready for 
the resumption of deployments. We will work with VA in the lead 
up to June to evaluate other critical factors that will impact 
readiness for the resumption of go-lives.
    These are big things to deliver, and doing so will enable 
deployments across VA more rapidly, with a more intuitive, 
easy-to-use system. That system will deliver on the promise of 
seamless care to improve health care for our Nation's veterans 
and servicemembers. We look forward to continuing to work with 
you and the VA to achieve this goal.
    Thank you.

    [The prepared statement of Mr. Sicilia appears on page 46 
of the Appendix.]

    Chairman Tester. Thank you, Mike.
    And last but certainly not least, the Director for 
Information Technology and Cybersecurity at the Government 
Accounting Office, Carol Harris. Carol?

                   STATEMENT OF CAROL HARRIS

    Ms. Harris. Thank you. Chairman Tester, Ranking Member 
Moran, members of the Committee, thank you for inviting us to 
testify today on the status of VA's EHRM program. As requested, 
I will briefly summarize the findings from our recently 
completed review of this mission-critical system.
    As you know, VA provides health care services to roughly 9 
million veterans and their families and relies on a legacy 
system called VistA to do so. In June 2017, the Department 
initiated the EHRM program to replace VistA, and has obligated 
at least $9.4 billion on this program to date. It should also 
be noted that this is VA's fourth attempt at replacing the 
legacy system, and the implementation so far has been fraught 
with major issues.
    In our most recent work, we detailed VA's gaps to 
effectively manage organizational change as well as the extreme 
dissatisfaction among users and system issues. This afternoon I 
will highlight three key points from our work.
    First, more work needs to be done to adequately address 
VA's organizational change management challenges. Our recent 
review detailed eight leading practices for change management. 
VA had partially implemented seven and did not implement one. 
For example, the EHRM program has taken great care to analyze 
and collect VA's readiness to implement a new workflow and 
system. But their data indicated that users were not ready for 
such a change and the program did not have assurance that it 
had resolved potential problems in a timely fashion.
    For example, the Walla Walla and Columbus medical centers 
showed low scores for the knowledge of how to change and the 
ability to implement change on a day-to-day basis. Program 
officials said they were taking actions to provider user 
support in response to those concerns. However, the program did 
not conduct another assessment before deploying the system. Had 
they done so, they would have seen that users were still not 
ready, which was ultimately reflected in the post-deployment 
survey data.
    We made seven recommendations to VA regarding their change 
management activities, and until they are fully implemented 
future deployments will likely be at risk of similar 
challenges. This could hinder users' ability to effectively use 
the system, impede their knowledge of new workflows, and limit 
the utility of system improvements.
    My second point. Users of the new EHR system are generally 
dissatisfied, and this needs to be addressed before deployments 
resume. VA is well aware that its users are unhappy with the 
system. Their 2021 and 2022 User Satisfaction Surveys showed 
this.
    For example, about 6 percent of users agreed that the 
system enabled quality care, and roughly 4 percent of users 
agreed that the system made them as efficient as possible. 
These scores are among the lowest we have ever seen on a major 
Federal IT acquisition.
    Furthermore, VA has not established goals to assess user 
satisfaction. Having such goals in place would provide the 
Department with a basis for determining when satisfaction has 
improved and also help ensure that the system is not 
prematurely deployed to additional sites, which could risk 
patient safety. Accordingly, we recommended that VA set these 
goals and also demonstrate improvement toward meeting them 
prior to future system deployments.
    And finally, my third point. VA did not adequately identify 
and address EHR system issues. VA has not conducted an 
independent operational assessment of the new system, and as of 
January did not plan to do so. This critical evaluation 
performed by a third party would enable VA to systematically 
catalogue, report on, and track resolution of assessment 
findings with greater rigor, transparency, and accountability. 
DoD, in contrast, conducted one shortly after deploying MHS 
Genesis to its first site, and based on those findings paused 
deployment to other sites until the major issues were resolved. 
Accordingly, we recommended that VA make plans to have the 
independent assessment done.
    In summary, the successful implementation of the new system 
across VA will require a level of program management, 
adaptability to change, and sustained system performance that 
the Department and contractor have yet to demonstrate. The 
continuance of the EHRM is not without risks, but with strong 
oversight from this Committee, in addition to improved VA 
program management and contractor system performance, 
particularly through the implementation of our recommendations, 
we can increase the odds for success.
    Mr. Chairman, that concludes my statement, and I look 
forward to your questions.

    [The prepared statement of Ms. Harris appears on page 93 of 
the Appendix.]

    Chairman Tester. Well, thank you very much, Ms. Harris. I 
appreciate your testimony.
    I am going to start with Dr. Elnahal. Dr. Elnahal, I am 
sure you are familiar with the Sprint Report. Correct?
    Dr. Elnahal. Yes, Senator.
    Chairman Tester. Last time I checked there were 14 items on 
that report that needed to be fixed.
    Dr. Elnahal. Yes.
    Chairman Tester. What is your perspective as far as moving 
forward with this plan? Do you think that those 14 items have 
to be fixed before you move on, or do you think you can move on 
without fixing those?
    Dr. Elnahal. Chairman, I think it is important to 
understand that each of these issues needs to, at the very 
least, be mitigated at the sites where the system already 
exists, and certainly addressed in anticipation of future 
deployments. Ideally, the configuration of the system would 
ultimately change. We would hold Oracle Cerner accountable for 
making those changes, to eliminate the risk entirely. That is 
the gold standard we are shooting for.
    But now that we are mindful and aware of each of those 
risks, which was part of the reason for the Sprint, we are at 
least able to address them at the point of care.
    Chairman Tester. Okay. Dr. Evans, do you feel the same way, 
that those 14 items need to be fixed before you move on?
    Dr. Evans. I agree with Dr. Elnahal that the items--I mean, 
we certainly need to have a plan for those items and we also 
need to have mitigations in place, which we do, as the record 
is being used at five sites.
    Chairman Tester. Perfect. So the question is, how quickly 
can VA and Oracle get these changes done?
    Dr. Evans. We are in the process of analyzing that. I know 
that one of them we have already resolved. Five were actually 
partially addressed by the Block 8 software upgrade that was 
just mentioned, and analysis is ongoing with regard to how we 
might expediently resolve the others. I do not have a timeline 
for you.
    Chairman Tester. So I am gathering by the answer to that 
question that these are fairly complicated issues, these 14?
    Dr. Evans. Some of them will likely require work by Oracle 
Cerner to resolve. Some of them may be resolvable through a 
change in the configuration of the record, as Mr. Sicilia 
mentioned.
    Chairman Tester. So you have been on the job for three 
weeks, and so this is kind of an unfair question, but what the 
hell. I am asking them so I will do it. What kind of time frame 
are you anticipating it to be? Are we talking years? Months?
    Dr. Evans. Not years. I would imagine months.
    Chairman Tester. And is it your opinion that before this is 
moved to, say, a place like--not saying this would be the 
place, but it could be--Saginaw, Michigan, that these have to 
be pretty well tricked out and done?
    Dr. Evans. I think we--so before we go live at any site, 
whether it is in Saginaw or any other----
    Chairman Tester. Yep.
    Dr. Evans [continuing]. Location, we need to be confident 
that we are ready to go live and that we have things right.
    Chairman Tester. But you are going to have to look at 
certain metrics to make that determination. Are these the 
metrics you are looking at or are there other metrics beyond 
these that you are going to be looking at before you move 
forward?
    Dr. Evans. Those are metrics with regard to the actual 
solution itself, the software solution and the IT. There are 
other aspects of determining whether a site is ready to go 
live, and actually Ms. Harris mentioned some of those. They 
have to do with whether our employees are ready for the change. 
And so there is an assessment of the readiness of the people 
onsite where the change is going to occur, and also of the 
solution itself.
    Chairman Tester. There is going to have to be an assessment 
done of where the EHR is currently being used, with those 
employees?
    Dr. Evans. Is an assessment going to have to be done there?
    Chairman Tester. I mean, you said--we will use Saginaw as 
the example. You say you have to prepare those folks. Do you 
not also have to look at the folks that are using it right now 
and make sure that they are okay with it?
    Dr. Evans. Yes, absolutely, and that is one of the reasons 
why one of the first things I did was go to Columbus to speak 
to end users.
    Chairman Tester. Perfect.
    Mr. Sicilia, there is an independent research firm, KLAS. I 
am sure you are familiar with it. They did survey of VA users 
of this system, and they put it this way is that ``KLAS has 
measured EHR experience in 280 organizations around the world. 
VHA Cerner currently has the lowest EHR experience score of any 
organization measured.'' That is not exactly a booming 
compliment. What is your response to that?
    Mr. Sicilia. Yes, Mr. Chairman. Thank you for the question. 
No, it is not a booming endorsement by any means. And the real 
shame of it is when you compare it to the line right above it, 
which is MHS Genesis, which is the DoD system, it is the same 
system, it is the same code, it is the same database, it is the 
same infrastructure, the score is materially higher. When you 
compare it to Cerner and the general public the DoD's 
satisfaction is materially higher. The general public scores 
for Cerner are materially higher, and actually----
    Chairman Tester. So----
    Mr. Sicilia. So the issue----
    Chairman Tester [continuing]. The DoD is higher. The VA is 
not very good. What is the difference?
    Mr. Sicilia. Well, as I said, in the beginning, when you 
have 345 minutes a month of down time, they are not going to 
score very well, right? By and large we have addressed the 
issues where the system was not available when it should be 
available. We have addressed issues like the unknown queue. The 
remaining issues I would put into the category of things that I 
heard in Columbus last week, which are usability issues. They 
are configuration issues, ease-of-use issues, and frankly, 
allowing the providers a little bit more autonomy in the system 
to do some things.
    These are defaults that populate a dropdown of things like 
that. This is not a fundamental change to the system. If it was 
a fundamental change to the system, then it would be illogical 
for me to think that the same system could be working not only 
in other customers but in other sides of government as well.
    Chairman Tester. I am going to turn it over to Senator 
Moran here right now, but the bottom line is that at some point 
in time, how much money are we going to have to spend to make 
sure this program works and that veterans get the health care 
that they have earned. That is it.
    I think that there is plenty of blame to go around, and I 
am tired of putting blame out. I want to see production, and I 
want to see results, and I want to see time frames from both.
    Senator Moran.
    Senator Moran. Following up on a couple of things that you 
outlined in your questions, Mr. Chairman, first of all a 
continuation of this discussion, because, Mr. Sicilia, what I 
think I hear is that given a little bit more time the system 
will fundamentally work, the fixes that need to be made are 
made, but there is still then, as Dr. Evans indicated, the 
operational aspect, what needs to happen within the health care 
system, to be able to utilize a system that technically is 
capable.
    So, I mean, is that a fair assessment of what you were 
saying, is that there are two components here?
    Mr. Sicilia. Yes, I think that is a fair assessment. I 
mean, obviously, there are things that I would describe now, as 
we get past the major catastrophic interruptions to the system 
and into more ease-of-use systems, again, these are 
fundamentally easier things to change. These are not hard 
engineering efforts to change these things. As I said, these 
things can be changed in a matter of weeks, not even months but 
weeks.
    Then, obviously, there is change management, there is 
training readiness, there is site readiness, there is 
connectivity readiness, and all those things that have to be 
continued to be assessed on a site-by-site basis as well. So I 
would think it is fair to say that both of those things need to 
happen.
    Senator Moran. Dr. Evans, welcome to this capacity that you 
now serve in. Would you respond to that? I mean, if the system 
was working, that the technical capabilities of the system were 
there, then how much of the problem is solved? Let me ask it 
this way. So Cerner has an obligation to get the system to 
work. The VA has an obligation to make sure that is the case, 
but in addition to that, to train, educate, figure out how to 
utilize the system within the VA.
    So if the system had technical capabilities to function 
properly then how much of the problem has gone away?
    Dr. Evans. You know, so first of all, I do not think we are 
yet at the point where we can say with full confidence that the 
system is technically performing where it----
    Senator Moran. No, I did not say that, and I do not know 
that even Mr. Sicilia said that. He says they are in the 
process of fixing these problems. My question is a 
hypothetical. If they fix the problems within the system, the 
technical capabilities of the system, then are there still 
problems left at the VA in its implementation? The system 
works--can the VA then utilize the system and care for 
veterans?
    Dr. Evans. Yes, so I think in many ways the question you 
are asking is are end users in the VA ready to adopt this 
change. That is, if they are given a system that is highly 
reliable, where there is not a lot of lag in the system, and 
they are not watching the spinning wheel, where it is doing 
what they need to do to be able to enter orders, order 
prescriptions, review the data that they need, the tool is kind 
of getting out of the way of clinical care. Are they ready to 
adopt and move to this new solution? I think the answer to that 
is yes. I think VA clinicians, clinical staff, they want a tool 
that is going to help them take care of veterans. That is their 
motivation.
    There is work we need to do to make sure we are preparing 
them for that change, that we are helping them understand what 
that change is, that we are creating a feedback loop where we 
are understanding what the issues are and then rapidly 
resolving them. But I do think they are ready to move in this 
direction.
    Senator Moran. Dr. Elnahal or Dr. Evans, either one of you 
may answer this if you would. The GAO recommended you establish 
user satisfaction targets and measure progress toward meeting 
them prior to future system deployments. Do you commit to do 
that and stop the future EHRM deployments until user 
satisfaction is met?
    Dr. Elnahal. I am happy to start, Senator. I think it is an 
important question because there really is not much daylight 
between users believing that the tool in front of them, our 
clinicians, is the right one to be able to serve the clinical 
needs of veterans and the actual veteran outcome, which is what 
we are all shooting for.
    And so absolutely, it is important for us to increase user 
satisfaction. We do so through multiple ways. We have to, 
again, change the configuration of the system, as Dr. Evans 
mentioned. We have to train right. And we have to assess that 
as its own target moving forward.
    So yes, we do commit to assessing user readiness and user 
adoption and satisfaction.
    Senator Moran. But if you assess--I appreciate that you are 
willing to assess, but then the question is what are you going 
to do with the assessment. Until the assessment indicates that 
the user satisfaction is where it needs to be, if it is not 
there are you still deploying to new sites within the VA?
    Dr. Elnahal. Well, if you ask me in a vacuum, Senator, I 
would want user satisfaction to improve substantially. That is 
an outcome that I would want to see, especially before we 
accelerate deployments in a manner that DoD has been able to 
accomplish. I think that users will----
    Senator Moran. I am sorry. What is the vacuum that you are 
in? You have a set of criteria. The GAO says meet the criteria. 
The question is, do you pause before you deploy to more 
locations until that is met? I do not know the vacuum that is. 
If criteria is not met are you still going to deploy?
    Dr. Elnahal. Forgive my wording. What I meant to say was we 
really want to see user satisfaction improve, and I believe 
that it will improve once we do follow through on all of the 
Sprint solutions, which is a combination of holding Oracle 
Cerner accountable for configuration changes, for us to improve 
training, and for us to organize ourselves and support our end 
users with the right change management, which had everything to 
do with our build of governance.
    So yes, I would want to see end user satisfaction improve 
before we accelerate deployment. And I do not know if Dr. 
Evans----
    Dr. Evans. I agree. I mean, I think there is still an 
opportunity--there will be opportunities to learn, but to your 
point, we have folks who are using this system on a daily 
basis, where we can assess an improvement in satisfaction.
    And, you know, I do think that there is--we just released 
three critical pharmacy updates, and we are hearing some good 
news about those pharmacy updates. There are more to come 
amongst the pharmacy community. So there are places where we 
are starting to see some user satisfaction improvement, but to 
your point, we need more in order to support any acceleration 
of the schedule.
    Senator Moran. I will come back to this in a second round, 
but I think my question is worthy of a yes-or-no answer, and I 
do not know what the answer is. So I will come back to it.
    Chairman Tester. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Mr. Chairman, thank you very much.
    You know, we are almost five years into this EHR contract, 
and from the very start, before the original Cerner contract 
was even agreed to by the Trump administration, I have been 
raising concerns from my constituents, in Spokane and in Walla 
Walla, and I believe that I have been very patient and 
reasonable in pressing the VA and Oracle Cerner to get this 
system to work the way it should.
    Now I have heard from providers who are now burned out 
trying to navigate this broken interface on top of what has 
already been an incredibly trying time for health care workers, 
and I have heard directly from my constituents, who have 
received a late cancer diagnosis because of the flaws in the 
system, and everything in between. None of this is okay, and 
something that concerns me deeply is we have not heard a lot 
about how those voices, that on-the-ground perspective, will be 
taken into account when we determine the future of this 
program.
    VA is now in the decision-making process about whether to 
renew this contract. This is a key moment. So Dr. Elnahal, I 
need to know. Who is representing the frontline experience from 
Eastern Washington, who has been using the system, and how 
exactly is the patient and provider experience represented in 
that decision-making?
    Dr. Elnahal. I think it is a really important question, 
Senator, and we focus squarely on that in the Sprint effort, in 
collaboration with the program. We built a governance structure 
that takes the views of end users into consideration in the 
first instance. The most important input we have is the input 
we have from frontline clinicians like Dr. Evans, who are 
telling us about the problems that need to be fixed to meet the 
veteran care need.
    That cascades up into different levels of governance, our 
clinical councils, that ultimately make decisions on the 
changes we need to be able to meet safe and effective care.
    Senator Murray. So it is not the users who have been facing 
these challenges over and over again.
    Dr. Elnahal. Yes. Our governance now includes users from 
the five sites where it exists and leaders who are advising on 
what changes need to be made, based on their input.
    Senator Murray. Okay. I would like to see that chart.
    Dr. Elnahal. Absolutely, Senator.
    Senator Murray. Mr. Sicilia, Mann-Grandstaff has been 
dealing with serious and even life-threatening issues for over 
2 years now, since the rollout of the EHR, and many of the OIG 
reports have further confirmed what I have been hearing on the 
ground, over and over. There are problems in the system with 
suicide flags, with unknown queues, pharmacy issues, and I know 
that Oracle has begun working on some of those fixes. But we 
are still talking about the same problems 2 years later, and 
that is just so unacceptable. The stakes could not be any 
higher.
    So just tell me, why is it taking so long to update this 
system when we have been telling you the problems, from the 
ground up 2 years ago, and we are still getting, ``Well, we are 
going to have a fix for this''?
    Mr. Sicilia. Thank you for the question, Senator. To my 
knowledge the unknown queue issue has been addressed. I 
committed to this panel in July that we would deliver a fix on 
August 1, 2022. We did that. It is deployed now, on average, 
there is 1 order per day that shows up per site in the unknown 
queue. I think the last time we spoke here we were up at about 
1,500 orders in the unknown queue. So if that is still a 
problem, that is, in fact, news to me, and I am happy to come 
back to you in writing if there are additional problems. But I 
have not heard those.
    In terms of pharmacy, the last time we spoke the estimate 
was that it would take three years to address the pharmacy 
issues. My response to that was when that kind of estimate is 
given the real answer is nobody knows. So the first thing we 
did after that hearing in July was broke that down into smaller 
subsets. We delivered, in February, the top three fixes for 
pharmacy. The fourth fix, number four on the priority list, 
will be delivered in April to the VA. As Dr. Evans just 
mentioned, we have heard some positive feedback from sites 
about those pharmacy fixes.
    As far as behavioral health flags, behavioral health flags 
are now in the system and will continue to be added to all 
modules of the system on schedule in April. As well, the opioid 
advisor tool that has been deployed has flagged over 1,600, 
just at the five sites that are live, has flagged over 1,600 
potential opioid prescriptions that would have been made to 
patients who perhaps should not have received opioids.
    So I think a lot of the issues that have been reported have 
been addressed. I am disappointed to hear that that news has 
not made it to you, and certainly we will make sure that we 
respond in writing with formative date on each one of your 
questions.
    Senator Murray. I would like to see that in writing.
    Mr. Chairman, before I finish my time I just want to say, 
as Chair of the Appropriations Committee and Chair of the 
Military Construction and Veterans Affairs Subcommittee, and a 
longtime member of this Committee, I take my oversight 
responsibility pretty darn serious. And despite how much 
funding has been provided, this system is, by no means, living 
up to our promise to care for our veterans. The continued 
patient safety risks are totally unacceptable.
    So I want to be candid here because at the end of the day 
what I care about is getting this right for our veterans. And I 
do not believe that more money is what is going to solve this 
problem. And I am not sure it makes sense, Mr. Chairman, to 
continue to fully fund the budget request for this system until 
I can see that the system is working and not putting our 
veterans in harm's way. That responsibility is on both the VA 
and Oracle Cerner, and both entities need to step up.
    Chairman Tester. Senator Murray, thank you for those 
comments, and I would tell you, in short, our patience is 
running thin.
    Coach Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman. Thank you, and 
thanks to the witnesses for being here today, for discussing 
such an important topic, one that I know has taken many years 
and a lot of money. We need to do what makes financial and 
logistical sense, and most importantly, make sure it works for 
veterans and VA's health care providers. I hope we are well on 
the way of achieving this goal.
    However, I am going to use my five minutes today to relate 
to another topic. It relates to an interim final rule issued by 
the VA last September that allows the VA to provide abortions 
to veterans and their dependents. Since this rule was 
implemented six months ago the VA should be able to provide 
this Committee with the data.
    Dr. Elnahal, I have several questions I want to ask you and 
see if you can answer some of these. I am going to ask all 
three of them first and see if you can answer them.
    In the last six months, how many abortions has the VA 
facilitated, either at a medical facility or through community 
care? Number two, at what stage of pregnancy was each of the 
abortions? And number three, what exception was used for each 
of the abortions? Can you answer any of those three?
    Dr. Elnahal. Senator, respectfully, in a public forum like 
this I am concerned about both veteran and clinician safety if 
I give you that information right now, but we are happy to work 
with you and take that for the record.
    Senator Tuberville. Thank you. I figured that was coming. 
Well, the next questions we should not have a privacy issue so 
see if you can give me a response on these. Which VA doctors, 
therapists, social workers have been trained to counsel and 
refer veterans for abortions, how have they been trained, and 
how has the VA assessed their competency in women's health and 
prenatal care? Do you know that?
    Dr. Elnahal. Well, Senator, we want to ensure that the 
folks providing these services, again, in the limited 
exceptions that we have as defined by the IFR, the life of the 
veteran, if the health of the veteran is at risk, or in 
situations of rape or incest, and we need trained, qualified 
professionals to do that. So we have rolled out training. We 
have begun to do that, of course, for our women's health 
providers, our coordinators of care for women's health, our 
mental health providers where these conversations can come up, 
and that process is ongoing.
    Senator Tuberville. But have we not changed it to where 
abortion at any time, not the three exceptions?
    Dr. Elnahal. The criteria, Senator, is if, again, the 
veteran's life or health is at risk or in situations of rape or 
incest.
    Senator Tuberville. Those three. Those three exceptions. 
Okay.
    All right. It is my understanding that doctors now have the 
option to opt out of participating in this policy. Is that 
true?
    Dr. Elnahal. That is true, Senator.
    Senator Tuberville. Okay. How many doctors have chosen to 
opt out? Do you have any clue?
    Dr. Elnahal. I do not have that information now but will 
take that for the record and see what we can provide.
    Senator Tuberville. Was that included in this new rule, 
that they could opt out?
    Dr. Elnahal. Under the law, physicians have always had the 
right to opt out of care against which they have a 
conscientious objection, and we made that clear through formal 
policy, and the exact process by which they can do that, very 
recently we sent that guidance out to the field.
    Senator Tuberville. Yes. Do you have any clue how much it 
is costing the Veterans Administration to implement this rule? 
Do we have any kind of report on that?
    Dr. Elnahal. Well, the impact analysis, Senator, that we 
have done estimated that fewer than 1,000 veterans a year would 
need these services, and so we are really not talking about a 
significant percentage of the medical appropriations budget 
that we have.
    Senator Tuberville. Yes. You know, we have had this new 
interim law for six months, and I hate that we cannot discuss 
it a little bit more. You know, I am curious what prohibits 
this, you know, from privacy. I understand a little bit of it 
and I am really just wanting numbers. The last time I talked to 
Secretary McDonough about this we had started abortions. So 
hopefully we can get some numbers down the road. I think there 
should be an obligation from the VA to do that since it was 
changed from the VA and not through this body. So hopefully we 
can discuss this and get more information in the future.
    Thank you. Thank you, Mr. Chairman.
    Chairman Tester. Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman, very much. Thank 
you to the Chairman and to Senator Boozman for the discussion 
this morning over the Air Force breakfast and talking about 
patient safety and talking about mental health and all the 
things treating men and women in the service and after they get 
out of the service, as human beings.
    This week is National Patient Safety Week. I hear directly 
from VA employees in Ohio regarding safety concerns at the VA. 
No surprise. We should applaud those who have the courage to 
make sure veterans are receiving care in the safest possible 
environment, speaking out about it when necessary.
    I want to take a moment to thank Dr. Cox who testified last 
year in the HRM for his team at VHA for their work to make the 
electronic health record safer. We know VA's electronic record 
rollout had led to negative outcomes for Ohioans. As Mr. 
Sicilia talked, you were in Columbus recently. Today my office 
was briefed on three separate veterans, three individual 
veterans who died in part because of the Oracle Cerner EHRM's 
failings. Until the 14 technology fixes outlined in the HRM's 
Sprint Report are developed, tested, and placed, this should 
not move forward at any other facility. I think you are hearing 
that from the Chairman, the Ranking Member, Ms. Murray, and 
others.
    My first question is for Dr. Evans and Dr. Elnahal, if you 
would respond to this. I met with VA employees in Columbus a 
few months ago, right after you announced the assess and 
address period to find and fix problems with the EHRM product 
and after Dr. Elnahal's September visit. Frontline VA employees 
raised frustrations, the kind of frustrations Ms. Murray spoke 
about, about connectivity, system latency, workflows. 
Clinicians raised pharmacy and patient safety concerns, where 
they went around the table, one after another, talking about 
those. We see the effects on productivity, on worker morale, on 
veteran satisfaction.
    In January, specific clinics' productivity were still below 
go-live and access to specific clinics at Chalmers, the 
Columbus facility, primary care, rheumatology, and neurology 
remain limited. So go-live, the facility has hired additional 
staff, and employees are working overtime to meet veteran 
needs. You know all that.
    No new system launches perfectly, of course. However, we 
are almost a year post go-live in Columbus. Veteran 
satisfaction is low. Worker morale is low, as indicated by the 
GAO report.
    So how, Dr. Elnahal and Dr. Evans, how can you recommend 
moving forward to more complex facilities if the current sites 
are not back to pre go-live productivity levels? I mean, you 
have talked about Cleveland. You have talked about Cincinnati. 
You have talked about Ann Arbor. You have talked about Seattle. 
How do you go to more complex facilities when you cannot get it 
right in an ambulatory place like Columbus?
    In either order. Dr. Evans, do you want to start?
    Dr. Evans. Sure. First of all, I was just in Columbus 
myself last week, and I heard many of those same things, and we 
need to address those issues. There is just no two ways about 
it. In any system, as you said, there are going to be 
challenges when we roll out a new system, but it is very, very 
important for us to be sensitive to the operations on the front 
lines of care, and to be identifying where those challenges 
are, and fixing them.
    To your question about highly complex sites, like those 
that you mentioned that have some, what we would refer to as 
our Level 1 medical centers, where there is more complex care 
delivered, I think the VA recently made a decision to move 
back. We had been considering moving forward with a go-live in 
Ann Arbor, Michigan.
    Senator Brown. This fall, right? This late summer or fall?
    Dr. Evans. That is correct.
    Senator Brown. And you are moving that back?
    Dr. Evans. We have moved that back.
    Senator Brown. As you have Cleveland and Cincinnati.
    Dr. Evans. That is correct. And I think, you know, again, 
this gets to the core principle that I mentioned earlier, and 
that is we need to know that we are ready to safely deploy a 
record that will meet the needs of the organization before we 
go live at sites, particularly at complex sites, but I would 
argue that would apply to any site. It does not matter whether 
it is highly complex or not complex.
    Senator Brown. Okay. Dr. Elnahal?
    Dr. Elnahal. Yes, thank you, Senator, for the question. As 
you remember, it was actually my visit to Columbus where I 
heard directly from frontline users and I observed their 
workflows, about the concerns they had around veteran care that 
prompted us to do the assess and address after I had a 
conversation with the Secretary about what I saw. And the need 
to restore productivity is not an end in and of itself. It has 
everything to do with access to care, and it is also a marker 
about the degree of workarounds and issues that our clinicians 
have to go through to work around the system rather than having 
the system function for their needs.
    So I do see--and I agree with everything Dr. Evans said 
about a site-by-site assessment that considers not only 
productivity but everything else we have discussed--patient 
safety risks, a number of other metrics. But there is a ray of 
hope in that Walla Walla has just reached predeployment 
productivity recently. They have strategies for their workflows 
that have been able to achieve that. And so we are learning 
deeply from that experience, and we plan on having that 
experience be taught and shared in terms of those best 
practices, not only for sites going forward, like Saginaw, but 
to sites that already have the system, like Columbus.
    Senator Brown. Thank you, and Mr. Chairman, thank you for 
giving me one more. Mr. Sicilia, I would like to ask you one 
question. It has been a year ago since the purchase of Cerner. 
Since that time VA employees have told me a lot of things--IT 
tickets being closed without communicating that back to the 
clinicians, degradations, outages that affect veterans' 
clinical care, not properly testing upgrades before they go 
live which cause pharmacy shortages.
    You are aware of this. I just do not see the benefit from 
your system. Veterans are frustrated by the delay in their 
care. The contract is coming up for renewal in May of this 
year. Without significant changes to the terms of any contract 
why should we support it? What benefits can I start seeing that 
you are providing?
    Mr. Sicilia. Well, I think on the issue of tickets being 
closed, this was feedback that I heard in Columbus last week, 
and I would agree with you. It is not where it needs to be, and 
it is on us to address that. On the issue of system 
availability, though, I think we have made dramatic strides, 
and we are now at the 99.9 percent system uptime SLA, that is 
contracted for.
    So I believe that some of that data is from older reports, 
and things have been remedied certainly in recent months. It 
has been nine months since we have owned the system and made 
material changes.
    As I said, if the core and fundamental aspects of the 
system were flawed it would not be powering health care for 
countries like the United Kingdom and others. So there are 
issues. We are working together with the VA and the VHA, and I 
think that list of 14 accurately summarizes the things that 
need to be addressed. Seven of those are already addressed and 
not yet rolled out, and the other seven are in planning to be 
rolled out.
    So I do believe that with the new leadership and the folks 
that have leaned in, we have a very good understanding of what 
needs to be fixed clinically to make the system better. I do 
know that the system does work and can work because it works 
all over the world. Obviously, this implementation has been 
particularly problematic.
    But as far as not testing the system and causing outages, 
my firm belief is that those days are behind us. I do not see 
that as a continued issue going forward. It has not been.
    Chairman Tester. Senator Tillis.
    Senator Brown. Thank you.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Chair Tester. Thank you all for 
being here. And Chair Tester, I am glad that we have a panel 
instead of two panels. We have got all the stakeholders at the 
same one.
    Ms. Harris, I spent a lot of time doing large-scale systems 
implementation work, contracts, price, all that sort of stuff. 
As your office completed the review, did you make any 
determination--I have not read the report, just the summary--
any determination about contract obligations and who was 
responsible between Cerner and the VA in the execution?
    Ms. Harris. That was not part of the scope of the review 
that we performed, but I mean, I think that it is fair to say 
that Oracle Cerner has not performed as well as they could 
have, given the volume and the severity of the system issues 
that have occurred and also the lack of timeliness to resolve 
them, which was part of our review, in terms of the trouble 
ticket resolution and not meeting the SLA timeframes.
    Clearly I think that the contract as currently written has 
not sufficiently motivated Oracle Cerner to perform better, I 
mean, just in looking at the ticket resolution timeliness, just 
on that alone.
    I think that the other component of that is the IT 
oversight piece on the side of VA. I think that this is a 
relatively new thing for VA. They have, for 40 years, been in 
the business of building systems, like VistA, and it is a 
completely different skill set in building IT versus buying, as 
you know. And so I think the department has struggled to make 
this transition, and that is evidenced by its past failed 
attempts to replace VistA with other commercial products, as 
well as what you are seeing going on right now.
    Senator Tillis. And Mr. Sicilia, you mentioned that I think 
you said that you transferred ownership of the system about 
nine months ago. Can you give me, if you have the information 
in front of you, the trouble ticket resolution. You have 
transferred ownership. I am assuming they are going through an 
implementation. They may need some fixes to address process 
issues. Where are we now? I would have expected a lot of 
trouble tickets before you went live in the Northwest, fewer 
now. Has that happened or do you have a continuous flow of 
additional requests?
    Mr. Sicilia. It is not uncommon to have a continuous flow 
of tickets in a system this big.
    Senator Tillis. More of a scale issue.
    Mr. Sicilia. Yes. I think the current issue and the 
feedback that I heard on the ground in Columbus was that there 
is a feeling among the providers, the end users of the system, 
that we are closing tickets too quickly in order to meet a 
metric. And I think, frankly, that feedback was probably fair. 
I think there are some things that we need to do better, and we 
took that as an action item to get through.
    But we closed 94 percent of the outstanding tickets. I am 
not so sure, though, that the qualitative measures are the only 
measures that matter. The quantitative measures, the quality of 
the close, communication back to the end users is an area for 
improvement.
    I do not think we are at the point, and I do not have the 
numbers in front of me here--I am happy to supply those back in 
writing--I do not think we are at the point where we have a 
massive amount of tickets that we do not know what to do with 
or have issues that have not been surfaced in the past.
    Senator Tillis. Mr. Elnahal--did I pronounce your name 
right?
    Dr. Elnahal. Yes, Senator.
    Senator Tillis. Okay. I know that you all are moving 
forward with the current implementation date. There are some 
improvements that have been recommended. Does that suggest that 
the improvements will be implemented, or are you moving ahead 
and you will work on any sort of recommendations from the GAO 
as you can get to them?
    Dr. Elnahal. So I read through the entire GAO information 
that was received from Ms. Harris and digesting all of that. I 
do want to reinforce that we are going to assess readiness site 
by site. And so when you say that we have a schedule, we have a 
schedule, but the assessment for readiness for deployment at 
Saginaw has not been completed.
    Senator Tillis. All right. So you will do a go/no-go based 
on that assessment.
    Dr. Elnahal. Exactly, and we are reviewing all the 
improvements we think need to be made before we would consider 
the likelihood of a safe and effective deployment to occur.
    Senator Tillis. I am about out of time, but, you know, I 
anticipated that you were going to have some challenges, 
because if you take a look at the VISNs and you take a look at 
the way that they have matured over years, they are like 
fingerprints. When you started this process you had several 
different variations, in some cases variations within a given 
VISN that you had to deal with. That is a huge systems process, 
change management challenge. So it is not surprising to me. The 
scale of it in terms of cost is a bit surprising.
    But I think it is important for everyone to know that we 
have to plow through. We have to address these problems. One of 
the reasons why I was okay with the Cerner decision is it is a 
common platform with the DoD. I know that they are not perfect, 
but my ultimate goal is to see integration there.
    My last question, as you go through implementation, has to 
do with what I heard just earlier. One of the things that we 
wanted to make sure got done, which seems to be having some 
problems right now, is with non-VA care. And when you look at 
the implementation of the PACT Act and the additional stressors 
that I think are going to drive you to non-VA care in many 
instances as you ramp up, has that problem been solved? Are we 
going to see that integration, that ability for non-VA 
providers to access the same chart in a reasonable period of 
time? And that is for anybody that can answer the question.
    Dr. Evans. Yes, Senator. I think actually this is a 
particularly important part of what we have accomplished in 
this project already, as a part related to but not directly 
related to the electronic health record change itself, has been 
the implementation of what we call the Joint Health Information 
Exchange. And we, the DoD and VA combined, as well as the Coast 
Guard, the Federal Electronic Health Record are now exchanging 
data through the Joint Health Information Exchange with 65 
percent, I believe, is the last I saw, of the American health 
care system, records digitally. And those are available not 
just to users at the five sites that are using the Oracle 
Cerner EHR but can be reviewed as well by clinicians at sites 
that are still using VistA.
    Senator Tillis. I may be working on dated information. I 
got the impression--and I will go back to the person that 
informed me on this--that exchanges are something I spent some 
time on in the state legislature. It is one thing for one of 
the providers to publish it. It is another thing for people to 
fully subscribe to it and exploit it. So if that 65 percent 
number--and I will take it at face value--it would be 
interesting to see if they are fully exploiting it in the 
manner that I would expect them to, and it would be the same 
way that any health care provider in the VA would.
    Thank you, Mr. Chairman. I am sorry I went so far over.
    Chairman Tester. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you, Mr. Chairman. Thank you very 
much. You know, I have been on this Committee for a little more 
than 12 years. I have been on the Armed Services Committee the 
same amount of time. I do not know whether you have recently 
read The Iliad and The Odyssey, about the decades-long war that 
the Greeks conducted. This reminds me of The Iliad and The 
Odyssey. It seems endless. And I do not know what to tell my 
constituents about why it seems to have been such a dismal 
failure.
    Can you tell me, Dr. Evans?
    Dr. Evans. I have teenagers who are taking high school 
English so I have seen The Iliad and The Odyssey recently at my 
house.
    I think as for the question of the change here, this is a 
very, very, very significant change for the Veterans Health 
Administration. As I mentioned in my opening remarks, 
electronic health records really, it is much more than a 
record. It is what drives the workflow. It is what, frankly, in 
many ways, supports how clinicians think about patient care.
    And so I think it is important to understand the depth of 
the change.
    Senator Blumenthal. I know it is an important and complex 
change, but it is equally important and complex for a lot of 
very big corporations that get it right, and then they have to 
change, they have to update. This technology is changing. I 
almost feel like the VA begins to get there and then somehow 
the system escapes them because of advancing technology because 
they do not--and I say ``they'' because it is not just you. It 
is a decade plus.
    Would you say that the VA is now fully integrated with the 
Department of Defense?
    Dr. Evans. So I have been seeing patients at the VA for 21 
years. I cannot remember a time in the last decade where I was 
not able to access data from the Department of Defense health 
care system in order to support a patient who came into my 
clinic who had either received care in the DoD recently or was 
receiving care in both.
    Senator Blumenthal. But with all due respect, sir, that 
does not answer my question, because the fact that you could 
access records does not mean that the systems are integrated 
electronically. If you are saying yes, it is done----
    Dr. Evans. Right. So here is what I would say. So 
interoperability has multiple layers. If we are talking about 
if the data is available digitally for me to review in order to 
understand and take care of patients, the answer to that 
question is yes, across the enterprise. But is that enough, and 
the answer to that is no.
    We need to get to a point where the data is not just 
available but it is computable, so that the colonoscopy that 
was done eight years ago triggers a reminder for me to order a 
new colonoscopy at the 10-year mark for a patient. That is, 
that I do not have to go look it up in a digital repository 
somewhere but that that data element is driving clinical care 
decisions. And that is what we are striving to achieve with 
this.
    Senator Blumenthal. And the answer then to my question is 
no, it is not fully integrated, because if it were, if that 
patient had gotten that kind of test 10 years ago only within 
the VA system, I presume that after 10 years, or whatever the 
right time is, there would be a red light that goes on and you 
would have said, ``Joe, you need to come back.'' If it is not 
happening from the DoD to the VA, you are not fully integrated.
    And I am running out of time so I know this is a big and 
complex question and I know I have asked it in a very 
simplistic way.
    Dr. Evans. And if I may----
    Senator Blumenthal. Go ahead.
    Dr. Evans [continuing]. I completely agree, and that is 
where we are headed with this project. That is the benefit of 
having an integrated Federal record, and frankly, the benefit 
of having health information exchanges with the Oracle Cerner 
record, that records that we are getting from the private 
sector can be ingested into the VA record to drive that kind of 
clinical decision support. So that is where we need to go.
    Senator Blumenthal. My staff was told yesterday that there 
were six catastrophic events related to a feature of the 
electronic health record modernization program in the last 
couple years. Four of the events resulted in a fatality, one 
from Spokane and three from Columbus, Ohio. Is that accurate?
    Dr. Evans. Let me just start by saying that patient safety 
is incredibly important to us, and I think you heard Dr. 
Elnahal mention that. One of our goals in the VA is to see zero 
patient harm. It is hard to achieve. Health care is an 
inherently risky endeavor. But our goal is zero patient harm. 
And we take every episode where there is harm and we evaluate 
it very carefully, and we try to understand why. And often 
there are many contributors to what can lead to unintentional 
patient harm.
    It is never good. We are never satisfied when this happens. 
But we learn from it by identifying what the factors are. And 
there are many factors--medication errors that can occur, the 
electronic health record can contribute, physical 
infrastructure issues in our facilities. There are many 
potential contributors to patient safety, of which the EHR is 
one. And yes, there have been cases where we have found that, 
frankly, with both our EHR on the VistA side as well as with 
the Oracle Cerner EHR, that the EHR has been a potential 
contributor to that harm.
    Senator Blumenthal. A potential proximate cause, as we say 
in the law.
    Chairman Tester. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
for the hearing.
    This is something that we have followed for months, as you 
all know, and it is a source of frustration for us that the 
implementation is not happening.
    Mr. Sicilia, I would love to come to you. I appreciate the 
efforts that your company has made in developing a new platform 
that would modernize the EHR structure. We hear that that has 
been a problem. We think this could be helpful. This rollout 
has not met the expectations of anyone. Transitioning these 
platforms are difficult. At Vanderbilt Hospital there in 
Nashville there was a lot of pioneering work early on that went 
into the EHRs and how they could be utilized. There has been 
frustration that the VA has just not been able to make this 
system applicable, user friendly, interoperable. The list of 
questions goes on.
    But what I would like to hear from you, let us just say if 
this program is unsuccessful, you cannot get this platform 
going, what challenges do you see in integrating electronic 
records among the various shareholders that might need these--
DoD, other VA programs, people that are going to go into 
community care. So kind of walk me through what the challenges 
are on this.
    Mr. Sicilia. Well, if the program is not successful and it 
were to revert back to VistA, which is the current system, 
VistA was created on a technology called MUMPS, which was 
introduced during the Carter Administration, and by and large 
still remains on the same platform. I think interoperability 
would be a real challenge because those systems are very 
difficult to get to modern cloud platforms and to turn it into 
what is usually called ``software as a service,'' which means 
that the system is automatically updated, automatically 
secured, and automatically maintained by, in this case, the 
vendor, Oracle.
    So I think that becomes, to be a very difficult----
    Senator Blackburn. Okay. Then let me ask you this. Have you 
seen VA's program for restructuring?
    Mr. Sicilia. Excuse me?
    Senator Blackburn. Have you seen the VA's proposal for 
restructuring? Are you read into that?
    Mr. Sicilia. For restructuring VistA?
    Senator Blackburn. For their entire EHR.
    Mr. Sicilia. We are the vendor for----
    Senator Blackburn. Right. But VA has an approach. Are they 
working with you? Are they stonewalling you?
    Mr. Sicilia. No, they are not stonewalling. VA is not 
stonewalling. I would particularly with the addition of Dr. 
Elnahal and Dr. Evans in the last few months and weeks, I would 
describe the collaboration among all parties as excellent, 
certainly better than it has ever been in the nine months that 
I have been associated with this program, and I am very 
optimistic that we are at exactly the moment where DoD was in 
their initial rollout, which I would call a page-turn moment.
    Senator Blackburn. Okay.
    Mr. Sicilia. And I think we are----
    Senator Blackburn. That is great. That is good to hear. So 
do you feel like your recommendations are being listened to and 
that VA is responsive?
    Mr. Sicilia. I do.
    Senator Blackburn. Okay. And Mr. DelBene, let me come to 
you because in your nomination hearing, to my QFRs, I asked you 
about the EHR modernization and flipping the system, making it 
workable. And here was your response: ``What is most important 
is to make sure that these projects run in a highly effective 
manner, accomplishing agreed-upon goals for each project in a 
cost-effective manner.''
    So the posture this program is in right now, is it cost-
effective? Is it highly effective? Is it meeting agreed-upon 
goals? Where are you on this?
    Mr. DelBene. Thank you for the question. I definitely think 
we have made progress, as has been cited by the up time hitting 
the goal recently. I think we still have a way to go, to be 
honest. There is another set of measurements, kind of a second 
click down, where we are not yet meeting the goals. One is 
incident free time, the period of time when there is not an 
incident in the implementation somewhere. We still are not 
meeting a goal there.
    We are making progress, but there is a way to go still.
    Senator Blackburn. Okay. And Ms. Harris, the GAO finding, 
``VA medical staff appear apprehensive about adopting the new 
EHR system.'' What is their dissatisfaction? Why are they 
apprehensive? Why do they not want to move to an EHR system 
that could be interoperable, that you could have some of your 
multi-stakeholders, DoD, utilizing an interoperable system? Why 
are they resisting this?
    Ms. Harris. I think change is hard, and I think that, you 
know, within VA in particular, for the past multiple decades, 
these medical centers have been able to do what they want, 
which is evidenced by the 130 versions of----
    Senator Blackburn. Do they understand this is their job? Do 
they understand this is their job? Is it the union that is 
resisting? Who is resisting on this? Why do they not want to do 
this? I have never in my life seen such resistance to 
modernizing a program. You have got a vendor sitting right next 
to you. They are a making a good-faith effort to bring 
something forward. Why can you not tell employees, ``This is 
your job. If you do not want to do this, go work somewhere 
else''?
    Ms. Harris. We have not done the detailed work to get to 
what you are asking.
    Senator Blackburn. What is your timeline? What is your 
timeline for getting this program to the point that you are 
going to be able to see VA? I mean, you are the GAO. You are 
telling them what they are doing.
    I guess that question is more properly placed to another of 
you on the staff, probably Mr. Elnahal. What is your timeline? 
How long does the transition take? I know that the Chairman 
asked you and you said months.
    Dr. Elnahal. Well, I think the thread of your question, 
Senator, has a lot to do with the responsibility we have to 
take in the health care system to prepare for the change and 
execute on the change. And we took that seriously with the 
Sprint effort that we submitted to all of you on this 
Committee. We have built a structure that holds all of our 
leaders accountable for owning this effort, but also one that 
requires us to really define the changes needed so that at the 
end of the day for our end users it is usable and it is an 
efficient system.
    Senator Blackburn. I am way over my time. I hope you all 
realize the frustration is that VA ought to be able to do this, 
and there does not seem to be a willingness. And Ms. Harris, I 
appreciate that GAO had that report for us. But I think we are 
all frustrated with the lack of willingness to modernize this 
system and be of service to the veterans. Thank you.
    Chairman Tester. Thank you, Senator Blackburn.
    I am going to stick with you, Ms. Harris. Your report, and 
I think in your opening statement you said that there was one 
remaining recommendation that had not been addressed, or did I 
hear you wrong, from the report?
    Ms. Harris. Well, we made 10 recommendations.
    Chairman Tester. How many are still open?
    Ms. Harris. They are all open.
    Chairman Tester. They are all still open. So that means 
they have not been addressed, right?
    Ms. Harris. That is correct. But VA did concur with all of 
those recommendations.
    Chairman Tester. And how old are they?
    Ms. Harris. I am sorry?
    Chairman Tester. How old were these recommendations? When 
were they made?
    Ms. Harris. Well, we have made a total of 15--well, we have 
15 open recommendations related to the EHR, and the oldest one 
is from June 2020.
    Chairman Tester. Okay. So you have only been on the job for 
three weeks. What is the plan here?
    Dr. Evans. I think that some of the recommendations that 
were mentioned are just coming out right now. We concur with 
them and we will be acting on them. I mean, change management, 
communication, it is critical.
    Chairman Tester. Yes. Okay, good.
    Going back to you, Ms. Harris, have you ever seen a 
contract? Do you look at contracts?
    Ms. Harris. We do look at contracts.
    Chairman Tester. Have you ever seen a contract--correct me 
if I am wrong, okay, because I am not always right--have you 
ever seen a contract that appears to be really out of balance, 
favoring the vendor, and where the agency oversight of that 
contract, I believe, is lacking?
    Ms. Harris. Well, I think that the contract certainly is 
not necessarily in the best favor of the government in this 
particular case, to be blunt.
    Chairman Tester. Okay. Good. So that brings me to you, Mr. 
Parrish, who has not been asked any questions, and I do not 
want you to feel too lonely down at the end. But where are you 
at in contract negotiations?
    Mr. Parrish. Well, Mr. Chairman, as you may or may not know 
we have begun our renegotiation of the contract for the new 
option period that would theoretically begin on the 17th of 
May. However, given the procurement rules, I am limited in what 
details I can actually give in a public hearing. But that said, 
I do want to----
    Chairman Tester. So let us just ask you it this way. Do you 
intend to have a contract negotiated by the time this one runs 
out, which is, what, the 17th of May or something?
    Mr. Parrish. Yes, sir. So, a couple of points that I can 
add for you. The key component is, as everyone on the Committee 
has acknowledged, there have been some challenges around system 
reliability and user adoption, and we have insisted for those 
improvements to be made by Cerner, and they have done some but 
nearly not enough.
    And so, one of the key items that we are doing, and we are 
looking at instituting, is improving, the frustration that you 
acknowledged around, the limited enforcement mechanisms of the 
May 2018 contract, because it is very restrictive, and what we 
are allowed to recover, as you acknowledge, we only received 
$325,000.
    Chairman Tester. So I want to ask you this. How is that 
enforcement applied? Is it applied via the checkbook, or is it 
applied some other way?
    Mr. Parrish. Well, right now, as you know, it is very 
limited.
    Chairman Tester. I know.
    Mr. Parrish. But what we are renegotiating with the Oracle 
team is to strengthen and add more enforcement, especially 
around service level agreements. We want to bring industry 
standards in.
    Chairman Tester. But how do you hold their feet to the 
fire? Is it going to be by money?
    Mr. Parrish. Yes, sir. It will be by money and by--I guess 
that is really the main.
    Chairman Tester. Do you anticipate this next contract will 
be more favorable to the American taxpayer?
    Mr. Parrish. That is absolutely the plan. Yes, sir.
    Chairman Tester. Okay. Dr. Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Thank you all.
    Ms. Harris, I think your latest recommendation was that 
there be an independent review of this process to just kind of 
have a third-party look at it. Sometimes you are so close--it 
does not mean the VA is not doing their job or Oracle. It is 
just that you are so close you cannot. What do you think about 
that process being a regular process? It would not just be this 
one time but it would be once a year, once every six months, 
some interval in which some objective person could say, 
``Everybody step back. I am a new eye. X, Y and Z.'' Thoughts 
about that?
    Ms. Harris. I think that makes a lot of sense. I mean, the 
more eyes that you have on the system implementation, 
particularly an objective third party, the better. And you look 
at DoD, for example, and their rollout of MHS Genesis, and 
having that independent operational analysis completed after 
their first initial deployment, they put a pause based on the 
results of that assessment, they addressed all the major 
findings there, and then subsequently restarted the 
deployments----
    Senator Cassidy. Let me stop you.
    Ms. Harris [continuing]. And it was much smoother.
    Senator Cassidy. Because it is kind of like--it is kind of 
a tale of two departments. It was apparently going kind of 
swimmingly in the DoD, with high provider satisfaction, and it 
is obviously not going very well in VA, with very low provider 
satisfaction. I would be interested in knowing more about that, 
but it sounds like you are somewhat attributing that to this 
sort of third party coming in. ``Okay, stop, everybody. Time 
out.'' Almost like a marriage counselor, and then kind of 
getting things back online. Is that a fair characterization?
    Ms. Harris. Yes. It is objective, and it is comprehensive, 
and it would allow VA to systematically catalogue what the 
major issues are and then to address them, point by point.
    Senator Cassidy. Which of the gentlemen from the VA should 
comment on this--I apologize. I have been at a series of 
meetings out of here--as to whether or not you would accept 
that or even think it is a good idea?
    Dr. Evans. Again, I am new in this position, but I will say 
this. I completely agree that the perspective of those who are 
outside of the narrow window of executing program is valuable, 
and frankly, we value the input from the GAO, we value the 
input we have received from the OIG, and we value the input 
that we have received from other partners.
    Senator Cassidy. So knowing that you value it, but I am 
really asking, would you be open to systematizing this third-
party review, that it would not be an ad hoc, maybe it is about 
time to do it, but rather apparently such as DoD did, on a 
regular basis, now is the time for the person to come, kind of 
like JCAHO coming in for a hospital. I do not know if they go 
to the VA or not. But everybody kind of resets. Your thoughts?
    Dr. Evans. I mean, I think, look, I would certainly be open 
to having those discussions, to figure out what that could look 
like.
    Senator Cassidy. That is a little bit----
    Dr. Evans. Or do you want me to say--I mean, yes.
    Senator Cassidy. Mr. Sicilia, what do you think about that? 
Is there value there?
    Mr. Sicilia. Yes, it is a common practice among our 
commercial customers that third parties do quality reviews.
    Senator Cassidy. A common practice----
    Mr. Sicilia [continuing]. Among our commercial customers.
    Senator Cassidy. No, I heard what you said but I just was 
kind of like digesting the thought, that the common practice, 
the best practice, which has worked with DoD and worked in the 
commercial setting--and I am not pointing fingers at anybody. 
We are trying to find solutions here because we are $30 billion 
in and counting, apparently, in terms of potential liability.
    Mr. Sicilia, have you ever met with Secretary McDonough?
    Mr. Sicilia. I have not.
    Senator Cassidy. How about your CEO?
    Mr. Sicilia. No, she has not.
    Senator Cassidy. Is there any value in you meeting with 
him?
    Mr. Sicilia. I think we did make an offer for a meeting. It 
has not yet been accepted. It would be common that we have top-
to-top meetings in a deployment such as this size.
    Senator Cassidy. I apologize if you have answered this, but 
again, I have been gone. Is there just a succinct answer why 
this has gone so differently in DoD versus how it is going in 
VA?
    Mr. Sicilia. If there was a very succinct and very easy, I 
think we would have flipped that switch. I would say that the 
range of services in the VA is more complex than it is, in many 
cases, in the DoD. However, in upcoming go-lives this month, we 
will go live at some of the most complex DoD sites that there 
are, and the readiness assessment on those is squarely in favor 
of a go-live in the system.
    Senator Cassidy. Can I stop you for a second? It does seem, 
though, that scheduling and pharmacy benefits are core 
competency of any system, and what we saw about the deaths and 
the morbidity associated with the current system related to 
scheduling and pharmacy. So knowing that there might be 
something else--allied health, specialties, whatever, 
whatever--that is core competency of any EHR. How could that 
have broken down?
    Mr. Sicilia. The pharmacy process, as you may know, at VA 
is different than it is in all of private medicine and in the 
DoD. That said, it is an obligation to deliver those features. 
The initial estimate, when I first testified in front of this 
Committee in July of last year, was that it would take three 
years to fix the pharmacy issues. We delivered the top three 
issues in four months, and the next prioritized issue on the 
list will be delivered in April. So I think we have made 
material improvements in the pharmacy module here in the nine 
months that we have been involved.
    Senator Cassidy. Well, thank you all for trying to make 
something good happen for the veterans. I appreciate it, and I 
yield.
    Chairman Tester. Senator Moran.
    Senator Moran. Ms. Harris, let me confirm my understanding 
is that the GAO recommendation is for certain criteria to be 
met by the VA before there is a further expansion of the sites 
in which this system is to be utilized. Is that true?
    Ms. Harris. Yes, that is true.
    Senator Moran. So what is the GAO recommendation in that 
regard?
    Ms. Harris. To establish goals associated with user 
satisfaction and to have marked improvement against those goals 
before continuing on with deployments.
    Senator Moran. And do you outline the nature of those 
goals?
    Ms. Harris. We do not outline the nature of the goals. I 
think that should be up to the VA to establish what the 
appropriateness of those goals should be, and I think VA, with 
Dr. Evans and Dr. Elnahal, should be working very closely 
together to identify what the appropriateness of those goals 
should be. But what is important is that VA does this and that 
they measure against it, and before they do anything else, in 
terms of proceeding forward with deployments, that they have 
significant improvements in their user satisfaction.
    Senator Moran. And is that the only criteria in the sense, 
yes, the VA needs to determine the desired outcome, but user 
satisfaction, is there something more that you mentioned in 
your report?
    Ms. Harris. There is. So in terms of priority that is the 
most important priority, but also relative to change management 
as well, we made seven specific recommendations on improving 
their organizational change management, and the VA should be 
implementing those and be in a better position before they 
continue on with deployments as well, in that regard.
    Senator Moran. And the VA's response to those 
recommendations, that recommendation?
    Ms. Harris. They did concur with all of our 
recommendations.
    Senator Moran. And the sense that they are following 
through--if they concur with your recommendations then do I 
have the answer I was looking for earlier? If they concur with 
your recommendations then there would be a pause. The answer to 
my question is yes.
    Ms. Harris. That is TBD. I mean, from everything that I 
have heard now it sounds like they will continue to proceed 
with deployments.
    Senator Moran. And that is different than what you were 
told by the VA in response to your recommendations?
    Ms. Harris. Well, they concurred with the recommendations 
but they did not provide specificity in terms of the timelines 
for implementing those recommendations. So I assume that they 
would take into account the pause and get back to us with time 
frames for the new schedule for deployments once they have 
implemented those recommendations.
    Senator Moran. So, Dr. Elnahal, what am I missing? Why is 
it difficult to say--I mean, we have heard from a number of my 
colleagues about the health consequences to veterans as a 
result of the utilization of the EHR system. I am not sure I 
can understand why if that is true, which seems to be the case, 
then if it is a matter of certainly health and welfare, and 
perhaps life, then what would be the reason that it is 
difficult for you to say, we are going to wait for criteria to 
be met, satisfaction, before we expand the number of hospital 
sites that are going to be utilizing the system?
    Dr. Elnahal. I do not think you are missing anything, 
Senator. We concurred with that recommendation. I would want to 
see improvements in user satisfaction and adoption of this 
system before we deploy further. I just wanted to clear that 
clearly.
    Senator Moran. Let me try the question again, and if you do 
not see that, then what?
    Dr. Elnahal. Well, what we are doing now, with Dr. Evans 
and his team, is refreshing what we call the broader readiness 
criteria, apropos of Ms. Harris' and her team's recommendation 
to us to clarify those goals around readiness for deployment 
and beyond. So we are working on that now, feverishly, and as 
we do that, site-by-site we are going to assess readiness. And 
if we are not ready against those criteria, we will not go live 
at those sites.
    Senator Moran. So is the unknown at this moment the 
criteria?
    Dr. Elnahal. We are refreshing those criteria. I am 
interested in what Dr. Evans' perspective is as well. But we 
are refreshing those criteria as a team right now.
    Senator Moran. So the Department of Veterans Affairs comes 
up with criteria that they say today needs to be met before 
there is further expansion of the system, and if that criteria 
is not met then the expansion would not occur. And the thing 
that we do not yet know today is what the exact criteria is. Is 
that a summary of what you are testifying?
    Dr. Elnahal. Yes, Senator. There are obviously criteria 
that the program has used before. We paused deployments back in 
July, at the Secretary's request. We extended that pause in 
October to do the Sprint analysis. And now, of course, we have 
much more information about vulnerabilities in the system, 
things we need to do in VHA to better prepare for the change 
management recommendations that Ms. Harris mentioned.
    So that criteria needs to be refreshed, and that is what we 
are doing right now.
    Senator Moran. And may I assume that at least seemingly to 
me was a reluctance to say there would be this delay if their 
criteria was not met, you are not concerned that if you said 
that, that then Oracle Cerner would be less intent on 
fulfilling its obligations under the contract?
    Dr. Elnahal. We expect Oracle Cerner to follow through on 
our requirements.
    Senator Moran. Anything here, Mr. Sicilia?
    Mr. Sicilia. I think that obviously end user satisfaction 
is critically important. It is not just a contractual 
requirement. It is a moral requirement as well, given the fact 
that these people are caring for our Nation's veterans.
    I would say, in concert with Ms. Harris, that I think the 
end user surveys has to be paired with a change management 
process. If you just survey people and make that the only 
criteria, and you ask them, ``Would you like to change?'' 
usually the answer is not positive, right. So in any kind of 
survey where change is associated, without a strong change 
management process accompanying it, you will inherently get 
more negative answers than positive answers.
    However, I will say that the feedback that I heard in 
Columbus was very pointed, it was very well formed. I think the 
people who are using this system have put a tremendous amount 
of thought into it. I think they know what they need to make it 
better, and I think we can deliver it. And disinformation would 
say that the only feedback is just general surveys and 
sometimes can backfire because without accompanying process 
around them, you know, you can survey forever before you get to 
the resumption.
    Senator Moran. Dr. Elnahal, your criteria is broader than 
just user satisfaction?
    Dr. Elnahal. Yes, Senator. We have to consider everything 
from operational readiness of the facility, making sure that a 
certain number of employees were trained appropriately. We are 
working on revamping training, starting the training much 
further in advance of deployment, looking at specific user 
roles, tailoring to specific user roles. There are a number of 
things we are doing with training. And yes, there are a good 
number of other criteria.
    Senator Moran. And I will belabor this a while longer. The 
criteria that you are utilizing will be based upon outcomes 
from the places that the system is already deployed, to 
determine whether to deploy it elsewhere.
    Dr. Elnahal. Yes, especially user satisfaction. That is the 
only place where we would be able to get that information. And 
with Block 8 and some of the changes we have made since the 
beginning of the Sprint, I do hope to see that users are saying 
more often that the system is meeting the needs for veterans.
    Senator Moran. And the places that the system is going to 
be deployed, in the next series, what input or what criteria is 
required from them to determine whether to further deploy?
    Dr. Evans. I mean, I think----
    Senator Moran. I think this is my last question on this 
topic and then I have one more.
    Dr. Evans. So we need to assess the readiness of the 
solution itself, that is its technical performance, the 
reliability, system response time, et cetera, and 
configuration, whether it is meeting the needs. And a piece of 
that leads to user satisfaction. As we have been talking about, 
we also need to assess the readiness of a site to engage in 
change.
    So we will be focusing on improvements at existing sites, 
assessing satisfaction, and frankly, the system performance, 
the configuration changes that you have heard mentioned 
earlier, that we can make to improve the path forward, that is 
critical. But as we look for it at future sites we have to ask 
the same questions. And so the criteria will apply to both.
    Senator Moran. The 14 patient safety issues that have been 
identified, they should be fixed before further deployment?
    That is a question, not a statement.
    Dr. Evans. Yes. We should have a clear and unambiguous plan 
and an assessment of what must be fixed before we go live. I 
would argue that our lean is that they should all be fixed. But 
remember, this system is in use right now. We have mitigations 
in place for existing sites. Ideally we have them all fixed 
before we go live.
    Senator Moran. Dr. Elnahal--my last question, Mr. Chairman, 
although you made the mistake of telling me I could go as long 
as I wanted.
    Chairman Tester. Yes, well, the vote is about to close, but 
that is okay.
    Senator Moran. I do not think so. Not quite yet.
    First of all, I would compliment you and your political 
skills. Despite the number of times your name was 
mispronounced, in every instance in which you were asked if was 
being pronounced correctly your answer was yes. I guess I 
should not question your veracity based upon that evidence.
    Doctor, do we have your commitment that staff and existing 
Cerner EHR site will make liberal use of their authorities 
under the MISSION Act to refer veterans who might be worried 
about any of their safety or well-being to community providers 
until improvements are made or until the best interest of the 
veteran is altered?
    I did not ask my question very well. Let me try this again. 
I want to make sure that you are going to utilize Community 
Care as an alternative in regard to any veteran that may have 
concerns about the system.
    Dr. Elnahal. Well, I will start, Senator, by saying that I 
have been giving the benefit of the doubt in the pronunciation 
of my name since I was a child.
    On that question, absolutely. Where we are not able to meet 
the access standards, which are in place and something we 
adhere to, regardless of whether our facilities have Cerner or 
VistA, we offer community care. And we have seen increases in 
utilization of community care at the five sites, because of 
decrements in productivity that you would expect after a go-
live. We are seeing one facility reach pre-deployment 
productivity, but the four others have not. And you have seen 
across the board, and we have seen, community care utilization 
go up, because we need to make sure that veterans get the care 
one way or the other.
    Senator Moran. Thank you for your answers. Thank you, Mr. 
Chairman.
    Chairman Tester. I have got one more too. Senator Moran, I 
figure you probably did too, but that is okay if you need to 
go.
    I was looking down this Committee. Many of the people on 
this Committee are either on the Authorization Committee for 
the Department of Defense or on Appropriations Committee for 
the Department of Defense. Mr. DelBene, in a recent interview, 
Secretary McDonough said, ``Too often we are a downstream 
consumer of this infrastructure, and too often our concerns 
become secondary to, for example, the DoD, which manages big 
parts of this network, and this makes implementation of this 
system harder than it might be.''
    Could you respond to that?
    Mr. DelBene. Thank you for the question. I support his 
statement there. I think this is a complicated system that has 
dependencies between the VA and the DoD. There are services 
that we consume from the DoD, such as login and patient safety, 
or patient information exchange, that we have had issues around 
reliability, and we have been speaking to our peers at the DoD 
to try to get those resolved. But that is one area.
    And the other area I think is around getting us to a point 
of shared governance, such that we manage the enclave together. 
I think it is just a matter of history, that they started this 
deployment and that we have added on as kind of a second 
tenant. We need to get to a place where we share in all those 
kinds of decision-making, and we are working with them on that. 
But it is that, to what the Secretary said, around the 
frustration that we sometimes have of we think we need to go in 
this direction, and how do we get that to be executed across 
the two organizations.
    Chairman Tester. One of the solutions that we had to solve 
any kind of problems between the DoD and VA--because, by the 
way, turf is always a problem around this place--is the Joint 
Executive Committee. Is it working?
    Mr. DelBene. I think we are able to bring issues to the JEC 
when they get raised. I think the problems are, as you say, in 
a very large organization when we get down to the specifics of 
getting a particular issue resolved, it can sometimes get 
bogged down, and despite the best intentions of both sides to 
resolve those issues.
    Chairman Tester. Okay. Last question, and this is your 
opinion. You have been in this business of technology your 
whole life. You have been in this position for a couple of 
years now? Pretty close?
    Mr. DelBene. Fifteen months.
    Chairman Tester. Fifteen months. Time does not fly when you 
are having fun. But is this something that can be done before I 
get really old?
    Mr. DelBene. I do think it can be done. I was trying to 
figure out how not to speak about your age. But I do believe it 
can be done. I think that we are in a very different position 
than we were when we started this rollout. I think we have made 
great progress in the sites that have gone active, and we 
understand the issues and we are driving the issues.
    I think there is a long road still to get to absolute 
perfection, but I think we are on that path. And so I do think 
it can be implemented, and successfully, for the benefit of our 
veterans.
    Chairman Tester. Mike Sicilia said a bit ago that the 
players in place were better--if I paraphrase this wrong you 
correct me--were better now than they have been in the past. 
Fair statement, Mike?
    Mr. Sicilia. I would say that is fair. I would not say the 
other players were bad by any means.
    Chairman Tester. But they are better now than they have 
been in the past.
    Mr. Sicilia. We have enjoyed more collaboration.
    Chairman Tester. Perfect.
    For you, since you are the IT guy, do we have the people in 
place to make this work, from a VA perspective?
    Mr. DelBene. From a VA perspective I definitely think we 
have the right people in place. I think our oversight of this 
project is strong, I think we are holding Oracle Cerner 
accountable for strong deployment, and I do think we have a 
good team in place to execute.
    Chairman Tester. Then I would ask the same question to you, 
Mike, but I know your answer is going to be, ``We are going to 
have the right team, come hell or high water.'' Right?
    Mr. Sicilia. Yes, sir. That is correct.
    Chairman Tester. All right. Let me close this out. I want 
to thank you all for being here today. This has been a good 
hearing, only if it results in progress. Okay? If we are back 
here even three months from now, still talking about the same 
old stuff, then we have got some issues. I think everybody up 
and down the rostrum made very, very good points about what the 
expectations are, and I think that it is driven by one thing, 
and that is making sure our veterans get the health care they 
have earned in a way that they deserve. Okay?
    Status quo is unacceptable. I think we all know it, up and 
down the line. We are tired of excuses. We want to have 
results. And I would just say that if everybody puts their 
shoulder to the wheel, and the wheel is going in the same 
direction, I have confidence. But I will tell you that my 
confidence has been waning, and so I really do want to see 
results.
    Thank you all for being here. This hearing is now 
adjourned.
    [Whereupon, at 5:26 p.m., the hearing was adjourned.]






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